NFPA Technical Committee on Fire Service Occupational Safety and Health MEETING AGENDA DoubleTree San Diego Downtown San Diego, CA October 7-9, 2010 Task Group Meetings October 7, Technical Committee Meeting October 8-9 1. Chair Benarick calls meeting to order on October 8, 2010 at 8:00 am 2. Welcome and Opening Remarks. 3. Introduction of attendees (Attachment A). 4. Approval of the minutes of the May 13-14, 2010 meeting and August 30, 2010 Conference Call (Attachment B). 5. Review purpose of meeting and document schedule. (Attachment C) 6. ECommittee Page Overview 7. Task Group Reports. a. Diabetes (Attachment D) b. Prosthetics & Amputees c. Heart & Epilepsy (Attachment E) d. Pregnancy (Attachment F) e. Coagulation & Meds f. Vehicle & Highway Operations g. SCBA & Air Management h. PPE/Proximity i. Collapse Zones j. Hearing Aids (Attachment G) k. PSA (Attachment H) 8. Research Projects 9. NFPA 1561 10. Old business. 11. New Business. 12. Date and location of next meeting, February 10-12, 2011 San Antonio, TX. 13. Adjournment.
Transcript
NFPA Technical Committee on Fire Service Occupational Safety and Health
MEETING AGENDA DoubleTree San Diego Downtown
San Diego CA October 7-9 2010
Task Group Meetings October 7 Technical Committee Meeting October 8-9
1 Chair Benarick calls meeting to order on October 8 2010 at 800 am
2 Welcome and Opening Remarks 3 Introduction of attendees (Attachment A)
4 Approval of the minutes of the May 13-14 2010 meeting and August 30 2010 Conference Call
(Attachment B)
5 Review purpose of meeting and document schedule (Attachment C) 6 ECommittee Page Overview
7 Task Group Reports
a Diabetes (Attachment D) b Prosthetics amp Amputees c Heart amp Epilepsy (Attachment E) d Pregnancy (Attachment F) e Coagulation amp Meds f Vehicle amp Highway Operations g SCBA amp Air Management h PPEProximity i Collapse Zones j Hearing Aids (Attachment G) k PSA (Attachment H)
8 Research Projects
9 NFPA 1561
10 Old business
11 New Business
12 Date and location of next meeting February 10-12 2011 San Antonio TX
13 Adjournment
ATTACHMENT A
2
Address List 9172010
Fire Service Occupational Safety and Health FIX-AAAKenneth Willette
Glenn P Benarick
FIX-AAAChair211 Winged Elm Circle
Aiken SC 29803
NFPA Fire Service SectionAlternate Murrey E Loflin
PhoneCell 803-644-7093
FaxEmail gbenarprodigynet
U 1011992 Murrey E Loflin
FIX-AAASecretary (Alternate)West Virginia University
Fire Service Extension
West virginia State Fire Academy
2600 Old Mill Road
Weston WV 26452-8077
NFPA Fire Service SectionPrincipal Glenn P Benarick
PhoneCell 304-293-8288 304-276-2843
Fax 304-293-2107
Email meloflinmailwvuedu
U 411993
Donald Aldridge
FIX-AAAPrincipalLion Apparel Inc
6450 Poe Avenue Suite 300
Dayton OH 45414
Alternate Andrew G SchwartzPhoneCell 937-415-2801 937-212-0206
Fax 937-913-5545
Email daldridgelionapparelcom
M 111985 David J Barillo
FIX-AAAPrincipalUniversity of Florida College of Medicine
PO Box 100286
Gainesville FL 32610-0286
PhoneCell 352-265-0262
FaxEmail dbarilloearthlinknet
SE 1122000
Lawrence T Bennett
FIX-AAAPrincipalUniverity of Cincinnati
Fire Science Department
2220 Victory Park Way ML 0103
Room 301
Cincinnati OH 45206-2837
PhoneCell 513-556-6583
Fax 513-556-4856
Email lawrencebennettucedu
SE 7232008 Paul Blake
FIX-AAAPrincipalCity of Baytown Fire amp Rescue Services
201 East Wye Drive
Baytown TX 77521
Industrial Emergency Response Working GroupPhoneCell 281-420-5329
Fax 281-420-5367
Email shonblakebaytownorg
E 4171998
Sandy Bogucki
FIX-AAAPrincipalYale University Emergency Medicine
464 Congress Avenue Suite 260
New Haven CT 06519-1315
PhoneCell 203-785-6159
Fax 203-785-3196
Email sandyboguckiyaleedu
SE 711996 Dennis R Childress
FIX-AAAPrincipalOrange County Fire Authority
PO Box 75003
San Clemente CA 92673-0167
California State Firefighters AssociationPhoneCell 949-218-7441
Fax 949-218-7499
Email den4fireaolcom
U 711993
13
Address List 9172010
Fire Service Occupational Safety and Health FIX-AAAKenneth Willette
Dominic J Colletti
FIX-AAAPrincipalHale Products Inc
700 Spring Mill Avenue
Conshohocken PA 19428
Fire Apparatus Manufacturers AssociationAlternate Leroy B Coffman III
PhoneCell 610-940-2437
Fax 610-825-6440
Email dcollettiidexcorpcom
M 4171998 Thomas J Cuff Jr
FIX-AAAPrincipalFiremens Association of the State of New York
127 Shelter Lane
Levittown NY 11756-1218
PhoneCell 516-735-4081 516-351-0942
Fax 516-579-9063
Email tomc621aolcom
U 10101997
Michael L Finkelman
FIX-AAAPrincipal182 Melanie Drive
East Meadow NY 11554
Association of Fire DistrictsState of New YorkPhoneCell 516-579-7570 516-369-8648
Fax 516-542-0593
Email mikexx00aolcom
U 7282006 Stephen N Foley
FIX-AAAPrincipalUS Department of Homeland Security
US Fire Administration
16825 South Seton Avenue
Emmitsburg MD 21727
PhoneCell 301-447-1304
Fax 301-447-1178
Email stephenfoleydhsgov
SE 1042007
Thomas Hillenbrand
FIX-AAAPrincipalUnderwriters Laboratories Inc
333 Pfingsten Road
Northbrook IL 60062-2096
Alternate Steven D CorradoPhoneCell 847-664-2603
Fax 847-313-2603
Email thomasahillenbrandusulcom
RT 7241997 Scott D Kerwood
FIX-AAAPrincipalHutto Fire Rescue
501 Exchange
PO Box 175
Hutto TX 78634
International Association of Fire ChiefsAlternate Brett R Bowman
PhoneCell 512-759-2616 512-413-1404
Fax 512-846-1946
Email sdkerwoodhuttofirerescueorg
E 711995
Jonathan D Kipp
FIX-AAAPrincipalPrimex
3
46 Donovan Street
Concord NH 03301
PhoneCell 603-225-2841
Fax 603-228-3905
Email jkippnhprimexorg
I 111989 Steve Kreis
FIX-AAAPrincipalCity of Phoenix Fire Department
150 South 12th Street
Phoenix AZ 85034-2301
PhoneCell 602-495-5848
Fax 602-262-4429
Email stevelkreisphoenixgov
E 1032002
24
Address List 9172010
Fire Service Occupational Safety and Health FIX-AAAKenneth Willette
Michael A Laton
FIX-AAAPrincipalSperian Protective Apparel
160 Woodstream Way
Fayetteville GA 30214
International Safety Equipment AssociationPhoneCell 770-861-0350
FIX-AAANonvoting MemberNational Institute for Occupational Safety amp Health
4676 Columbia Parkway R-9
Cincinnati OH 45226
Alternate Jay L TarleyPhoneCell 513-841-4583
Fax 513-844-4488
Email thalescdcgov
RT 452001
William R Hamilton
FIX-AAANonvoting MemberUS Department of Labor
Occupational Safety amp Health Administration
200 Constitution Ave NW Room N3609
Washington DC 20210
Alternate Andrew LevinsonPhoneCell 202-693-2077
Fax 202-693-1663
Email hamiltonbilldolgov
E 342009 Andrew Levinson
FIX-AAAAlt to Nonvoting MemberUS Department of Labor
Occupational Safety amp Health Administration
200 Constitution Ave NW Room N3718
Washington DC 20210
Occupational Safety amp Health AdministrationPrincipal William R Hamilton
PhoneCell 202-693-2048
Fax 202-693-1678
Email levinsonandrewdolgov
E 7282006
Jay L Tarley
FIX-AAAAlt to Nonvoting MemberUS Department of Health amp Human Services
National Institute for Occupational Safety amp Health
1095 Willowdale Road MS 1808
Morgantown WV 26505
Principal Thomas R HalesPhoneCell 304-285-5858
Fax 304-285-5774
Email jst9cdcgov
RT 3152007 Kenneth Willette
FIX-AAAStaff LiaisonNational Fire Protection Association
1 Batterymarch Park
Quincy MA
PhoneCell 617-984-7299
Fax 617-984-7056
Email kwillettenfpaorg
792010
68
ATTACHMENT B
9
Technical Committee on Fire Service Occupational Safety and Health
Meeting Minutes May 13 ndash 14 2010
Holiday Inn Inner Harbor MD
Attendees Glenn Benarick Chairman Ken Holland Staff Liaison Michael Finkelman Craig Fry Joe Rivera Stephen Raynis Steve Kreis Dennis Childress Don Stewart Phil Stittleburg David Ross Michael Laton Kim Zagaris Tom Hillenbrand Dominic Colletti Andy Schwartz Brett Bowman Guest David Bernzweig Thursday May 13 NFPA 1500 task groups (Vehicle amp Safety OPS SCBA amp Air Mgt PPEProximity) met to discuss the work they have completed since the last meeting The task groups will present their report to the entire TC on May 14th Not enough 1582 task group members were able to make the meeting so there were no reports or work from those task groups Friday May 14 TC meeting called to order at approximately 0800 by Glenn Benarick TC Chair Ken Holland (NFPA Public Fire Protection Staff) in attendance filling in for Frank Florence Ken made two presentations one on the Codes and Standards Development Process and the other on the general procedures for this Pre-ROP meeting The Staff Liaison remains fluid as Frank is not expected back any time soon
10
One guest in attendance Dave Bernzweig (Columbus OH Fire) Dave is assisting TC with SCBAAir Mgt issues The document revision cycles remain as requested NFPA 1500 amp 1582 Annual 2012 NFPA 1521 amp 1561 Fall 2013 NFPA 1581 1583 1584 Annual 2014 The October 7-9 2010 dates are the primary request for our next meeting Location is San Diego Notice will be sent out as soon as approval is received Discussion on the next revision of 1561 will be held at the October meeting regarding changing the document title to ldquoCommand Safety for Fire Department Operationsrdquo This is a suggestion of the TC Chair Ken Holland conducted a briefing for the TC on how to access and use the committee web page Staff will be posting as much information as possible up on the e-committee page for the entire committee More use will be made of this tool Discussion on monocular vision Dennis Childress presented the current issue in Ventura County CA Further discussionwork may be necessary Don Stewart agreed to take the lead Brief discussion held on pregnancy and the need for fire departments to ensure policies match current law The rep from the Diabetes Association declined the invitation to participate at this meeting due to no discussion of the issue planned She has indicated a desire to attend the October meeting There were no reports from these and all other 1582 task groups It is very important for the 1582 TG Chairs to be ready to report in October The following task group reports will be posted on the ecommittee page PPEProximity New definition of proximity fire fighting
VehicleHighway OPS Discussion on use of vehicle data recorders Collapse Zones Submission from Jay Tarley SCBAAir Mgt New exit strategy for SCBA Discussion on having the low air alarm activate when the bottle volume reaches 600 liters Further discussion to take place on ldquobuddy breathingrdquo
On Day 2 Casey Grant (NFPA Fire Protection Research Foundation) made a presentation on Research Planning for FSOSH Dr Ellen Sogolow (DHSFEMA) also present during this presentation She discussed the role of the AFGRampD activities See ecommittee page for his presentation Chair
11
will be in contact with Mr Grant for future work between the TC and the Foundation Also on Day 2 Ken Willette (Division Manager ndash NFPA Public Fire Protection Division) delivered a presentation on the initiative developed by Kelvin Cochran (US Fire Administrator) to reduce fire fighter injuries and deaths NFPA 1500 is an integral part of this initiative See ecommittee page for presentation The Chair will be coordinating a committee conference call in the coming weeks The purpose will be to review the work which needs to be completed for the October meeting The primary focus of the call will be on 1582 issues NOTE Subsequent to the meeting I have had some discussions with a fire chief in Kentucky on the use of hearing aids The TC especially the doctors need to review the current language in 1582 and decide if revisions are needed Also most of you know that Kelvin Cochran has left the USFA unexpectedly to return to Atlanta as their fire chief I have been in contact with the Acting Administrator Glenn Gaines to inform him that our committee remains focused on the work to reduce fire fighter injuries and deaths I told him that I would keep him informed of our work He indicated that one of his primary goals is to bring fire service organizations together in order to create a safe working environment Of particular interest to him is reducing heart related injuries and deaths Submitted by Glenn Benarick
12
Technical Committee on Fire Service Occupational Safety and Health
Conference Call Meeting Minutes August 30th 2010
Members participating
Glenn Benarick TC Chair
Murrey Loflin Secretary Dr Sandy Bogucki
Thomas Cuff Stephen Foley
Scott Kerwood Tammy Lopes
David Love Dr David Prezant
Joe Rivera David Ross
Mario Rueda Phil Stittleburg
Phil Vorlander Dominic Colletti
Thomas Hillenbrand
Denise Smith Brett Bowman Alternate
Andrew Schwartz Alternate Mike Young Alternate
Dr Thomas Hales Non-Voting Member Ken Holland NFPA Staff Liaison
Casey Grant NFPAResearch Foundation Staff Katie Hathway Guest from ADA
Dr Jim Fleming Guest from Phoenix Fire Dept
The chair welcomed everyone to the conference call in which he hoped
would last only an hour The purpose was to discuss any task groups that had reports for proposed changes to NFPA 1582 for the
committee This is in hopes to ensure the committee is ready for their
pre-ROP meeting in October The following topics were discussed and are in no specific order
Comments from ADA Katie Hathaway and the group went into deep
discussion regarding ones medical history and diagnosis of diabetes
13
and some proposed changesremoval of text based on research
findings The specific proposed changes will be available for the committee at their next meeting Some members on the call felt that
this issue was covered in another law enforcement document which might better serve this issue
Research topics for FSOSH projects Casey Grant offered his time to
answer any questions regarding his presentation from the May meeting in Baltimore There was also discussion about further
involvement of the Research Foundation with this committee and some of the medical requirements within the documents Glenn and Casey
are going to be in contact offline to discuss this further
Prosthetics amp Amputees report Nothing new to report
Heart amp Hypertension report There was discussion about the need for
periodic EKGrsquos that were done both in resting and non-resting states as well as discussion about stress test requirements and frequency of
such tests The hopes were to develop text that would point to annual versus periodic evaluations of EKGrsquos and stress tests
Epilepsy report Nothing new to report
Pregnancy report The initial textlanguage has been provided to the
group through email and e-committee page posting
Coagulation amp Meds report Nothing new to report
Hearing Aid discussion Nothing new to report
The committee also discussed the evaluation and documentation of
PSA results and test requirements for the purposes of consistency The proposed text and changes have been posted on the e-committee
page as well
All of the proposed text changes from the May meeting in Baltimore have been emailed out and posted on the e-committee page If there
are any questions or concerns that something was missed please contact Glenn Steven Sawyer or Ken Holland to ensure they are
resolved
The conference call lasted approximately an hour and was adjourned at 1400 hours
14
ATTACHMENT C
15
2012 ANNUAL REVISION CYCLE
PROCESS STAGE PROCESS STEP DATES
FOR TC DATES
FOR TCC 1 PRELIMINARY 10 Notification of intent to enter cycle 7910 7910
2 REPORT ON
PROPOSALS (ROP)
21 Proposal closing date 112310 112310 22 Final date for ROP meeting 22511 2411 23 Final date for mailing TC ballots 31811 21811 24 Receipt of (TC) ballots by staff liaison 42211 31111 25 Receipt of TC recirculation ballots 5611 31811 26 Final date for TCC meeting 41511 27 Final date for mailing TCC ballots 42211 28 Receipt of TCC ballots 51311 29 Receipt of TCC recirculation ballots 52011 210 Final copy (w ballot statements) to Secretary Standards Council 51311 52711 211 Completion of Reports 52011 6311 212 ROP Published and Posted 62411 62411
3 REPORT ON
COMMENTS
(ROC)
31 Comment closing date 83011 83011 32 Final date for ROC meeting 11411 10711 33 Final date for mailing TC ballots 111811 102111 34 Receipt of (TC) ballots by staff liaison 12211 111111 35 Receipt of TC recirculation ballots 12911 111811 36 Final date for TCC meeting 121611 37 Final date for mailing TCC ballots 122311 38 Receipt of TCC ballots 11312 39 Receipt of TCC recirculation ballots 12012 310 Final copy (w ballot statements) to Secretary Standards Council 122311 12712 311 Completion of Reports 11312 2312 312 ROC Published and Posted 22412 22412
4 TECH SESSION
PREPARATION amp
ISSUANCE OF
CONSENT
DOCUMENTS
41 Notice of Intent to Make a Motion (NITMAM) Closing Date 4612 4612 42 Posting of Filed NITMAM 5412 5412
43 Council Issuance Date for Consent Documents 52912 52912
44 Appeal Closing Date for Consent Documents 61312 61312
5 TECHNICAL
SESSION 50 Association Meeting for Documents with Certified Amending Motions
64-712 64-712
6
APPEALS amp
ISSUANCE OF
DOCUMENTS
WCAMS
61 Appeal closing date for Documents with Certified Amending Motions
62712 62712
62 Council issuance for Documents with Certified Amending Motions 8912 8912
Proposal Closing Dates may vary according to documents and schedules for Revision Cycles may change Please check the NFPA website (wwwnfpaorg) for the most up-to-date information on proposal closing dates and schedules
16
ATTACHMENT D
17
This weekrsquos conference call mentioned the Diabetes chapter written for the ACOEM document Guidance for the Medical Evaluation of the Law Enforcement Officer The task group working on this chapter (led Richard Miller of the Secret Service and our very own Dan Samo) worked with the ADA or over 2-3 years to come up with a consensus document
Please find the Chapter attached ltltDiabetes Guidance Sept 2010pdfgtgt
Regarding Dan Loeberrsquos points
1) Physical Evaluation Form - We could modify the LEO form (see end of the attached Chapter)
2) Duration required for stable regiment
1582 for IDDM Type 1 1 yr
Type 2 6 m
Oral Agents None specifically
ACOEM Police for IDDM Type 1 6m
Type 2 3m
Oral Agents 1m
The police document is much clearer about the decision regarding medical fitness for duty is the responsibility of the police physician with the treating diabetes-expert physician providing the data to the police physician to make an informed decision In this regard the police officer must provide the police physician with downloaded self monitoring glucose data for the 1 3 and 6 month time periods (see section 433)
3) HA1C ndash NFPA lt 8 over 3 month period
ACOEM Police ndash (Section 4333) Specifies the frequency on measurement and if gt8 requires further evaluation
Some other discrepancies End organ complications
NFPA ndash end organ complications (eye kidney heart neuro) ndash restriction
ACOEM Police ndash end organ complication -- requires further evaluation
18
Hypoglycemia (incapacitating ndash defined differently between the two documents (434)
NFPA ndash 0 episodes in past year le1 in past 5 yrs
ACOEM Police ndash 0 episodes in past year le2 in past 3 yrs
Given Dan Samorsquos and Richard Millerrsquos work with the ADALoeber it would be helpful to get their opinions on whether any of the changes requested by Loeber are appropriate for FF with DM
Tom
Thomas Hales MD MPH
Senior Medical Epidemiologist
NIOSH CDC
4676 Columbia Pkwy R-9
Cincinnati OH 45241
(513) 841-4583
trh1cdcgov
19
43 ndash DIABETES MELLITUS
431 ndash INTRODUCTION
The educated and motivated law enforcement officer (LEO) with well-managed diabetes mellitus can be capable of
safe and effective job performance1 However diabetes mellitus may place LEOs at risk for sudden incapacitation
thus jeopardizing their ability to perform critical job functions (These job functions include those listed in Sections
32 333 351 352 36 and 37 and discussed in Appendix A)
Therefore an individualized assessment of the LEOrsquos diabetes should be performed using the following evaluative
criteria to determine whether the individuals condition permits safe and effective job performance Such evaluation
must include the following key elements which are discussed in detail below
history of blood glucose control
knowledge of diabetes and its management
current stability of blood glucose
risk for significant hypoglycemia or hyperglycemia and
presence of diabetic complications
432 ndash OVERVIEW OF MEDICAL EVALUATION
The treating endocrinologist or other physician knowledgeable regarding diabetes management should provide
a narrative report certifying whether the LEO has or has not met the criteria set out in Sections 4321 through
4354 below In addition the physician should include supporting data (see Appendix B for the Physician Evalu-
ation Form)
4321 The LEO is under the care of an endocrinologist or other physician knowledgeable regarding diabetes
management Outpatient and in-patient medical record(s) for the last 3 years or since date of diagnosis
(whichever is shorter) should be reviewed by the treating physician and provided to the police physician
4322 If the LEO has type 1 diabetes the individual has been on a basalbolus regimena or an insulin pump
using analogue insulins for the 6 months prior to evaluation2
4323 If the LEO has type 2 diabetes on insulin the individual has been on a stable medication regimenb
for the 3 months prior to evaluation3 If on oral agents alone the LEO has been on a stable medication regimen
for the month prior to evaluationc
ACOEM Guidance for the Medical Evaluation of Law Enforcement Officers 1
43 ndash DIABETES MELLITUS
aA basalbolus insulin regimen consists of the use of a basal insulin (Glargine NPH) in a once or twice daily regimen to provide between-
meal insulin combined with the use of a short acting insulin (Regular Lispro Aspart or Glulisine) at mealtimes Insulin pumps are small
(beeper sized) battery powered devices that deliver small amounts of short-acting insulin in a constant infusion to meet basal insulin
requirements The wearer selects an additional mealtime bolus to be infused at the time of meals For more information on pumps visit
the manufacturerrsquos web sites ndash wwwMinimedcom wwwcozmorecom wwwanimascorpcom wwwdisetroniccom
bA stable insulin regimen is defined as maintaining the same types of insulin (long acting intermediate acting short or rapid acting)
Changes in insulin dose are part of the appropriate self-management of diabetes and do not disqualify an applicant or incumbent under
this section
cChanges in dose within the evaluation period will be allowed but addition of a new class of medications or insulin should result in a new
period of observation
one month for addition of a sulfonylurea or metformin
two months for the addition of a thiazolidinedione to insulin or a sulfonylurea or
three months for the addition of insulin
20
4324 If the LEO uses an insulin pump documentation is needed as follows
proper understanding and education in the use of the insulin pump
start date for the use of the pump
history of insulin site infectionsd
history of pump cessation and pump malfunction
backup plan for pump malfunction including use of injectable insulin and
frequency of infusion set changes
4325 The LEO has been educated in diabetes and its management and thoroughly informed of and under-
stands the procedures that must be followed to monitor and manage hisher diabetes and what procedures
should be followed if complications arise3
433 ndash QUANTITATIVE GLUCOSE MONITORING
4331 The LEO has documentation of ongoing self-monitoring of blood glucose
4332 This must be done with a glucose meter that stores every reading records date and time of reading
and from which data can be downloaded (Most meters now have this capability)
4333 Monitoring logs must be available covering the time period (1 3 or 6 months) as described in
Sections 4322 and 4323 The frequency of glucose monitoring must follow a schedule acceptable to the
police physician in consultation with the treating physician
Testing schedules are individual What follows is a common pattern but individual patterns may differ
2 ACOEM Guidance for the Medical Evaluation of Law Enforcement Officers
43 ndash DIABETES MELLITUS
dIndividual has not had more than one pump-site infection that caused him or her to miss work or usual daily activities in the preceding 6
months
THERAPEUTIC REGIMEN GLUCOSE TESTING SCHEDULE
Diet alone Once or twice a week
Metformin Thiazolidinediones or Alpha
Glucosidase inhibitors alone or in
combination
Once or twice a week
Sulfonylureas meglitanides nateglinide ndash
alone or in combination with the above group
Twice a day ndash AM and at supper with any
suspected hypoglycemic episodes
Insulin ndash one shot in combination with orals Twice a day ndash AM and at supper with any
suspected hypoglycemic episodes
2 to 3 times AM once a week
Insulin ndash two or more shots Insulin pump 3 to 4 times a day ndash at meals and bedtime
2 to 3 times AM once a week with any
suspected hypoglycemic episodes
21
4334 The LEO has had hemoglobin A1C measured at least 4 times a year (intervals of 2 to 3 months) over
the last 12 months prior to evaluation if diagnosis has been present for more than a year4 If hemoglobin A1C is
gt8 this may signal a problem with the LEOrsquos diabetes management that warrants further assessment5
434 ndash INCAPACITATING EVENTS
4341 The LEO has not had any incapacitating episodes within the past 1 year and no more than 2 episodes
in the past 3 years or since diagnosis of diabetes (whichever is shorter) of
43411 Severe hypoglycemia (loss of consciousness seizures or coma requiring assistance of others or
needing urgent treatment [glucagon injectionIV glucose]) or
43412 Blood sugar lt60 mgdl with unawareness demonstrated in current glucose logs6
435 ndash CHRONIC COMPLICATION SCREENING
4351 Chronic complications of diabetes are associated with increased risk for severe hypoglycemic
episodes and warrant further assessmente
4352 The components of screening for chronic complications are
43521 A complete eye exam by a qualified ophthalmologist or optometrist including a dilated retinal
exam demonstrating no more than mild background diabetic retinopathyf7
43522 Normal vibratory testing with a 128 Hz tuning forkg normal testing with 10 gram Semmes-
Weinstein monofilamentg and normal orthostatic blood pressureh and pulse testing89
ACOEM Guidance for the Medical Evaluation of Law Enforcement Officers 3
43 ndash DIABETES MELLITUS
ePresence of chronic complications of diabetes in and of themselves may not require the implementation of work restrictions
fNo more than one dot blot or flame-shaped hemorrhages or microaneurysm in all four fundus quadrants
gThe Michigan Diabetes Research and Training Center of the University of Michigan Health System recommends the following guidance
(see wwwmedumichedumdrtcprofsdocumentssviMNSI_howtopdf) for conducting vibratory and monofilament testing8
Vibration Sensation Vibration sensation should be performed with the great toe unsupported Vibration sensation will be tested bi-
laterally using a 128 Hz tuning fork placed over the dorsum of the great toe on the boney prominence of the DIP joint Patients whose
eyes are closed will be asked to indicate when they can no longer sense the vibration from the vibrating tuning fork In general the
examiner should be able to feel vibration from the hand-held tuning fork for 5 seconds longer on his distal forefinger than a normal subject
can at the great toe (eg examiners DIP joint of the first finger versus patients toe) If the examiner feels vibration for 10 or more seconds
on his or her finger then vibration is considered decreased A trial should be given when the tuning fork is not vibrating to be certain that
the patient is responding to vibration and not pressure or some other clue Vibration is scored as 1) present if the examiner senses the
vibration on his or her finger for lt10 seconds 2) reduced if sensed for 10 seconds or 3) absent (no vibration detection)
Monofilament Testing For this examination it is important that the patients foot be supported (ie allow the sole of the foot to rest on
a flat warm surface) The filament should initially be pre-stressed (4-6 perpendicular applications to the dorsum of the examiner s first
finger) The filament is then applied to the dorsum of the great toe midway between the nail fold and the DIP joint Do not hold the toe
directly The filament is applied perpendicularly and briefly (lt1 second) with an even pressure When the filament bends the force of
10 grams has been applied The patient whose eyes are closed is asked to respond yes if heshe feels the filament Eight correct responses
out of 10 applications is considered normal 1 to 7 correct responses indicates reduced sensation and no correct answers translates into
absent sensation
hOrthostatic hypotension is a physical finding defined by the American Autonomic Society and the American Academy of Neurology as a
systolic blood pressure decrease of at least 20 mm Hg or a diastolic blood pressure decrease of at least 10 mm Hg within 3 minutes of
standing
22
43523 Normal cardiac physical exam Cardiac stress testing to at least 12 METS is recommended and
should begin based on either the criteria of the American Heart AssociationAmerican College of
Cardiologyi10 or those of the American Diabetes Associationj11
Diabetics who have a normal cardiac stress test will be retested every one to three years based on
individual clinical assessment This assessment should consider
the age of the individual
the number and persistence of coronary artery disease (CAD) risk factors
the severity of CAD risk factors
43524 Microalbumincreatinine ratio 301 measured or calculatedk creatinine clearance
gt60 mlmin12
436 ndash ONGOING EVALUATION AND REQUIREMENTS
4361 Should have medical records and glucose meter logs reviewed periodically Because of the nature of
diabetes it is important that regular medical follow up be provided to the LEO The frequency and content of
the evaluation should be determined on an individual basis by the police physician in consultation with the
treating physicianl
4362 Must advise police physician of any change in type of medication
4363 Must advise police physician of any episodes of significant hypoglycemia or hyperglycemia
Urine microalbumincreatinine ratio _________________
III Treating Physician Statement
The above named individual meets all of the criteria provided on this form
Yes No ndash not recommended for position
No but IS recommended for position (letter of explanation attached)
It is my opinion that the above named individual is well-educated and well-motivated in diabetes self-management and has
achieved a level of diabetes management to be capable of safe and effective job performance as a law enforcement officer
I have reached this opinion after careful review of the above criteria
___________________________________________________________ ___________________________Signature of Physician Date
______________________________________________________________ ___________________________Printed or Typed Name of Physician Telephone Number
10 ACOEM Guidance for the Medical Evaluation of Law Enforcement Officers
43 ndash DIABETES MELLITUS
29
439 ndash REFERENCES
1 American Diabetes Association Diagnosis and classification of diabetes mellitus Diabetes Care 200427 Suppl
1S5-S10 See httpcarediabetesjournalsorgcgicontentfull27suppl_1s5
2 American Diabetes Association Continuous subcutaneous insulin infusion Diabetes Care 200427 Suppl 1S110
See httpcarediabetesjournalsorgcgicontentfull27suppl_1s110
3 Mensing C Boucher J Cypress M et al National standards for diabetes self-management education Diabetes
Care 200528 Suppl 1S72-9 See httpcarediabetesjournalsorgcgicontentfull28suppl_1s72
4 Goldstein DE Little RR Lorenz RA Malone JI Nathan DM Peterson CM American Diabetes Association Tests
of glycemia in diabetes Diabetes Care 200427 Suppl 1S91-3
See httpcarediabetesjournalsorgcgicontentfull27suppl_1s91
5 The Diabetes Control and Complications Trial Research Group Hypoglycemia in the Diabetes Control and
Complications Trial Diabetes 199746(2)271-86 See wwwncbinlmnihgovpubmed9000705 for abstract
6 American Diabetes Association Hypoglycemia and employmentlicensure Diabetes Care 200528 Suppl 1S61
See httpcarediabetesjournalsorgcgicontentfull28suppl_1s61
7 Viswanath K McGavin DD Diabetic Retinopathy Clinical Findings and Management J Comm Eye Health
200316(46)21-4 See wwwcehjournalorg0953-683316jceh_16_46_021html
8 Michigan Diabetes Research and Training Center University of Michigan Health System How to use the Michigan
Neuropathy Screening Instrument See wwwmedumichedumdrtcprofsdocumentssviMNSI_howtopdf
9 Bradley JG Davis KA Orthostatic hypotension Am Fam Physician 200368(12)2393-8
See wwwaafporgafp200312152393html
10 Gibbons RJ Balady GJ Bricker JT et al ACCAHA 2002 guideline update for exercise testing a report of the
American College of CardiologyAmerican Heart Association Task Force on Practice Guidelines (Committee on
Exercise Testing) J Am Coll Cardiol 200240(8)1531-40
See wwwaccorgqualityandscienceclinicalguidelinesexerciseexercise_cleanpdf
11 American Diabetes Association Standards of medical care in diabetes Diabetes Care 200528 Suppl 1S4-S36
Erratum in Diabetes Care 200528(4)990 See httpcarediabetesjournalsorgcgicontentfull28suppl_1s4
12 Molitch ME DeFronzo RA Franz MJ et al American Diabetes Association Nephropathy in diabetes Diabetes
Care 200427 Suppl 1S79-83 See httpcarediabetesjournalsorgcgicontentfull27suppl_1s79
13 Kitabchi AE Umpierrez GE Murphy MB et al American Diabetes Association Hyperglycemic crises in diabetes
Diabetes Care 200427 Suppl 1S94-102 See httpcarediabetesjournalsorgcgicontentfull27suppl_1s94
14 US Centers for Disease Control and Prevention National Diabetes Fact Sheet 2007
See wwwcdcgovdiabetespubspdfndfs_2007pdf
ACOEM Guidance for the Medical Evaluation of Law Enforcement Officers 11
43 ndash DIABETES MELLITUS
30
ATTACHMENT E
31
Typos A6921(2) 7th line down test should be plural 94201 Paragraph 2 target organ damage is used though end organ damage was defined earlier and in the appendix for that paragraph
A94201 Para A (1) d Id suggest deleting the phrases in brackets Im not sure either are predictably true or politically wise
a) tests for left ventricular hypertrophy Unfortunately use of the EKG to detect left ventricular hypertrophy is very insensitive (eg 5 sensitivity) The echocardiogram is the best test for diagnosing left ventricular hypertrophy but [it is relatively expensive and not readily available in small rural communities ] conducting echocardiograms on asymptomatic fire fighters with Stage 1 hypertension should be reserved only for those with long-standing hypertension
In addition
7761 A resting EKG shall be performed as part of the baseline medical evaluation and shall be obtained periodically thereafter
Changing from annually to periodically is noted has the language in the wellness-fitness initiative been changed as well Our previous decision was that we would support the W-F language since there was no compelling evidence to either support or refute it
Thanks
Sandy
32
NFPA 1582‐ HTN Draft 1
Reason for Revision
1) New classification of BP by the Joint National Commission [Chobanian et al 2002]
2) A high prevalence of FF have either HTN (~20) and Pre‐HTN (~20) [Soteriades et al 2003]
3) Among FF studies have shown a strong association between HTN and a number of adverse
cardiovascular events [Kales et al 2009]
4) A large percentage of on‐duty FF fatalities were found to have left ventricular hypertrophy a
complication of HTN at autopsy
Language in 2007 Edition with draft revisions in Red (Track changes)
611 The medical evaluation of a candidate shall include a medical history examination and any laboratory tests required to detect physical or medical condition(s) that could adversely affect hisher ability to safely perform the essential job tasks outlined in 511 A611 The medical history should include the candidates known health problems such as major illnesses surgeries medication use and allergies Symptom review is also important for detecting early signs of illness A medical history should also include a personal health history a family health history a health habit history an immunization history and a reproductive history
An occupational history should also be obtained to collect information about the persons past occupational and environmental exposures
(a) BP should be measured according to the Joint National Commission (JNC) -7 recommendations BP should be measured with a properly calibrated and validated instrument Patients should be seated quietly for at least 5 minutes in a chair with feet on the floor and arm supported at heart level An appropriate-sized cuff (cuff bladder encircling at least 80 of the arm) should be used to ensure accuracy At least 2 measurements should be made Systolic BP is the point at which the first of 2 or more sounds is heard (phase 1) and diastolic BP is the point before the disappearance of sounds (phase 5) [Chobanian et al 2003]
(2) Head eyes ears nose and throat (HEENT)
Formatted Font (Default) Times New RomanFont color Black
33
692 Vascular System 6921 Category A medical conditions shall include the following
(1) Uncontrolled or poorly controlled hypertension
(2) Hypertension with evidence of end organ damage
or not controlled by approved medications
A6921(1) Uncontrolled or poorly controlled hHypertension increases the risk of a sudden cardiac event This sudden cardiac event would cause sudden incapacitation which that is uncontrolled poorly controlled or requires medication likely to interferes with the safe performance of essential job tasks Uncontrolled or poorly controlled hypertension can be defined as the presence of end organ damage (see below) or stage 2 hypertension (BP systolic gt160 mmHg or BP diastolic gt100 mmHg) is an illness that can lead to functional impairment and potential for sudden incapacitation Individuals with pre- stage 1 or stage 2 hypertension should be referred to their primary care physician for evaluation lifestyle modification and treatment [QUESTION FOR GROUP _- WHAT ABOUT HAVING CANDIDATE RETURN IN ONE MONTH UNDER TREATMENT WITH NORMAL BP]
A6921(2)
Chronic hypertension can damage the eye (retinopathy) the kidneys (nephropathy) the vascular system (stroke transient ischemic attack or peripheral artery disease) or the heart (left ventricular hypertrophy and heart failure) These hypertension complications are known as end organ damage The cardiac and vascular complications are associated with an increased risk of sudden incapacitation and sudden cardiac death (Koren et al 1991) Unfortunately the cardiac complications are frequently asymptomatic and valid screening tests are not fast and are not inexpensive Therefore determining who to screen for cardiac complications (such as echocardiogram for LVH or a measurement of left ventricular ejection fraction for heart failure) should be based on the severity and the duration of HTN
76 Physical Examination The annual physical examination shall include each of the following components
(a) BP shall be measured according to the Joint National Commission (JNC)-7 recommendations
A76(1)(a) BP should be measured with a properly calibrated and validated instrument Patients should be seated quietly for at least 5 minutes in a chair with feet on the floor and arm supported at heart level An appropriate-sized cuff (cuff bladder encircling at least 80 of the arm) should be used to ensure accuracy At least 2 measurements should be made Systolic BP is the point at which the first of 2 or more sounds is heard (phase 1) and diastolic BP is the point before the disappearance of sounds (phase 5) [Chobanian et al 2003]
(2) Head eyes ears nose and throat (HEENT)
34
9420 Uncontrolled Hypertension 94201 Physician Evaluation Severe uncontrolled hypertension [defined as systolic pressure greater than 180 mm Hg diastolic pressure greater than 100 mm Hg or mean systolic blood
pressure ( systolic + diastolic) greater than 120 mm Hg] or malignant hypertension (defined as hypertension with the presence of target organ damage) compromises the members ability to safely perform essential job tasks 1 5 7 9 and 13 and the physician shall report the applicable job limitations to the fire department
Members with Pre-hypertention (systolic 120-139 mmHg or diastolic 80-89 mmHg) Stage 1 hypertension (systolic 140-159 mmHg or diastolic 90-99 mmHg) or Stage 2 hypertension (systolic ge160 mmHg or diastolic ge100 mmHg) should be referred to their primary care physician for evaluation lifestyle modification and treatment
(1) Members with Stage I hypertension should be followed-up not only by their primary care physician but also by the FD physician every 3 to 6 months to ensure their blood pressure is under control and to determine whether screening tests for asymptomatic end organ damage are appropriate
(2) Members with Stage 2 hypertension or with end organ damage (retinopathy nephropathy vascular or cardiac complications) compromises the members ability to safely perform essential job tasks 1 5 7 9 and 130 and the physician shall report the applicable job limitations to the fire department
A94201 Severe uncontrolled hypertension is a significant risk factor for the development of coronary artery disease congestive heart failure and stroke Blood pressure increases as a normal response to exercise This response is further exaggerated by the emotional and physical stress of performing these critical tasks while operating in personal protective clothing at extremes of temperature This normal elevation of blood pressure under these response conditions can lead to life-threatening hypertensive emergencies if a members daily blood pressure is already elevated to high levels In addition hypertension is a progressive illness that when uncontrolled ultimately and inevitably leads to target organ damage Target organs that are sensitive to the effects of elevated blood pressure are the central nervous system vision heart major blood vessels and kidneys
Chronic hypertension can damage the eye (retinopathy) the kidneys (nephropathy) the vascular system (stroke transient ischemic attack or peripheral artery disease) or the heart (left ventricular hypertrophy and heart failure) These hypertension complications are known as end organ damage The cardiac and vascular complications are associated with an increased risk of sudden incapacitation and sudden cardiac death (Koren et al 1991) Fortunately with proper evaluation life style modification and treatment these complications can be avoided Life style modification includes weight reduction DASH eating plan reduction in dietary sodium an increase in aerobic physical activity and moderation in alcohol consumption [Chobanian 2003]
Formatted Font (Default) Times New Roman12 pt Font color Black
Formatted Font (Default) Times New Roman12 pt Font color Black
35
A94201 (1) Members with Stage I hypertension whose BP returns to either pre-hypertenion or normal with lifestyle modification andor treatment can return to an annual medical evaluation For members with long-standing Stage I hypertension whose BP has not been reduced additional evaluation for possible end organ damage should be considered This evaluation could include any or all of the following
a) a compete patient history for symptoms of heart failure (eg shortness of breath upon exertion) or transient ischemic attacks (TIAs)
b) dilated eye examination for retinopathy
c) blood creatinine measurement for nephropathy
d) tests for left ventricular hypertrophy Unfortunately use of the resting EKG to detect left ventricular hypertrophy is very insensitive (eg 5 sensitivity) The echocardiogram is the best test for diagnosing left ventricular hypertrophy
A 94201 (2) Due to the high risk of a sudden cardiovascular event members with Stage 2 hypertension should be restricted until their BP can be brought under control Once the BP is brought under control they should be followed in the same manner as a member with Stage I hypertension
Formatted Font (Default) Times New Roman12 pt
36
D22 Cardiology Gibbons R J GJ Balady J W Beasley et al 1997 ACCAHA guidelines for exercise testing a report of American College of CardiologyAmerican Heart Association Task Force on Practice Guidelines (Committee on Exercise Testing) J Am Coll Cardiol 30260ndash311
Gibbons RJ Balady GJ Bricker JT Chaitman BR Fletcher GF Froelicher VF Mark DB McCallister BD Mooss AN OrsquoReilly MG Winters WL Jr [2002] ACCAHA 2002 guideline update for exercise testing summary article a report of the ACCAHA Task Force on Practice Guidelines (Committee to Update the 1997 Exercise Testing guidelines) J Am Coll Cardiol 401531ndash 40
Chobanian AV Bakris GL Black HR Cushman WC Green LA Izzo JL Jr Jones DW Materson BJ Oparil S Wright JT Jr Roccella EJ the National High Blood Pressure Education Program Coordinating Committee [2003] The seventh report of the Joint National Committee [JNC-7] on Prevention Detection Evaluation and Treatment of High Blood Pressure JAMA 2892560ndash2571
Soteriades ES Kales SN Liarokapis D Christiani DC [2003] Prospective surveillance of hypertension in firefighters J Clin Hypertens 5315-320
Kales SN Tsismenakis AJ Zhang C Soteriades ES [2009] Blood pressure in fire fighters police officers and other emergency responders Am J Hypertens 2211-20
37
NFPA 1582‐ HTN Draft 1
Reason for Revision
1) New classification of BP by the Joint National Commission [Chobanian et al 2002]
2) A high prevalence of FF have either HTN (~20) and Pre‐HTN (~20) [Soteriades et al 2003]
3) Among FF studies have shown a strong association between HTN and a number of adverse
cardiovascular events [Kales et al 2009]
4) A large percentage of on‐duty FF fatalities were found to have left ventricular hypertrophy a
complication of HTN at autopsy
Language in 2007 Edition with draft revisions in Red (Track changes)
611 The medical evaluation of a candidate shall include a medical history examination and any laboratory tests required to detect physical or medical condition(s) that could adversely affect hisher ability to safely perform the essential job tasks outlined in 511 A611 The medical history should include the candidates known health problems such as major illnesses surgeries medication use and allergies Symptom review is also important for detecting early signs of illness A medical history should also include a personal health history a family health history a health habit history an immunization history and a reproductive history
An occupational history should also be obtained to collect information about the persons past occupational and environmental exposures
(a) BP should be measured according to the Joint National Commission (JNC) -7 recommendations BP should be measured with a properly calibrated and validated instrument Patients should be seated quietly for at least 5 minutes in a chair with feet on the floor and arm supported at heart level An appropriate-sized cuff (cuff bladder encircling at least 80 of the arm) should be used to ensure accuracy At least 2 measurements should be made Systolic BP is the point at which the first of 2 or more sounds is heard (phase 1) and diastolic BP is the point before the disappearance of sounds (phase 5) [Chobanian et al 2003]
(2) Head eyes ears nose and throat
38
692 Vascular System 6921 Category A medical conditions shall include the following
(1) Uncontrolled or poorly controlled hypertension
(2) Hypertension with evidence of end organ damage
A6921(1) Uncontrolled or poorly controlled hypertension increases the risk of a sudden cardiac event This sudden cardiac event would cause sudden incapacitation which interferes with the safe performance of essential job tasks Uncontrolled or poorly controlled hypertension can be defined as the presence of end organ damage (see below) or stage 2 hypertension (BP systolic gt160 mmHg or BP diastolic gt100 mmHg) Individuals with pre- stage 1 or stage 2 hypertension should be referred to their primary care physician for evaluation lifestyle modification and treatment [QUESTION FOR GROUP _- WHAT ABOUT HAVING CANDIDATE RETURN IN ONE MONTH UNDER TREATMENT WITH NORMAL BP]
A6921(2)Chronic hypertension can damage the eye (retinopathy) the kidneys (nephropathy) the vascular system (stroke transient ischemic attack or peripheral artery disease) or the heart (left ventricular hypertrophy and heart failure) These hypertension complications are known as end organ damage The cardiac and vascular complications are associated with an increased risk of sudden incapacitation and sudden cardiac death (Koren et al 1991) Unfortunately the cardiac complications are frequently asymptomatic and valid screening tests are not fast and are not inexpensive Therefore determining who to screen for cardiac complications (such as echocardiogram for LVH or a measurement of left ventricular ejection fraction for heart failure) should be based on the severity and the duration of HTN
76 Physical Examination The annual physical examination shall include each of the following components
(a) BP shall be measured according to the Joint National Commission (JNC)-7 recommendations
A76(1)(a) BP should be measured with a properly calibrated and validated instrument Patients should be seated quietly for at least 5 minutes in a chair with feet on the floor and arm supported at heart level An appropriate-sized cuff (cuff bladder encircling at least 80 of the arm) should be used to ensure accuracy At least 2 measurements should be made Systolic BP is the point at which the first of 2 or more sounds is heard (phase 1) and diastolic BP is the point before the disappearance of sounds (phase 5) [Chobanian et al 2003]
(2) Head eyes ears nose and throat9420 Hypertension 94201 Physician Evaluation Members with Pre-hypertention (systolic 120-139 mmHg or diastolic 80-89 mmHg) Stage 1 hypertension (systolic 140-159 mmHg or diastolic 90-99 mmHg) or Stage 2 hypertension (systolic ge160 mmHg or diastolic ge100 mmHg) should be referred to their primary care physician for evaluation lifestyle modification and treatment
39
(1) Members with Stage I hypertension should be followed-up not only by their primary care physician but also by the FD physician every 3 to 6 months to ensure their blood pressure is under control and to determine whether screening tests for asymptomatic end organ damage are appropriate
(2) Members with Stage 2 hypertension or with end organ damage (retinopathy nephropathy vascular or cardiac complications) compromises the members ability to safely perform essential job tasks 1 5 7 9 and 130 and the physician shall report the applicable job limitations to the fire department
A94201 Chronic hypertension can damage the eye (retinopathy) the kidneys (nephropathy) the vascular system (stroke transient ischemic attack or peripheral artery disease) or the heart (left ventricular hypertrophy and heart failure) These hypertension complications are known as end organ damage The cardiac and vascular complications are associated with an increased risk of sudden incapacitation and sudden cardiac death (Koren et al 1991) Fortunately with proper evaluation life style modification and treatment these complications can be avoided Life style modification includes weight reduction DASH eating plan reduction in dietary sodium an increase in aerobic physical activity and moderation in alcohol consumption [Chobanian 2003]
A94201 (1) Members with Stage I hypertension whose BP returns to either pre-hypertenion or normal with lifestyle modification andor treatment can return to an annual medical evaluation For members with long-standing Stage I hypertension whose BP has not been reduced additional evaluation for possible end organ damage should be considered This evaluation could include any or all of the following
a) a compete patient history for symptoms of heart failure (eg shortness of breath upon exertion) or transient ischemic attacks (TIAs)
b) dilated eye examination for retinopathy
c) blood creatinine measurement for nephropathy
d) tests for left ventricular hypertrophy Unfortunately use of the resting EKG to detect left ventricular hypertrophy is very insensitive (eg 5 sensitivity) The echocardiogram is the best test for diagnosing left ventricular hypertrophy
A 94201 (2) Due to the high risk of a sudden cardiovascular event members with Stage 2 hypertension should be restricted until their BP can be brought under control Once the BP is brought under control they should be followed in the same manner as a member with Stage I hypertension
D22 Cardiology
40
Hypertension
Gibbons RJ Balady GJ Bricker JT Chaitman BR Fletcher GF Froelicher VF Mark DB McCallister BD Mooss AN OrsquoReilly MG Winters WL Jr [2002] ACCAHA 2002 guideline update for exercise testing summary article a report of the ACCAHA Task Force on Practice Guidelines (Committee to Update the 1997 Exercise Testing guidelines) J Am Coll Cardiol 401531ndash 40
Chobanian AV Bakris GL Black HR Cushman WC Green LA Izzo JL Jr Jones DW Materson BJ Oparil S Wright JT Jr Roccella EJ the National High Blood Pressure Education Program Coordinating Committee [2003] The seventh report of the Joint National Committee [JNC-7] on Prevention Detection Evaluation and Treatment of High Blood Pressure JAMA 2892560ndash2571
Soteriades ES Kales SN Liarokapis D Christiani DC [2003] Prospective surveillance of hypertension in firefighters J Clin Hypertens 5315-320
Kales SN Tsismenakis AJ Zhang C Soteriades ES [2009] Blood pressure in fire fighters police officers and other emergency responders Am J Hypertens 2211-20
41
NFPA 1582‐ Draft Revisions for CVDHTN
EKG and stress tests
Reason for Revision
1) Change requirement for annual resting EKG to periodically to be more consistent with ACCAHA
recommendation (Schlant et al 1992)
2) Add language to clarify what constitutes a positive ST
3) Make criteria for conducting diagnostic ST in asymptomatic patients consistent with the
ACCAHA
Language in 2007 Edition with draft revisions in Red (Track changes)
776 Electrocardiograms (EKG)) and Stress Tests 7761 A resting EKG shall be performed as part of the baseline medical evaluation and shall be obtained periodically (every 1 to 5 years) annually thereafter
A7761 A baseline resting EKGs shall be conducted Follow-up resting EKGs should be conducted as clinically indicated but at a minimum of every 1 to 5 years The frequency of these follow-up resting EKGs should increase as a members age increases or with increasing number andor severity of coronary heart disease risk factors Members above the age of 40 should have annual resting EKGs (Schlant et al 1992)
7762 The fire department physician or other qualified medical evaluator shall compare EKGs obtained during yearly evaluations with baseline and subsequent EKGs
7763 Stress testing EKG with or without echocardiography or radionuclide scanning shall be performed as clinically indicated by history or symptoms
A7761 Baseline electrocardiography should be conducted (Periodic resting electrocardiograms have not been shown to be useful but can be reasonable as a members agefactors increase)
A7763 No firm guidelines for stress testingelectrocardiography in asymptomatic individuals have been developed Stress testingelectrocardiography as a screening tool is used as part of an evaluation of aerobic capacity during the annual occupational fitness evaluation Submaximal stress testingelectrocardiography testing to 85 percent is commonly used as part of this screening
Submaximal stress electrocardiography testing should not be used for diagnostic purposes Cardiology evaluation with maximal stress testingelectrocardiography together with imaging techniques (eg echocardiography technetium Tc99m sestamibi study andor coronary angiography) is necessary for diagnosticprognostic purposes for the following
42
(1) Fire fighters with positive or questionably positive changes on screening submaximal stress tests
(2) Fire fighters with new onset chest pain or other symptoms suggestive of coronary artery disease (CAD)
(3) Fire fighters with diabetes mellitus who
(a) are gt35 years old or
(b) have type I diabetes for more than 15 years or
(c) have type II diabetes for more than 10 years or
(d) have any other CHD risk factor (see below) or
(e) have the presence of microvascular disease (proliferative retinopathy)
(4) Fire fighters over the age of 45 (for men) and 55 (for women) with onetwo or more risk factors for CAD Risk factors for CAD include hypercholesterolemia (total cholesterol greater than 240 mgdL) hypertension (systolic gt140 mmHg or diastolic gt90 mmHg) smoking or family history of premature CAD (heart attack or sudden cardiac death in a first degree relative less than 60 years of age)
as defined below if stress electrocardiography with imaging is negative then repeat as clinically indicated or at least every 5 years
(5) Fire fighters with a Framingham Risk Score gt10 Risk calculator is available at [httphp2010nhlbihinnetatpiiicalculatorasp]
(6) Fire fighters identified in 9431
Negative stress tests should be repeated as clinically indicated or at least every 2 to 5 years
Interpreting stress tests as ldquopositiverdquo or ldquonegativerdquo is beyond the scope of this document However factors that should be taken into consideration should include the individualrsquos exercise capacity symptoms blood pressure response heart rate response EKG changes and the presence of arrhythmias (Gibbon et al 2002)
Risk factors for CAD include hypercholesterolemia (total cholesterol greater than 240 mgdL) hypertension (systolic greater than 140 andor diastolic greater than 90) smoking diabetes mellitus or family history of premature CAD (heart attack or sudden cardiac death in a first degree relative less than 60 years of age)
There are other non-invasive tests to screen for coronary artery disease One of the most promising appears to be coronary artery calcium (CAD) scoring by computed tomography In 2007 an expert committee published an update to their original guidance document The committeersquos consensus was that ldquoit may be reasonable to consider use of CAC measurement in such patients [between 10 and 20 10-year risk of estimated coronary event]helliprdquo The committee did not recommend CAC measurement in low risk patients [lt10 10-year risk of estimated coronary event] or in high risk patients [gt20 10-year risk of estimate coronary event] (Greenland et al 2007]
43
D22 Cardiology
Chobanian AV Bakris GL Black HR Cushman WC Green LA Izzo JL Jr Jones DW Materson BJ Oparil S Wright JT Jr Roccella EJ the National High Blood Pressure Education Program Coordinating Committee [2003] The seventh report of the Joint National Committee [JNC-7] on Prevention Detection Evaluation and Treatment of High Blood Pressure JAMA 2892560ndash2571
Gibbons RJ Balady GJ Bricker JT Chaitman BR Fletcher GF Froelicher VF Mark DB McCallister BD Mooss AN OrsquoReilly MG Winters WL Jr [2002] ACCAHA 2002 guideline update for exercise testing summary article a report of the ACCAHA Task Force on Practice Guidelines (Committee to Update the 1997 Exercise Testing guidelines) J Am Coll Cardiol 401531ndash 1540
Greenland et al [2007] ACCFAHA 2007 Clinical Expert Consensus Document on Coronary Artery Calcium Scoring By Computed Tomography in Global Cardiovascular Risk Assessment and in Evaluation of Patients With Chest Pain A Report of the American College of Cardiology Foundation Clinical Expert Consensus Task Force (ACCFAHA Writing Committee to Update the 2000 Expert Consensus Document on Electron Beam Computed Tomography) J Am Coll Cardiol 49378-402
Kales SN Tsismenakis AJ Zhang C Soteriades ES [2009] Blood pressure in fire fighters police officers and other emergency responders Am J Hypertens 2211-20
Schlant RC Adolph RJ DiMarco JP Dreifus LS Dunn MI Fisch C Garson A Jr Haywood LJ Levine HJ Murray JA Noble RJ Ronan JA Jr [1992] Guidelines for electrocardiography A report of the American College of CardiologyAmerican Heart Association Task Force on Assessment of Diagnostic and Therapeutic Cardiovascular Procedures (Committee on Electrocardiography) Circulation 85(3)1221-1228
Soteriades ES Kales SN Liarokapis D Christiani DC [2003] Prospective surveillance of hypertension in firefighters J Clin Hypertens 5315-320
Formatted Font Italic
Formatted Line spacing single
Formatted Font Italic
Formatted Font Italic
44
NFPA 1582‐ Draft Revisions for CVDHTN
EKG and stress tests
Reason for Revision
1) Change requirement for annual resting EKG to periodically to be more consistent with ACCAHA
recommendation (Schlant et al 1992)
2) Add language to clarify what constitutes a positive ST
3) Make criteria for conducting diagnostic ST in asymptomatic patients consistent with the
ACCAHA
Language in 2007 Edition with draft revisions in Red (Track changes)
776 Electrocardiograms (EKG) and Stress Tests 7761 A resting EKG shall be performed as part of the baseline medical evaluation and shall be obtained periodically (every 1 to 5 years) thereafter
A7761 A baseline resting EKGs shall be conducted Follow-up resting EKGs should be conducted as clinically indicated but at a minimum of every 1 to 5 years The frequency of these follow-up resting EKGs should increase as a members age increases or with increasing number andor severity of coronary heart disease risk factors Members above the age of 40 should have annual resting EKGs (Schlant et al 1992)
7762 The fire department physician or other qualified medical evaluator shall compare baseline and subsequent EKGs
7763 Stress testing with or without echocardiography or radionuclide scanning shall be performed as clinically indicated by history or symptoms
A7763 No firm guidelines for stress testing in asymptomatic individuals have been developed Stress testing as a screening tool is used as part of an evaluation of aerobic capacity during the annual occupational fitness evaluation Submaximal stress testing testing to 85 percent is commonly used as part of this screening
Submaximal stress testing should not be used for diagnostic purposes Cardiology evaluation with maximal stress testing together with imaging techniques (eg echocardiography technetium Tc99m sestamibi study) is necessary for diagnosticprognostic purposes for the following
(1) Fire fighters with positive or questionably positive changes on screening submaximal stress tests
(2) Fire fighters with new onset chest pain or other symptoms suggestive of coronary artery disease (CAD)
45
(3) Fire fighters with diabetes mellitus who
(a) are gt35 years old or
(b) have type I diabetes for more than 15 years or
(c) have type II diabetes for more than 10 years or
(d) have any other CHD risk factor (see below) or
(e) have the presence of microvascular disease (proliferative retinopathy)
(4) Fire fighters over the age of 45 (for men) and 55 (for women) with one or more risk factors for CAD Risk factors for CAD include hypercholesterolemia (total cholesterol greater than 240 mgdL) hypertension (systolic gt140 mmHg or diastolic gt90 mmHg) smoking or family history of premature CAD (heart attack or sudden cardiac death in a first degree relative less than 60 years of age)
(5) Fire fighters with a Framingham Risk Score gt10 Risk calculator is available at [httphp2010nhlbihinnetatpiiicalculatorasp]
(6) Fire fighters identified in 9431
Negative stress tests should be repeated as clinically indicated or at least every 2 to 5 years
Interpreting stress tests as ldquopositiverdquo or ldquonegativerdquo is beyond the scope of this document However factors that should be taken into consideration should include the individualrsquos exercise capacity symptoms blood pressure response heart rate response EKG changes and the presence of arrhythmias (Gibbon et al 2002)
There are other non-invasive tests to screen for coronary artery disease One of the most promising appears to be coronary artery calcium (CAD) scoring by computed tomography In 2007 an expert committee published an update to their original guidance document The committeersquos consensus was that ldquoit may be reasonable to consider use of CAC measurement in such patients [between 10 and 20 10-year risk of estimated coronary event]helliprdquo The committee did not recommend CAC measurement in low risk patients [lt10 10-year risk of estimated coronary event] or in high risk patients [gt20 10-year risk of estimate coronary event] (Greenland et al 2007]
D22 Cardiology
Resting EKG and Stress Tests
46
Chobanian AV Bakris GL Black HR Cushman WC Green LA Izzo JL Jr Jones DW Materson BJ Oparil S Wright JT Jr Roccella EJ the National High Blood Pressure Education Program Coordinating Committee [2003] The seventh report of the Joint National Committee [JNC-7] on Prevention Detection Evaluation and Treatment of High Blood Pressure JAMA 2892560ndash2571
Gibbons RJ Balady GJ Bricker JT Chaitman BR Fletcher GF Froelicher VF Mark DB McCallister BD Mooss AN OrsquoReilly MG Winters WL Jr [2002] ACCAHA 2002 guideline update for exercise testing summary article a report of the ACCAHA Task Force on Practice Guidelines (Committee to Update the 1997 Exercise Testing guidelines) J Am Coll Cardiol 401531ndash 1540
Greenland et al [2007] ACCFAHA 2007 Clinical Expert Consensus Document on Coronary Artery Calcium Scoring By Computed Tomography in Global Cardiovascular Risk Assessment and in Evaluation of Patients With Chest Pain A Report of the American College of Cardiology Foundation Clinical Expert Consensus Task Force (ACCFAHA Writing Committee to Update the 2000 Expert Consensus Document on Electron Beam Computed Tomography) J Am Coll Cardiol 49378-402
Kales SN Tsismenakis AJ Zhang C Soteriades ES [2009] Blood pressure in fire fighters police officers and other emergency responders Am J Hypertens 2211-20
Schlant RC Adolph RJ DiMarco JP Dreifus LS Dunn MI Fisch C Garson A Jr Haywood LJ Levine HJ Murray JA Noble RJ Ronan JA Jr [1992] Guidelines for electrocardiography A report of the American College of CardiologyAmerican Heart Association Task Force on Assessment of Diagnostic and Therapeutic Cardiovascular Procedures (Committee on Electrocardiography) Circulation 85(3)1221-1228
Soteriades ES Kales SN Liarokapis D Christiani DC [2003] Prospective surveillance of hypertension in firefighters J Clin Hypertens 5315-320
47
ATTACHMENT F
48
1
Current 1582 (2007) language in reference to pregnancy 43 (4) Report to the fire department physician any medical condition that could interfere with the ability of the individual to safely perform essential job tasks such as illness or injury use of prescription or nonprescription drugs and pregnancy 6112 Category B medical conditions shall include the following (1) Pregnancy for its duration A7792 (e) If HIV prophylaxis is to be given the following tests should be done i CBC ii Glucose renal and hepatic chemical function iii Pregnancy test for females B121 Pregnancy and Reproduction Federal regulations as well as many court decisions including the US Supreme Courtrsquos decision in International Union et al v Johnson Controls Inc [499 US 187 111 S Ct 1196 (1991)] have interpreted the requirements of Title VII with respect to pregnancy and reproduction The AHJ should seek the advice of counsel in resolving specific questions concerning these requirements as well as other requirements that can be imposed by state or local laws C211 (4) Review health status with the individual being evaluated Contraindications for evaluations shall be reviewed addressing any changes in the individualrsquos health status since their last medical evaluation that would warrant deferring the evaluation including (g) Pregnancy Recommendations to language enhancement
A female employee who is assigned to regular fire line duty shall report a pregnancy immediately to their respective Supervisor and the fire department physician The employee will then be given the option of a non-hazardous alternative duty position for the duration of her pregnancy (can we say this or is it even appropriate) Any pregnant employee wishing to remain on regular line duty shall be informed of the possible risks and consequences to herself and her fetus that are associated with continued line fire fighting duty Among those risk factors are exposure to teratogens known to have negative effects on the developing fetus such as smoke diesel fumes hazardous chemicals and extreme heat
49
Page 2
appendix It is recommended that the pregnant employee complete a release of liability form signed by herself and her health care provider utilizing NFPArsquos 13 critical tasks as a reference This will inform the health care provider of specific job-related tasks that will need to be performed in order to continue regular line duty These tasks are basic physical standards that any entry level firefighter would have to be able to complete competently The employeersquos health condition will be kept confidential by the department in accordance with HIPAA standards Employees are allowed to remain on active regular duty until they are no longer able to perform their duties in a reasonable manner andor their protective gear no longer fits correctly It is the responsibility of the health care provider to evaluate the pregnant employee If at any time the health care provider feels the pregnant employee can no longer perform the job related tasks this should be reported to the employer by the employee immediately
50
ATTACHMENT G
51
From GLENN BENARICKTo Sawyer SteveSubject RE RE 7743Date Monday August 30 2010 21633 PM
Yes thats my understanding
Glenn P Benarick 211 Winged Elm CircleAiken SC 29803803-644-7093gbenarprodigynet
--- On Mon 83010 Sawyer Steve ltssawyerNFPAorggt wrote
From Sawyer Steve ltssawyerNFPAorggtSubject RE RE 7743To GLENN BENARICK ltgbenarprodigynetgtDate Monday August 30 2010 212 PM
So it should be ldquoorrdquo instead of ldquoandrdquo for now
Steven F Sawyer
Senior Fire Service Specialist
Executive Secretary IFMAFire Service Section
NFPA
1 Batterymarch Park
Quincy MA 02169
6179847423
Fax 6179847056
ssawyernfpaorg
From GLENN BENARICK [mailtogbenarprodigynet] Sent Monday August 30 2010 1202 PMTo Sawyer SteveSubject Fw RE 7743
52
Steve a couple of our docs agree with April Boyer
Glenn P Benarick 211 Winged Elm Circle
Aiken SC 29803
803-644-7093
gbenarprodigynet
--- On Mon 83010 David Prezant ltprezandfdnynycgovgt wrote
From David Prezant ltprezandfdnynycgovgtSubject RE 7743To Thomas R (CDCNIOSHDSHEFS) Hales lttrh1cdcgovgt GLENNBENARICK ltgbenarprodigynetgtCc Sandy Bogucki ltsandyboguckiyaleedugtDate Monday August 30 2010 1004 AM
agree
we should change this to NHANES III rather than Knudson we should alsomodify this to allow not only for predicted cutoffs but all for use of thelower limit of normal cutoff This is important to prevent false-classificationof spirometry as abnormal in older groups and in taller grps The latter ofparticular import to firefighter occupational health surveillance
thanks
David Prezant MDChief Medical Officer Office of Medical AffairsCo-Director WTC Medical Monitoring amp Treatment ProgramsNew York City Fire Department9 Metrotech Center - Rm 4W-1Brooklyn NY 11201Phone 718-999-2696Fax 718-999-0665
Life is full of twists and turns
53
This email may contain confidential information If you are the unintendedrecipient of this email please send it back and delete from your directory
gtgtgt Hales Thomas R (CDCNIOSHDSHEFS) lttrh1cdcgovgt 8302010955 AM gtgtgt
Glen
This seems like a very reasonable comment and illustrates the importance of having clinicians providefeedback on the std Im not familiar with the software program of the various spirometers (NHANES IIIvs KnudsonATS vs both) Given the large role both Dave Prezant and Sandy Bogucki had for thepulmonary section let me forward to them for clarification
Tom
From GLENN BENARICK [mailtogbenarprodigynet] Sent Sunday August 29 2010 456 PMTo Hales Thomas R (CDCNIOSHDSHEFS)Subject FW 7743
Tom is April Boyer correct
Glenn P Benarick 211 Winged Elm Circle
Aiken SC 29803
803-644-7093
gbenarprodigynet
--- On Thu 82610 Sawyer Steve ltssawyerNFPAorggt wrote
From Sawyer Steve ltssawyerNFPAorggtSubject FW 7743To GLENN BENARICK ltgbenarprodigynetgtDate Thursday August 26 2010 925 PM
FYI Do you have any answer She is write
Steven
54
Steven F Sawyer
Senior Fire Service Specialist
Executive Secretary IFMAFire Service Section
NFPA
1 Batterymarch Park
Quincy MA 02169
6179847423
Fax 6179847056
ssawyernfpaorg
From April Boyer [mailtoaboyerbicclinicorg] Sent Thursday August 26 2010 232 PMTo Sawyer SteveCc RobinMWebbmilstateorusSubject 7743
Steven
The spirometry tests cannot be corrected according to both references as the NFPA states because thereferences are contradictory The first part of 7743 states to follow the ATS guidelines and use theKnudsen (we at Basin Immediate Care use the Nhanes III) The second part states to follow the ACOEMguidelines and use the Nhanes III in the occupational setting if available with your unit (which is availableon ours) 7743 does not use the word OR regarding both requirements it uses the word AND whenreferring to the first and second parts thence making 7743 contradictory I realize the NFPA 1582 hasnot been updated since 2007 unless I have just not received an updated version
Our question to you is which part of 7743 do you want us to follow the first or the second part Anyfacility that has an updated computerized spirometry system (as we do) will not be able to follow bothrequired parts for obvious reasons We can either follow the first part of 7743 and use an oldercorrected version of the Knudson by going into our system and changing out of the Nhanes III conversionOR we can follow the second part of 7743 and use the newer corrected version of Nhanes III which ourunit offers too
If you have any questions you may contact me at anytime and I also have many references in regards toboth parts of 7743 if you would like to see them
55
Thank you~
April
Confidentiality NoticeThis message may contain information that isconfidential or privileged
If you are not the intended recipientPlease advise the sender immediately and delete this message
56
ATTACHMENT H
57
NFPA 1582 771(7) Proposed revisions
Why
Preliminary results of two prospective randomized trials on the PSA test were published in 2009 These studies resulted in medical organizations that previously providing guidance to modify their recommendations
Current language
771 Blood Tests Blood tests shall be performed annually and shall include the following
(7) Prostate specific antigen (PSA) after age 40 for positive family history if African American or if otherwise clinically indicated after age 50 for all other male member
Suggested Revision
771 Blood Tests Blood tests shall be performed annually and shall include the following
(7) Prostate specific antigen (PSA) after age 40 for positive family history if African American or if otherwise clinically indicated after age 50 for all other male member
772 Prostate-Specific Antigen (PSA) test At age 50 fire fighters shall have an opportunity to make an informed decision with either the Fire Department physician or their health care provider concerning the PSA test For fire fighters at increased risk of prostate cancer (African-Americans or those with a first degree relative diagnosed with prostate cancer before age 65) shall have the opportunity for this informed decision at age 40
A772 The PSA as a screening test for prostate cancer in asymptomatic men is controversial controversial for two reasons First there is no consensus that PSA screening actually saves lives For example the PSA test may detect small cancers that would never become life threatening Second it is unclear that the benefits of PSA screening outweigh the risks of follow-up diagnostic tests and cancer treatments For example the prostate biopsy used to diagnose prostate cancer may cause bleeding and infection And prostate cancer treatments such as surgery and radiation therapy may cause incontinence (inability to control urine flow) erectile dysfunction (erections inadequate for intercourse) and other complications For these reasons it is important that the benefits and risks of prostate diagnostic procedures and treatment be taken into account when considering the PSA screening test These considerations can be taken account during discussions with the fire department physician or onersquos health care provider
D211 Cancer Screening
Smith R A C J Mettlin K J Davis and H Eyre 2000 ldquoAmerican Cancer Society guidelines for the early detection of cancerrdquo CA J Clin 50(1)34ndash49
Added references
58
Carroll P Albertsen PC Greene K et al [2010] Prostate-specific antigen best practice statement 2009 update Am Urological Assoc Available at httpwwwauanetorgcontentguidelines-and-quality-careclinical-guidelinesmain-reportspsa09pdf Date accessed September 2010
Ferrini R Woolf SH [2009] Screening for prostate cancer in American men American College of Preventive Medicine Practice Policy Statement Available at httpwwwacpmorgprostatehtm Date accessed September 2010
National Cancer Institute [2009] Prostate-specific antigen test National Cancer Institute Fact Sheet Available at httpwwwcancergovcancertopicsfactsheetDetectionPSA Date accessed September 2010
Wolf AMD Wender RC Etzioni RB et al [2010] American Cancer Society guideline for the early detection of prostate cancer Update 2010 Available at httpcaonlineamcancersocorgcgicontentfullcaac20066v1 Date accessed September 2010
59
ATTACHMENT A
2
Address List 9172010
Fire Service Occupational Safety and Health FIX-AAAKenneth Willette
Glenn P Benarick
FIX-AAAChair211 Winged Elm Circle
Aiken SC 29803
NFPA Fire Service SectionAlternate Murrey E Loflin
PhoneCell 803-644-7093
FaxEmail gbenarprodigynet
U 1011992 Murrey E Loflin
FIX-AAASecretary (Alternate)West Virginia University
Fire Service Extension
West virginia State Fire Academy
2600 Old Mill Road
Weston WV 26452-8077
NFPA Fire Service SectionPrincipal Glenn P Benarick
PhoneCell 304-293-8288 304-276-2843
Fax 304-293-2107
Email meloflinmailwvuedu
U 411993
Donald Aldridge
FIX-AAAPrincipalLion Apparel Inc
6450 Poe Avenue Suite 300
Dayton OH 45414
Alternate Andrew G SchwartzPhoneCell 937-415-2801 937-212-0206
Fax 937-913-5545
Email daldridgelionapparelcom
M 111985 David J Barillo
FIX-AAAPrincipalUniversity of Florida College of Medicine
PO Box 100286
Gainesville FL 32610-0286
PhoneCell 352-265-0262
FaxEmail dbarilloearthlinknet
SE 1122000
Lawrence T Bennett
FIX-AAAPrincipalUniverity of Cincinnati
Fire Science Department
2220 Victory Park Way ML 0103
Room 301
Cincinnati OH 45206-2837
PhoneCell 513-556-6583
Fax 513-556-4856
Email lawrencebennettucedu
SE 7232008 Paul Blake
FIX-AAAPrincipalCity of Baytown Fire amp Rescue Services
201 East Wye Drive
Baytown TX 77521
Industrial Emergency Response Working GroupPhoneCell 281-420-5329
Fax 281-420-5367
Email shonblakebaytownorg
E 4171998
Sandy Bogucki
FIX-AAAPrincipalYale University Emergency Medicine
464 Congress Avenue Suite 260
New Haven CT 06519-1315
PhoneCell 203-785-6159
Fax 203-785-3196
Email sandyboguckiyaleedu
SE 711996 Dennis R Childress
FIX-AAAPrincipalOrange County Fire Authority
PO Box 75003
San Clemente CA 92673-0167
California State Firefighters AssociationPhoneCell 949-218-7441
Fax 949-218-7499
Email den4fireaolcom
U 711993
13
Address List 9172010
Fire Service Occupational Safety and Health FIX-AAAKenneth Willette
Dominic J Colletti
FIX-AAAPrincipalHale Products Inc
700 Spring Mill Avenue
Conshohocken PA 19428
Fire Apparatus Manufacturers AssociationAlternate Leroy B Coffman III
PhoneCell 610-940-2437
Fax 610-825-6440
Email dcollettiidexcorpcom
M 4171998 Thomas J Cuff Jr
FIX-AAAPrincipalFiremens Association of the State of New York
127 Shelter Lane
Levittown NY 11756-1218
PhoneCell 516-735-4081 516-351-0942
Fax 516-579-9063
Email tomc621aolcom
U 10101997
Michael L Finkelman
FIX-AAAPrincipal182 Melanie Drive
East Meadow NY 11554
Association of Fire DistrictsState of New YorkPhoneCell 516-579-7570 516-369-8648
Fax 516-542-0593
Email mikexx00aolcom
U 7282006 Stephen N Foley
FIX-AAAPrincipalUS Department of Homeland Security
US Fire Administration
16825 South Seton Avenue
Emmitsburg MD 21727
PhoneCell 301-447-1304
Fax 301-447-1178
Email stephenfoleydhsgov
SE 1042007
Thomas Hillenbrand
FIX-AAAPrincipalUnderwriters Laboratories Inc
333 Pfingsten Road
Northbrook IL 60062-2096
Alternate Steven D CorradoPhoneCell 847-664-2603
Fax 847-313-2603
Email thomasahillenbrandusulcom
RT 7241997 Scott D Kerwood
FIX-AAAPrincipalHutto Fire Rescue
501 Exchange
PO Box 175
Hutto TX 78634
International Association of Fire ChiefsAlternate Brett R Bowman
PhoneCell 512-759-2616 512-413-1404
Fax 512-846-1946
Email sdkerwoodhuttofirerescueorg
E 711995
Jonathan D Kipp
FIX-AAAPrincipalPrimex
3
46 Donovan Street
Concord NH 03301
PhoneCell 603-225-2841
Fax 603-228-3905
Email jkippnhprimexorg
I 111989 Steve Kreis
FIX-AAAPrincipalCity of Phoenix Fire Department
150 South 12th Street
Phoenix AZ 85034-2301
PhoneCell 602-495-5848
Fax 602-262-4429
Email stevelkreisphoenixgov
E 1032002
24
Address List 9172010
Fire Service Occupational Safety and Health FIX-AAAKenneth Willette
Michael A Laton
FIX-AAAPrincipalSperian Protective Apparel
160 Woodstream Way
Fayetteville GA 30214
International Safety Equipment AssociationPhoneCell 770-861-0350
FIX-AAANonvoting MemberNational Institute for Occupational Safety amp Health
4676 Columbia Parkway R-9
Cincinnati OH 45226
Alternate Jay L TarleyPhoneCell 513-841-4583
Fax 513-844-4488
Email thalescdcgov
RT 452001
William R Hamilton
FIX-AAANonvoting MemberUS Department of Labor
Occupational Safety amp Health Administration
200 Constitution Ave NW Room N3609
Washington DC 20210
Alternate Andrew LevinsonPhoneCell 202-693-2077
Fax 202-693-1663
Email hamiltonbilldolgov
E 342009 Andrew Levinson
FIX-AAAAlt to Nonvoting MemberUS Department of Labor
Occupational Safety amp Health Administration
200 Constitution Ave NW Room N3718
Washington DC 20210
Occupational Safety amp Health AdministrationPrincipal William R Hamilton
PhoneCell 202-693-2048
Fax 202-693-1678
Email levinsonandrewdolgov
E 7282006
Jay L Tarley
FIX-AAAAlt to Nonvoting MemberUS Department of Health amp Human Services
National Institute for Occupational Safety amp Health
1095 Willowdale Road MS 1808
Morgantown WV 26505
Principal Thomas R HalesPhoneCell 304-285-5858
Fax 304-285-5774
Email jst9cdcgov
RT 3152007 Kenneth Willette
FIX-AAAStaff LiaisonNational Fire Protection Association
1 Batterymarch Park
Quincy MA
PhoneCell 617-984-7299
Fax 617-984-7056
Email kwillettenfpaorg
792010
68
ATTACHMENT B
9
Technical Committee on Fire Service Occupational Safety and Health
Meeting Minutes May 13 ndash 14 2010
Holiday Inn Inner Harbor MD
Attendees Glenn Benarick Chairman Ken Holland Staff Liaison Michael Finkelman Craig Fry Joe Rivera Stephen Raynis Steve Kreis Dennis Childress Don Stewart Phil Stittleburg David Ross Michael Laton Kim Zagaris Tom Hillenbrand Dominic Colletti Andy Schwartz Brett Bowman Guest David Bernzweig Thursday May 13 NFPA 1500 task groups (Vehicle amp Safety OPS SCBA amp Air Mgt PPEProximity) met to discuss the work they have completed since the last meeting The task groups will present their report to the entire TC on May 14th Not enough 1582 task group members were able to make the meeting so there were no reports or work from those task groups Friday May 14 TC meeting called to order at approximately 0800 by Glenn Benarick TC Chair Ken Holland (NFPA Public Fire Protection Staff) in attendance filling in for Frank Florence Ken made two presentations one on the Codes and Standards Development Process and the other on the general procedures for this Pre-ROP meeting The Staff Liaison remains fluid as Frank is not expected back any time soon
10
One guest in attendance Dave Bernzweig (Columbus OH Fire) Dave is assisting TC with SCBAAir Mgt issues The document revision cycles remain as requested NFPA 1500 amp 1582 Annual 2012 NFPA 1521 amp 1561 Fall 2013 NFPA 1581 1583 1584 Annual 2014 The October 7-9 2010 dates are the primary request for our next meeting Location is San Diego Notice will be sent out as soon as approval is received Discussion on the next revision of 1561 will be held at the October meeting regarding changing the document title to ldquoCommand Safety for Fire Department Operationsrdquo This is a suggestion of the TC Chair Ken Holland conducted a briefing for the TC on how to access and use the committee web page Staff will be posting as much information as possible up on the e-committee page for the entire committee More use will be made of this tool Discussion on monocular vision Dennis Childress presented the current issue in Ventura County CA Further discussionwork may be necessary Don Stewart agreed to take the lead Brief discussion held on pregnancy and the need for fire departments to ensure policies match current law The rep from the Diabetes Association declined the invitation to participate at this meeting due to no discussion of the issue planned She has indicated a desire to attend the October meeting There were no reports from these and all other 1582 task groups It is very important for the 1582 TG Chairs to be ready to report in October The following task group reports will be posted on the ecommittee page PPEProximity New definition of proximity fire fighting
VehicleHighway OPS Discussion on use of vehicle data recorders Collapse Zones Submission from Jay Tarley SCBAAir Mgt New exit strategy for SCBA Discussion on having the low air alarm activate when the bottle volume reaches 600 liters Further discussion to take place on ldquobuddy breathingrdquo
On Day 2 Casey Grant (NFPA Fire Protection Research Foundation) made a presentation on Research Planning for FSOSH Dr Ellen Sogolow (DHSFEMA) also present during this presentation She discussed the role of the AFGRampD activities See ecommittee page for his presentation Chair
11
will be in contact with Mr Grant for future work between the TC and the Foundation Also on Day 2 Ken Willette (Division Manager ndash NFPA Public Fire Protection Division) delivered a presentation on the initiative developed by Kelvin Cochran (US Fire Administrator) to reduce fire fighter injuries and deaths NFPA 1500 is an integral part of this initiative See ecommittee page for presentation The Chair will be coordinating a committee conference call in the coming weeks The purpose will be to review the work which needs to be completed for the October meeting The primary focus of the call will be on 1582 issues NOTE Subsequent to the meeting I have had some discussions with a fire chief in Kentucky on the use of hearing aids The TC especially the doctors need to review the current language in 1582 and decide if revisions are needed Also most of you know that Kelvin Cochran has left the USFA unexpectedly to return to Atlanta as their fire chief I have been in contact with the Acting Administrator Glenn Gaines to inform him that our committee remains focused on the work to reduce fire fighter injuries and deaths I told him that I would keep him informed of our work He indicated that one of his primary goals is to bring fire service organizations together in order to create a safe working environment Of particular interest to him is reducing heart related injuries and deaths Submitted by Glenn Benarick
12
Technical Committee on Fire Service Occupational Safety and Health
Conference Call Meeting Minutes August 30th 2010
Members participating
Glenn Benarick TC Chair
Murrey Loflin Secretary Dr Sandy Bogucki
Thomas Cuff Stephen Foley
Scott Kerwood Tammy Lopes
David Love Dr David Prezant
Joe Rivera David Ross
Mario Rueda Phil Stittleburg
Phil Vorlander Dominic Colletti
Thomas Hillenbrand
Denise Smith Brett Bowman Alternate
Andrew Schwartz Alternate Mike Young Alternate
Dr Thomas Hales Non-Voting Member Ken Holland NFPA Staff Liaison
Casey Grant NFPAResearch Foundation Staff Katie Hathway Guest from ADA
Dr Jim Fleming Guest from Phoenix Fire Dept
The chair welcomed everyone to the conference call in which he hoped
would last only an hour The purpose was to discuss any task groups that had reports for proposed changes to NFPA 1582 for the
committee This is in hopes to ensure the committee is ready for their
pre-ROP meeting in October The following topics were discussed and are in no specific order
Comments from ADA Katie Hathaway and the group went into deep
discussion regarding ones medical history and diagnosis of diabetes
13
and some proposed changesremoval of text based on research
findings The specific proposed changes will be available for the committee at their next meeting Some members on the call felt that
this issue was covered in another law enforcement document which might better serve this issue
Research topics for FSOSH projects Casey Grant offered his time to
answer any questions regarding his presentation from the May meeting in Baltimore There was also discussion about further
involvement of the Research Foundation with this committee and some of the medical requirements within the documents Glenn and Casey
are going to be in contact offline to discuss this further
Prosthetics amp Amputees report Nothing new to report
Heart amp Hypertension report There was discussion about the need for
periodic EKGrsquos that were done both in resting and non-resting states as well as discussion about stress test requirements and frequency of
such tests The hopes were to develop text that would point to annual versus periodic evaluations of EKGrsquos and stress tests
Epilepsy report Nothing new to report
Pregnancy report The initial textlanguage has been provided to the
group through email and e-committee page posting
Coagulation amp Meds report Nothing new to report
Hearing Aid discussion Nothing new to report
The committee also discussed the evaluation and documentation of
PSA results and test requirements for the purposes of consistency The proposed text and changes have been posted on the e-committee
page as well
All of the proposed text changes from the May meeting in Baltimore have been emailed out and posted on the e-committee page If there
are any questions or concerns that something was missed please contact Glenn Steven Sawyer or Ken Holland to ensure they are
resolved
The conference call lasted approximately an hour and was adjourned at 1400 hours
14
ATTACHMENT C
15
2012 ANNUAL REVISION CYCLE
PROCESS STAGE PROCESS STEP DATES
FOR TC DATES
FOR TCC 1 PRELIMINARY 10 Notification of intent to enter cycle 7910 7910
2 REPORT ON
PROPOSALS (ROP)
21 Proposal closing date 112310 112310 22 Final date for ROP meeting 22511 2411 23 Final date for mailing TC ballots 31811 21811 24 Receipt of (TC) ballots by staff liaison 42211 31111 25 Receipt of TC recirculation ballots 5611 31811 26 Final date for TCC meeting 41511 27 Final date for mailing TCC ballots 42211 28 Receipt of TCC ballots 51311 29 Receipt of TCC recirculation ballots 52011 210 Final copy (w ballot statements) to Secretary Standards Council 51311 52711 211 Completion of Reports 52011 6311 212 ROP Published and Posted 62411 62411
3 REPORT ON
COMMENTS
(ROC)
31 Comment closing date 83011 83011 32 Final date for ROC meeting 11411 10711 33 Final date for mailing TC ballots 111811 102111 34 Receipt of (TC) ballots by staff liaison 12211 111111 35 Receipt of TC recirculation ballots 12911 111811 36 Final date for TCC meeting 121611 37 Final date for mailing TCC ballots 122311 38 Receipt of TCC ballots 11312 39 Receipt of TCC recirculation ballots 12012 310 Final copy (w ballot statements) to Secretary Standards Council 122311 12712 311 Completion of Reports 11312 2312 312 ROC Published and Posted 22412 22412
4 TECH SESSION
PREPARATION amp
ISSUANCE OF
CONSENT
DOCUMENTS
41 Notice of Intent to Make a Motion (NITMAM) Closing Date 4612 4612 42 Posting of Filed NITMAM 5412 5412
43 Council Issuance Date for Consent Documents 52912 52912
44 Appeal Closing Date for Consent Documents 61312 61312
5 TECHNICAL
SESSION 50 Association Meeting for Documents with Certified Amending Motions
64-712 64-712
6
APPEALS amp
ISSUANCE OF
DOCUMENTS
WCAMS
61 Appeal closing date for Documents with Certified Amending Motions
62712 62712
62 Council issuance for Documents with Certified Amending Motions 8912 8912
Proposal Closing Dates may vary according to documents and schedules for Revision Cycles may change Please check the NFPA website (wwwnfpaorg) for the most up-to-date information on proposal closing dates and schedules
16
ATTACHMENT D
17
This weekrsquos conference call mentioned the Diabetes chapter written for the ACOEM document Guidance for the Medical Evaluation of the Law Enforcement Officer The task group working on this chapter (led Richard Miller of the Secret Service and our very own Dan Samo) worked with the ADA or over 2-3 years to come up with a consensus document
Please find the Chapter attached ltltDiabetes Guidance Sept 2010pdfgtgt
Regarding Dan Loeberrsquos points
1) Physical Evaluation Form - We could modify the LEO form (see end of the attached Chapter)
2) Duration required for stable regiment
1582 for IDDM Type 1 1 yr
Type 2 6 m
Oral Agents None specifically
ACOEM Police for IDDM Type 1 6m
Type 2 3m
Oral Agents 1m
The police document is much clearer about the decision regarding medical fitness for duty is the responsibility of the police physician with the treating diabetes-expert physician providing the data to the police physician to make an informed decision In this regard the police officer must provide the police physician with downloaded self monitoring glucose data for the 1 3 and 6 month time periods (see section 433)
3) HA1C ndash NFPA lt 8 over 3 month period
ACOEM Police ndash (Section 4333) Specifies the frequency on measurement and if gt8 requires further evaluation
Some other discrepancies End organ complications
NFPA ndash end organ complications (eye kidney heart neuro) ndash restriction
ACOEM Police ndash end organ complication -- requires further evaluation
18
Hypoglycemia (incapacitating ndash defined differently between the two documents (434)
NFPA ndash 0 episodes in past year le1 in past 5 yrs
ACOEM Police ndash 0 episodes in past year le2 in past 3 yrs
Given Dan Samorsquos and Richard Millerrsquos work with the ADALoeber it would be helpful to get their opinions on whether any of the changes requested by Loeber are appropriate for FF with DM
Tom
Thomas Hales MD MPH
Senior Medical Epidemiologist
NIOSH CDC
4676 Columbia Pkwy R-9
Cincinnati OH 45241
(513) 841-4583
trh1cdcgov
19
43 ndash DIABETES MELLITUS
431 ndash INTRODUCTION
The educated and motivated law enforcement officer (LEO) with well-managed diabetes mellitus can be capable of
safe and effective job performance1 However diabetes mellitus may place LEOs at risk for sudden incapacitation
thus jeopardizing their ability to perform critical job functions (These job functions include those listed in Sections
32 333 351 352 36 and 37 and discussed in Appendix A)
Therefore an individualized assessment of the LEOrsquos diabetes should be performed using the following evaluative
criteria to determine whether the individuals condition permits safe and effective job performance Such evaluation
must include the following key elements which are discussed in detail below
history of blood glucose control
knowledge of diabetes and its management
current stability of blood glucose
risk for significant hypoglycemia or hyperglycemia and
presence of diabetic complications
432 ndash OVERVIEW OF MEDICAL EVALUATION
The treating endocrinologist or other physician knowledgeable regarding diabetes management should provide
a narrative report certifying whether the LEO has or has not met the criteria set out in Sections 4321 through
4354 below In addition the physician should include supporting data (see Appendix B for the Physician Evalu-
ation Form)
4321 The LEO is under the care of an endocrinologist or other physician knowledgeable regarding diabetes
management Outpatient and in-patient medical record(s) for the last 3 years or since date of diagnosis
(whichever is shorter) should be reviewed by the treating physician and provided to the police physician
4322 If the LEO has type 1 diabetes the individual has been on a basalbolus regimena or an insulin pump
using analogue insulins for the 6 months prior to evaluation2
4323 If the LEO has type 2 diabetes on insulin the individual has been on a stable medication regimenb
for the 3 months prior to evaluation3 If on oral agents alone the LEO has been on a stable medication regimen
for the month prior to evaluationc
ACOEM Guidance for the Medical Evaluation of Law Enforcement Officers 1
43 ndash DIABETES MELLITUS
aA basalbolus insulin regimen consists of the use of a basal insulin (Glargine NPH) in a once or twice daily regimen to provide between-
meal insulin combined with the use of a short acting insulin (Regular Lispro Aspart or Glulisine) at mealtimes Insulin pumps are small
(beeper sized) battery powered devices that deliver small amounts of short-acting insulin in a constant infusion to meet basal insulin
requirements The wearer selects an additional mealtime bolus to be infused at the time of meals For more information on pumps visit
the manufacturerrsquos web sites ndash wwwMinimedcom wwwcozmorecom wwwanimascorpcom wwwdisetroniccom
bA stable insulin regimen is defined as maintaining the same types of insulin (long acting intermediate acting short or rapid acting)
Changes in insulin dose are part of the appropriate self-management of diabetes and do not disqualify an applicant or incumbent under
this section
cChanges in dose within the evaluation period will be allowed but addition of a new class of medications or insulin should result in a new
period of observation
one month for addition of a sulfonylurea or metformin
two months for the addition of a thiazolidinedione to insulin or a sulfonylurea or
three months for the addition of insulin
20
4324 If the LEO uses an insulin pump documentation is needed as follows
proper understanding and education in the use of the insulin pump
start date for the use of the pump
history of insulin site infectionsd
history of pump cessation and pump malfunction
backup plan for pump malfunction including use of injectable insulin and
frequency of infusion set changes
4325 The LEO has been educated in diabetes and its management and thoroughly informed of and under-
stands the procedures that must be followed to monitor and manage hisher diabetes and what procedures
should be followed if complications arise3
433 ndash QUANTITATIVE GLUCOSE MONITORING
4331 The LEO has documentation of ongoing self-monitoring of blood glucose
4332 This must be done with a glucose meter that stores every reading records date and time of reading
and from which data can be downloaded (Most meters now have this capability)
4333 Monitoring logs must be available covering the time period (1 3 or 6 months) as described in
Sections 4322 and 4323 The frequency of glucose monitoring must follow a schedule acceptable to the
police physician in consultation with the treating physician
Testing schedules are individual What follows is a common pattern but individual patterns may differ
2 ACOEM Guidance for the Medical Evaluation of Law Enforcement Officers
43 ndash DIABETES MELLITUS
dIndividual has not had more than one pump-site infection that caused him or her to miss work or usual daily activities in the preceding 6
months
THERAPEUTIC REGIMEN GLUCOSE TESTING SCHEDULE
Diet alone Once or twice a week
Metformin Thiazolidinediones or Alpha
Glucosidase inhibitors alone or in
combination
Once or twice a week
Sulfonylureas meglitanides nateglinide ndash
alone or in combination with the above group
Twice a day ndash AM and at supper with any
suspected hypoglycemic episodes
Insulin ndash one shot in combination with orals Twice a day ndash AM and at supper with any
suspected hypoglycemic episodes
2 to 3 times AM once a week
Insulin ndash two or more shots Insulin pump 3 to 4 times a day ndash at meals and bedtime
2 to 3 times AM once a week with any
suspected hypoglycemic episodes
21
4334 The LEO has had hemoglobin A1C measured at least 4 times a year (intervals of 2 to 3 months) over
the last 12 months prior to evaluation if diagnosis has been present for more than a year4 If hemoglobin A1C is
gt8 this may signal a problem with the LEOrsquos diabetes management that warrants further assessment5
434 ndash INCAPACITATING EVENTS
4341 The LEO has not had any incapacitating episodes within the past 1 year and no more than 2 episodes
in the past 3 years or since diagnosis of diabetes (whichever is shorter) of
43411 Severe hypoglycemia (loss of consciousness seizures or coma requiring assistance of others or
needing urgent treatment [glucagon injectionIV glucose]) or
43412 Blood sugar lt60 mgdl with unawareness demonstrated in current glucose logs6
435 ndash CHRONIC COMPLICATION SCREENING
4351 Chronic complications of diabetes are associated with increased risk for severe hypoglycemic
episodes and warrant further assessmente
4352 The components of screening for chronic complications are
43521 A complete eye exam by a qualified ophthalmologist or optometrist including a dilated retinal
exam demonstrating no more than mild background diabetic retinopathyf7
43522 Normal vibratory testing with a 128 Hz tuning forkg normal testing with 10 gram Semmes-
Weinstein monofilamentg and normal orthostatic blood pressureh and pulse testing89
ACOEM Guidance for the Medical Evaluation of Law Enforcement Officers 3
43 ndash DIABETES MELLITUS
ePresence of chronic complications of diabetes in and of themselves may not require the implementation of work restrictions
fNo more than one dot blot or flame-shaped hemorrhages or microaneurysm in all four fundus quadrants
gThe Michigan Diabetes Research and Training Center of the University of Michigan Health System recommends the following guidance
(see wwwmedumichedumdrtcprofsdocumentssviMNSI_howtopdf) for conducting vibratory and monofilament testing8
Vibration Sensation Vibration sensation should be performed with the great toe unsupported Vibration sensation will be tested bi-
laterally using a 128 Hz tuning fork placed over the dorsum of the great toe on the boney prominence of the DIP joint Patients whose
eyes are closed will be asked to indicate when they can no longer sense the vibration from the vibrating tuning fork In general the
examiner should be able to feel vibration from the hand-held tuning fork for 5 seconds longer on his distal forefinger than a normal subject
can at the great toe (eg examiners DIP joint of the first finger versus patients toe) If the examiner feels vibration for 10 or more seconds
on his or her finger then vibration is considered decreased A trial should be given when the tuning fork is not vibrating to be certain that
the patient is responding to vibration and not pressure or some other clue Vibration is scored as 1) present if the examiner senses the
vibration on his or her finger for lt10 seconds 2) reduced if sensed for 10 seconds or 3) absent (no vibration detection)
Monofilament Testing For this examination it is important that the patients foot be supported (ie allow the sole of the foot to rest on
a flat warm surface) The filament should initially be pre-stressed (4-6 perpendicular applications to the dorsum of the examiner s first
finger) The filament is then applied to the dorsum of the great toe midway between the nail fold and the DIP joint Do not hold the toe
directly The filament is applied perpendicularly and briefly (lt1 second) with an even pressure When the filament bends the force of
10 grams has been applied The patient whose eyes are closed is asked to respond yes if heshe feels the filament Eight correct responses
out of 10 applications is considered normal 1 to 7 correct responses indicates reduced sensation and no correct answers translates into
absent sensation
hOrthostatic hypotension is a physical finding defined by the American Autonomic Society and the American Academy of Neurology as a
systolic blood pressure decrease of at least 20 mm Hg or a diastolic blood pressure decrease of at least 10 mm Hg within 3 minutes of
standing
22
43523 Normal cardiac physical exam Cardiac stress testing to at least 12 METS is recommended and
should begin based on either the criteria of the American Heart AssociationAmerican College of
Cardiologyi10 or those of the American Diabetes Associationj11
Diabetics who have a normal cardiac stress test will be retested every one to three years based on
individual clinical assessment This assessment should consider
the age of the individual
the number and persistence of coronary artery disease (CAD) risk factors
the severity of CAD risk factors
43524 Microalbumincreatinine ratio 301 measured or calculatedk creatinine clearance
gt60 mlmin12
436 ndash ONGOING EVALUATION AND REQUIREMENTS
4361 Should have medical records and glucose meter logs reviewed periodically Because of the nature of
diabetes it is important that regular medical follow up be provided to the LEO The frequency and content of
the evaluation should be determined on an individual basis by the police physician in consultation with the
treating physicianl
4362 Must advise police physician of any change in type of medication
4363 Must advise police physician of any episodes of significant hypoglycemia or hyperglycemia
Urine microalbumincreatinine ratio _________________
III Treating Physician Statement
The above named individual meets all of the criteria provided on this form
Yes No ndash not recommended for position
No but IS recommended for position (letter of explanation attached)
It is my opinion that the above named individual is well-educated and well-motivated in diabetes self-management and has
achieved a level of diabetes management to be capable of safe and effective job performance as a law enforcement officer
I have reached this opinion after careful review of the above criteria
___________________________________________________________ ___________________________Signature of Physician Date
______________________________________________________________ ___________________________Printed or Typed Name of Physician Telephone Number
10 ACOEM Guidance for the Medical Evaluation of Law Enforcement Officers
43 ndash DIABETES MELLITUS
29
439 ndash REFERENCES
1 American Diabetes Association Diagnosis and classification of diabetes mellitus Diabetes Care 200427 Suppl
1S5-S10 See httpcarediabetesjournalsorgcgicontentfull27suppl_1s5
2 American Diabetes Association Continuous subcutaneous insulin infusion Diabetes Care 200427 Suppl 1S110
See httpcarediabetesjournalsorgcgicontentfull27suppl_1s110
3 Mensing C Boucher J Cypress M et al National standards for diabetes self-management education Diabetes
Care 200528 Suppl 1S72-9 See httpcarediabetesjournalsorgcgicontentfull28suppl_1s72
4 Goldstein DE Little RR Lorenz RA Malone JI Nathan DM Peterson CM American Diabetes Association Tests
of glycemia in diabetes Diabetes Care 200427 Suppl 1S91-3
See httpcarediabetesjournalsorgcgicontentfull27suppl_1s91
5 The Diabetes Control and Complications Trial Research Group Hypoglycemia in the Diabetes Control and
Complications Trial Diabetes 199746(2)271-86 See wwwncbinlmnihgovpubmed9000705 for abstract
6 American Diabetes Association Hypoglycemia and employmentlicensure Diabetes Care 200528 Suppl 1S61
See httpcarediabetesjournalsorgcgicontentfull28suppl_1s61
7 Viswanath K McGavin DD Diabetic Retinopathy Clinical Findings and Management J Comm Eye Health
200316(46)21-4 See wwwcehjournalorg0953-683316jceh_16_46_021html
8 Michigan Diabetes Research and Training Center University of Michigan Health System How to use the Michigan
Neuropathy Screening Instrument See wwwmedumichedumdrtcprofsdocumentssviMNSI_howtopdf
9 Bradley JG Davis KA Orthostatic hypotension Am Fam Physician 200368(12)2393-8
See wwwaafporgafp200312152393html
10 Gibbons RJ Balady GJ Bricker JT et al ACCAHA 2002 guideline update for exercise testing a report of the
American College of CardiologyAmerican Heart Association Task Force on Practice Guidelines (Committee on
Exercise Testing) J Am Coll Cardiol 200240(8)1531-40
See wwwaccorgqualityandscienceclinicalguidelinesexerciseexercise_cleanpdf
11 American Diabetes Association Standards of medical care in diabetes Diabetes Care 200528 Suppl 1S4-S36
Erratum in Diabetes Care 200528(4)990 See httpcarediabetesjournalsorgcgicontentfull28suppl_1s4
12 Molitch ME DeFronzo RA Franz MJ et al American Diabetes Association Nephropathy in diabetes Diabetes
Care 200427 Suppl 1S79-83 See httpcarediabetesjournalsorgcgicontentfull27suppl_1s79
13 Kitabchi AE Umpierrez GE Murphy MB et al American Diabetes Association Hyperglycemic crises in diabetes
Diabetes Care 200427 Suppl 1S94-102 See httpcarediabetesjournalsorgcgicontentfull27suppl_1s94
14 US Centers for Disease Control and Prevention National Diabetes Fact Sheet 2007
See wwwcdcgovdiabetespubspdfndfs_2007pdf
ACOEM Guidance for the Medical Evaluation of Law Enforcement Officers 11
43 ndash DIABETES MELLITUS
30
ATTACHMENT E
31
Typos A6921(2) 7th line down test should be plural 94201 Paragraph 2 target organ damage is used though end organ damage was defined earlier and in the appendix for that paragraph
A94201 Para A (1) d Id suggest deleting the phrases in brackets Im not sure either are predictably true or politically wise
a) tests for left ventricular hypertrophy Unfortunately use of the EKG to detect left ventricular hypertrophy is very insensitive (eg 5 sensitivity) The echocardiogram is the best test for diagnosing left ventricular hypertrophy but [it is relatively expensive and not readily available in small rural communities ] conducting echocardiograms on asymptomatic fire fighters with Stage 1 hypertension should be reserved only for those with long-standing hypertension
In addition
7761 A resting EKG shall be performed as part of the baseline medical evaluation and shall be obtained periodically thereafter
Changing from annually to periodically is noted has the language in the wellness-fitness initiative been changed as well Our previous decision was that we would support the W-F language since there was no compelling evidence to either support or refute it
Thanks
Sandy
32
NFPA 1582‐ HTN Draft 1
Reason for Revision
1) New classification of BP by the Joint National Commission [Chobanian et al 2002]
2) A high prevalence of FF have either HTN (~20) and Pre‐HTN (~20) [Soteriades et al 2003]
3) Among FF studies have shown a strong association between HTN and a number of adverse
cardiovascular events [Kales et al 2009]
4) A large percentage of on‐duty FF fatalities were found to have left ventricular hypertrophy a
complication of HTN at autopsy
Language in 2007 Edition with draft revisions in Red (Track changes)
611 The medical evaluation of a candidate shall include a medical history examination and any laboratory tests required to detect physical or medical condition(s) that could adversely affect hisher ability to safely perform the essential job tasks outlined in 511 A611 The medical history should include the candidates known health problems such as major illnesses surgeries medication use and allergies Symptom review is also important for detecting early signs of illness A medical history should also include a personal health history a family health history a health habit history an immunization history and a reproductive history
An occupational history should also be obtained to collect information about the persons past occupational and environmental exposures
(a) BP should be measured according to the Joint National Commission (JNC) -7 recommendations BP should be measured with a properly calibrated and validated instrument Patients should be seated quietly for at least 5 minutes in a chair with feet on the floor and arm supported at heart level An appropriate-sized cuff (cuff bladder encircling at least 80 of the arm) should be used to ensure accuracy At least 2 measurements should be made Systolic BP is the point at which the first of 2 or more sounds is heard (phase 1) and diastolic BP is the point before the disappearance of sounds (phase 5) [Chobanian et al 2003]
(2) Head eyes ears nose and throat (HEENT)
Formatted Font (Default) Times New RomanFont color Black
33
692 Vascular System 6921 Category A medical conditions shall include the following
(1) Uncontrolled or poorly controlled hypertension
(2) Hypertension with evidence of end organ damage
or not controlled by approved medications
A6921(1) Uncontrolled or poorly controlled hHypertension increases the risk of a sudden cardiac event This sudden cardiac event would cause sudden incapacitation which that is uncontrolled poorly controlled or requires medication likely to interferes with the safe performance of essential job tasks Uncontrolled or poorly controlled hypertension can be defined as the presence of end organ damage (see below) or stage 2 hypertension (BP systolic gt160 mmHg or BP diastolic gt100 mmHg) is an illness that can lead to functional impairment and potential for sudden incapacitation Individuals with pre- stage 1 or stage 2 hypertension should be referred to their primary care physician for evaluation lifestyle modification and treatment [QUESTION FOR GROUP _- WHAT ABOUT HAVING CANDIDATE RETURN IN ONE MONTH UNDER TREATMENT WITH NORMAL BP]
A6921(2)
Chronic hypertension can damage the eye (retinopathy) the kidneys (nephropathy) the vascular system (stroke transient ischemic attack or peripheral artery disease) or the heart (left ventricular hypertrophy and heart failure) These hypertension complications are known as end organ damage The cardiac and vascular complications are associated with an increased risk of sudden incapacitation and sudden cardiac death (Koren et al 1991) Unfortunately the cardiac complications are frequently asymptomatic and valid screening tests are not fast and are not inexpensive Therefore determining who to screen for cardiac complications (such as echocardiogram for LVH or a measurement of left ventricular ejection fraction for heart failure) should be based on the severity and the duration of HTN
76 Physical Examination The annual physical examination shall include each of the following components
(a) BP shall be measured according to the Joint National Commission (JNC)-7 recommendations
A76(1)(a) BP should be measured with a properly calibrated and validated instrument Patients should be seated quietly for at least 5 minutes in a chair with feet on the floor and arm supported at heart level An appropriate-sized cuff (cuff bladder encircling at least 80 of the arm) should be used to ensure accuracy At least 2 measurements should be made Systolic BP is the point at which the first of 2 or more sounds is heard (phase 1) and diastolic BP is the point before the disappearance of sounds (phase 5) [Chobanian et al 2003]
(2) Head eyes ears nose and throat (HEENT)
34
9420 Uncontrolled Hypertension 94201 Physician Evaluation Severe uncontrolled hypertension [defined as systolic pressure greater than 180 mm Hg diastolic pressure greater than 100 mm Hg or mean systolic blood
pressure ( systolic + diastolic) greater than 120 mm Hg] or malignant hypertension (defined as hypertension with the presence of target organ damage) compromises the members ability to safely perform essential job tasks 1 5 7 9 and 13 and the physician shall report the applicable job limitations to the fire department
Members with Pre-hypertention (systolic 120-139 mmHg or diastolic 80-89 mmHg) Stage 1 hypertension (systolic 140-159 mmHg or diastolic 90-99 mmHg) or Stage 2 hypertension (systolic ge160 mmHg or diastolic ge100 mmHg) should be referred to their primary care physician for evaluation lifestyle modification and treatment
(1) Members with Stage I hypertension should be followed-up not only by their primary care physician but also by the FD physician every 3 to 6 months to ensure their blood pressure is under control and to determine whether screening tests for asymptomatic end organ damage are appropriate
(2) Members with Stage 2 hypertension or with end organ damage (retinopathy nephropathy vascular or cardiac complications) compromises the members ability to safely perform essential job tasks 1 5 7 9 and 130 and the physician shall report the applicable job limitations to the fire department
A94201 Severe uncontrolled hypertension is a significant risk factor for the development of coronary artery disease congestive heart failure and stroke Blood pressure increases as a normal response to exercise This response is further exaggerated by the emotional and physical stress of performing these critical tasks while operating in personal protective clothing at extremes of temperature This normal elevation of blood pressure under these response conditions can lead to life-threatening hypertensive emergencies if a members daily blood pressure is already elevated to high levels In addition hypertension is a progressive illness that when uncontrolled ultimately and inevitably leads to target organ damage Target organs that are sensitive to the effects of elevated blood pressure are the central nervous system vision heart major blood vessels and kidneys
Chronic hypertension can damage the eye (retinopathy) the kidneys (nephropathy) the vascular system (stroke transient ischemic attack or peripheral artery disease) or the heart (left ventricular hypertrophy and heart failure) These hypertension complications are known as end organ damage The cardiac and vascular complications are associated with an increased risk of sudden incapacitation and sudden cardiac death (Koren et al 1991) Fortunately with proper evaluation life style modification and treatment these complications can be avoided Life style modification includes weight reduction DASH eating plan reduction in dietary sodium an increase in aerobic physical activity and moderation in alcohol consumption [Chobanian 2003]
Formatted Font (Default) Times New Roman12 pt Font color Black
Formatted Font (Default) Times New Roman12 pt Font color Black
35
A94201 (1) Members with Stage I hypertension whose BP returns to either pre-hypertenion or normal with lifestyle modification andor treatment can return to an annual medical evaluation For members with long-standing Stage I hypertension whose BP has not been reduced additional evaluation for possible end organ damage should be considered This evaluation could include any or all of the following
a) a compete patient history for symptoms of heart failure (eg shortness of breath upon exertion) or transient ischemic attacks (TIAs)
b) dilated eye examination for retinopathy
c) blood creatinine measurement for nephropathy
d) tests for left ventricular hypertrophy Unfortunately use of the resting EKG to detect left ventricular hypertrophy is very insensitive (eg 5 sensitivity) The echocardiogram is the best test for diagnosing left ventricular hypertrophy
A 94201 (2) Due to the high risk of a sudden cardiovascular event members with Stage 2 hypertension should be restricted until their BP can be brought under control Once the BP is brought under control they should be followed in the same manner as a member with Stage I hypertension
Formatted Font (Default) Times New Roman12 pt
36
D22 Cardiology Gibbons R J GJ Balady J W Beasley et al 1997 ACCAHA guidelines for exercise testing a report of American College of CardiologyAmerican Heart Association Task Force on Practice Guidelines (Committee on Exercise Testing) J Am Coll Cardiol 30260ndash311
Gibbons RJ Balady GJ Bricker JT Chaitman BR Fletcher GF Froelicher VF Mark DB McCallister BD Mooss AN OrsquoReilly MG Winters WL Jr [2002] ACCAHA 2002 guideline update for exercise testing summary article a report of the ACCAHA Task Force on Practice Guidelines (Committee to Update the 1997 Exercise Testing guidelines) J Am Coll Cardiol 401531ndash 40
Chobanian AV Bakris GL Black HR Cushman WC Green LA Izzo JL Jr Jones DW Materson BJ Oparil S Wright JT Jr Roccella EJ the National High Blood Pressure Education Program Coordinating Committee [2003] The seventh report of the Joint National Committee [JNC-7] on Prevention Detection Evaluation and Treatment of High Blood Pressure JAMA 2892560ndash2571
Soteriades ES Kales SN Liarokapis D Christiani DC [2003] Prospective surveillance of hypertension in firefighters J Clin Hypertens 5315-320
Kales SN Tsismenakis AJ Zhang C Soteriades ES [2009] Blood pressure in fire fighters police officers and other emergency responders Am J Hypertens 2211-20
37
NFPA 1582‐ HTN Draft 1
Reason for Revision
1) New classification of BP by the Joint National Commission [Chobanian et al 2002]
2) A high prevalence of FF have either HTN (~20) and Pre‐HTN (~20) [Soteriades et al 2003]
3) Among FF studies have shown a strong association between HTN and a number of adverse
cardiovascular events [Kales et al 2009]
4) A large percentage of on‐duty FF fatalities were found to have left ventricular hypertrophy a
complication of HTN at autopsy
Language in 2007 Edition with draft revisions in Red (Track changes)
611 The medical evaluation of a candidate shall include a medical history examination and any laboratory tests required to detect physical or medical condition(s) that could adversely affect hisher ability to safely perform the essential job tasks outlined in 511 A611 The medical history should include the candidates known health problems such as major illnesses surgeries medication use and allergies Symptom review is also important for detecting early signs of illness A medical history should also include a personal health history a family health history a health habit history an immunization history and a reproductive history
An occupational history should also be obtained to collect information about the persons past occupational and environmental exposures
(a) BP should be measured according to the Joint National Commission (JNC) -7 recommendations BP should be measured with a properly calibrated and validated instrument Patients should be seated quietly for at least 5 minutes in a chair with feet on the floor and arm supported at heart level An appropriate-sized cuff (cuff bladder encircling at least 80 of the arm) should be used to ensure accuracy At least 2 measurements should be made Systolic BP is the point at which the first of 2 or more sounds is heard (phase 1) and diastolic BP is the point before the disappearance of sounds (phase 5) [Chobanian et al 2003]
(2) Head eyes ears nose and throat
38
692 Vascular System 6921 Category A medical conditions shall include the following
(1) Uncontrolled or poorly controlled hypertension
(2) Hypertension with evidence of end organ damage
A6921(1) Uncontrolled or poorly controlled hypertension increases the risk of a sudden cardiac event This sudden cardiac event would cause sudden incapacitation which interferes with the safe performance of essential job tasks Uncontrolled or poorly controlled hypertension can be defined as the presence of end organ damage (see below) or stage 2 hypertension (BP systolic gt160 mmHg or BP diastolic gt100 mmHg) Individuals with pre- stage 1 or stage 2 hypertension should be referred to their primary care physician for evaluation lifestyle modification and treatment [QUESTION FOR GROUP _- WHAT ABOUT HAVING CANDIDATE RETURN IN ONE MONTH UNDER TREATMENT WITH NORMAL BP]
A6921(2)Chronic hypertension can damage the eye (retinopathy) the kidneys (nephropathy) the vascular system (stroke transient ischemic attack or peripheral artery disease) or the heart (left ventricular hypertrophy and heart failure) These hypertension complications are known as end organ damage The cardiac and vascular complications are associated with an increased risk of sudden incapacitation and sudden cardiac death (Koren et al 1991) Unfortunately the cardiac complications are frequently asymptomatic and valid screening tests are not fast and are not inexpensive Therefore determining who to screen for cardiac complications (such as echocardiogram for LVH or a measurement of left ventricular ejection fraction for heart failure) should be based on the severity and the duration of HTN
76 Physical Examination The annual physical examination shall include each of the following components
(a) BP shall be measured according to the Joint National Commission (JNC)-7 recommendations
A76(1)(a) BP should be measured with a properly calibrated and validated instrument Patients should be seated quietly for at least 5 minutes in a chair with feet on the floor and arm supported at heart level An appropriate-sized cuff (cuff bladder encircling at least 80 of the arm) should be used to ensure accuracy At least 2 measurements should be made Systolic BP is the point at which the first of 2 or more sounds is heard (phase 1) and diastolic BP is the point before the disappearance of sounds (phase 5) [Chobanian et al 2003]
(2) Head eyes ears nose and throat9420 Hypertension 94201 Physician Evaluation Members with Pre-hypertention (systolic 120-139 mmHg or diastolic 80-89 mmHg) Stage 1 hypertension (systolic 140-159 mmHg or diastolic 90-99 mmHg) or Stage 2 hypertension (systolic ge160 mmHg or diastolic ge100 mmHg) should be referred to their primary care physician for evaluation lifestyle modification and treatment
39
(1) Members with Stage I hypertension should be followed-up not only by their primary care physician but also by the FD physician every 3 to 6 months to ensure their blood pressure is under control and to determine whether screening tests for asymptomatic end organ damage are appropriate
(2) Members with Stage 2 hypertension or with end organ damage (retinopathy nephropathy vascular or cardiac complications) compromises the members ability to safely perform essential job tasks 1 5 7 9 and 130 and the physician shall report the applicable job limitations to the fire department
A94201 Chronic hypertension can damage the eye (retinopathy) the kidneys (nephropathy) the vascular system (stroke transient ischemic attack or peripheral artery disease) or the heart (left ventricular hypertrophy and heart failure) These hypertension complications are known as end organ damage The cardiac and vascular complications are associated with an increased risk of sudden incapacitation and sudden cardiac death (Koren et al 1991) Fortunately with proper evaluation life style modification and treatment these complications can be avoided Life style modification includes weight reduction DASH eating plan reduction in dietary sodium an increase in aerobic physical activity and moderation in alcohol consumption [Chobanian 2003]
A94201 (1) Members with Stage I hypertension whose BP returns to either pre-hypertenion or normal with lifestyle modification andor treatment can return to an annual medical evaluation For members with long-standing Stage I hypertension whose BP has not been reduced additional evaluation for possible end organ damage should be considered This evaluation could include any or all of the following
a) a compete patient history for symptoms of heart failure (eg shortness of breath upon exertion) or transient ischemic attacks (TIAs)
b) dilated eye examination for retinopathy
c) blood creatinine measurement for nephropathy
d) tests for left ventricular hypertrophy Unfortunately use of the resting EKG to detect left ventricular hypertrophy is very insensitive (eg 5 sensitivity) The echocardiogram is the best test for diagnosing left ventricular hypertrophy
A 94201 (2) Due to the high risk of a sudden cardiovascular event members with Stage 2 hypertension should be restricted until their BP can be brought under control Once the BP is brought under control they should be followed in the same manner as a member with Stage I hypertension
D22 Cardiology
40
Hypertension
Gibbons RJ Balady GJ Bricker JT Chaitman BR Fletcher GF Froelicher VF Mark DB McCallister BD Mooss AN OrsquoReilly MG Winters WL Jr [2002] ACCAHA 2002 guideline update for exercise testing summary article a report of the ACCAHA Task Force on Practice Guidelines (Committee to Update the 1997 Exercise Testing guidelines) J Am Coll Cardiol 401531ndash 40
Chobanian AV Bakris GL Black HR Cushman WC Green LA Izzo JL Jr Jones DW Materson BJ Oparil S Wright JT Jr Roccella EJ the National High Blood Pressure Education Program Coordinating Committee [2003] The seventh report of the Joint National Committee [JNC-7] on Prevention Detection Evaluation and Treatment of High Blood Pressure JAMA 2892560ndash2571
Soteriades ES Kales SN Liarokapis D Christiani DC [2003] Prospective surveillance of hypertension in firefighters J Clin Hypertens 5315-320
Kales SN Tsismenakis AJ Zhang C Soteriades ES [2009] Blood pressure in fire fighters police officers and other emergency responders Am J Hypertens 2211-20
41
NFPA 1582‐ Draft Revisions for CVDHTN
EKG and stress tests
Reason for Revision
1) Change requirement for annual resting EKG to periodically to be more consistent with ACCAHA
recommendation (Schlant et al 1992)
2) Add language to clarify what constitutes a positive ST
3) Make criteria for conducting diagnostic ST in asymptomatic patients consistent with the
ACCAHA
Language in 2007 Edition with draft revisions in Red (Track changes)
776 Electrocardiograms (EKG)) and Stress Tests 7761 A resting EKG shall be performed as part of the baseline medical evaluation and shall be obtained periodically (every 1 to 5 years) annually thereafter
A7761 A baseline resting EKGs shall be conducted Follow-up resting EKGs should be conducted as clinically indicated but at a minimum of every 1 to 5 years The frequency of these follow-up resting EKGs should increase as a members age increases or with increasing number andor severity of coronary heart disease risk factors Members above the age of 40 should have annual resting EKGs (Schlant et al 1992)
7762 The fire department physician or other qualified medical evaluator shall compare EKGs obtained during yearly evaluations with baseline and subsequent EKGs
7763 Stress testing EKG with or without echocardiography or radionuclide scanning shall be performed as clinically indicated by history or symptoms
A7761 Baseline electrocardiography should be conducted (Periodic resting electrocardiograms have not been shown to be useful but can be reasonable as a members agefactors increase)
A7763 No firm guidelines for stress testingelectrocardiography in asymptomatic individuals have been developed Stress testingelectrocardiography as a screening tool is used as part of an evaluation of aerobic capacity during the annual occupational fitness evaluation Submaximal stress testingelectrocardiography testing to 85 percent is commonly used as part of this screening
Submaximal stress electrocardiography testing should not be used for diagnostic purposes Cardiology evaluation with maximal stress testingelectrocardiography together with imaging techniques (eg echocardiography technetium Tc99m sestamibi study andor coronary angiography) is necessary for diagnosticprognostic purposes for the following
42
(1) Fire fighters with positive or questionably positive changes on screening submaximal stress tests
(2) Fire fighters with new onset chest pain or other symptoms suggestive of coronary artery disease (CAD)
(3) Fire fighters with diabetes mellitus who
(a) are gt35 years old or
(b) have type I diabetes for more than 15 years or
(c) have type II diabetes for more than 10 years or
(d) have any other CHD risk factor (see below) or
(e) have the presence of microvascular disease (proliferative retinopathy)
(4) Fire fighters over the age of 45 (for men) and 55 (for women) with onetwo or more risk factors for CAD Risk factors for CAD include hypercholesterolemia (total cholesterol greater than 240 mgdL) hypertension (systolic gt140 mmHg or diastolic gt90 mmHg) smoking or family history of premature CAD (heart attack or sudden cardiac death in a first degree relative less than 60 years of age)
as defined below if stress electrocardiography with imaging is negative then repeat as clinically indicated or at least every 5 years
(5) Fire fighters with a Framingham Risk Score gt10 Risk calculator is available at [httphp2010nhlbihinnetatpiiicalculatorasp]
(6) Fire fighters identified in 9431
Negative stress tests should be repeated as clinically indicated or at least every 2 to 5 years
Interpreting stress tests as ldquopositiverdquo or ldquonegativerdquo is beyond the scope of this document However factors that should be taken into consideration should include the individualrsquos exercise capacity symptoms blood pressure response heart rate response EKG changes and the presence of arrhythmias (Gibbon et al 2002)
Risk factors for CAD include hypercholesterolemia (total cholesterol greater than 240 mgdL) hypertension (systolic greater than 140 andor diastolic greater than 90) smoking diabetes mellitus or family history of premature CAD (heart attack or sudden cardiac death in a first degree relative less than 60 years of age)
There are other non-invasive tests to screen for coronary artery disease One of the most promising appears to be coronary artery calcium (CAD) scoring by computed tomography In 2007 an expert committee published an update to their original guidance document The committeersquos consensus was that ldquoit may be reasonable to consider use of CAC measurement in such patients [between 10 and 20 10-year risk of estimated coronary event]helliprdquo The committee did not recommend CAC measurement in low risk patients [lt10 10-year risk of estimated coronary event] or in high risk patients [gt20 10-year risk of estimate coronary event] (Greenland et al 2007]
43
D22 Cardiology
Chobanian AV Bakris GL Black HR Cushman WC Green LA Izzo JL Jr Jones DW Materson BJ Oparil S Wright JT Jr Roccella EJ the National High Blood Pressure Education Program Coordinating Committee [2003] The seventh report of the Joint National Committee [JNC-7] on Prevention Detection Evaluation and Treatment of High Blood Pressure JAMA 2892560ndash2571
Gibbons RJ Balady GJ Bricker JT Chaitman BR Fletcher GF Froelicher VF Mark DB McCallister BD Mooss AN OrsquoReilly MG Winters WL Jr [2002] ACCAHA 2002 guideline update for exercise testing summary article a report of the ACCAHA Task Force on Practice Guidelines (Committee to Update the 1997 Exercise Testing guidelines) J Am Coll Cardiol 401531ndash 1540
Greenland et al [2007] ACCFAHA 2007 Clinical Expert Consensus Document on Coronary Artery Calcium Scoring By Computed Tomography in Global Cardiovascular Risk Assessment and in Evaluation of Patients With Chest Pain A Report of the American College of Cardiology Foundation Clinical Expert Consensus Task Force (ACCFAHA Writing Committee to Update the 2000 Expert Consensus Document on Electron Beam Computed Tomography) J Am Coll Cardiol 49378-402
Kales SN Tsismenakis AJ Zhang C Soteriades ES [2009] Blood pressure in fire fighters police officers and other emergency responders Am J Hypertens 2211-20
Schlant RC Adolph RJ DiMarco JP Dreifus LS Dunn MI Fisch C Garson A Jr Haywood LJ Levine HJ Murray JA Noble RJ Ronan JA Jr [1992] Guidelines for electrocardiography A report of the American College of CardiologyAmerican Heart Association Task Force on Assessment of Diagnostic and Therapeutic Cardiovascular Procedures (Committee on Electrocardiography) Circulation 85(3)1221-1228
Soteriades ES Kales SN Liarokapis D Christiani DC [2003] Prospective surveillance of hypertension in firefighters J Clin Hypertens 5315-320
Formatted Font Italic
Formatted Line spacing single
Formatted Font Italic
Formatted Font Italic
44
NFPA 1582‐ Draft Revisions for CVDHTN
EKG and stress tests
Reason for Revision
1) Change requirement for annual resting EKG to periodically to be more consistent with ACCAHA
recommendation (Schlant et al 1992)
2) Add language to clarify what constitutes a positive ST
3) Make criteria for conducting diagnostic ST in asymptomatic patients consistent with the
ACCAHA
Language in 2007 Edition with draft revisions in Red (Track changes)
776 Electrocardiograms (EKG) and Stress Tests 7761 A resting EKG shall be performed as part of the baseline medical evaluation and shall be obtained periodically (every 1 to 5 years) thereafter
A7761 A baseline resting EKGs shall be conducted Follow-up resting EKGs should be conducted as clinically indicated but at a minimum of every 1 to 5 years The frequency of these follow-up resting EKGs should increase as a members age increases or with increasing number andor severity of coronary heart disease risk factors Members above the age of 40 should have annual resting EKGs (Schlant et al 1992)
7762 The fire department physician or other qualified medical evaluator shall compare baseline and subsequent EKGs
7763 Stress testing with or without echocardiography or radionuclide scanning shall be performed as clinically indicated by history or symptoms
A7763 No firm guidelines for stress testing in asymptomatic individuals have been developed Stress testing as a screening tool is used as part of an evaluation of aerobic capacity during the annual occupational fitness evaluation Submaximal stress testing testing to 85 percent is commonly used as part of this screening
Submaximal stress testing should not be used for diagnostic purposes Cardiology evaluation with maximal stress testing together with imaging techniques (eg echocardiography technetium Tc99m sestamibi study) is necessary for diagnosticprognostic purposes for the following
(1) Fire fighters with positive or questionably positive changes on screening submaximal stress tests
(2) Fire fighters with new onset chest pain or other symptoms suggestive of coronary artery disease (CAD)
45
(3) Fire fighters with diabetes mellitus who
(a) are gt35 years old or
(b) have type I diabetes for more than 15 years or
(c) have type II diabetes for more than 10 years or
(d) have any other CHD risk factor (see below) or
(e) have the presence of microvascular disease (proliferative retinopathy)
(4) Fire fighters over the age of 45 (for men) and 55 (for women) with one or more risk factors for CAD Risk factors for CAD include hypercholesterolemia (total cholesterol greater than 240 mgdL) hypertension (systolic gt140 mmHg or diastolic gt90 mmHg) smoking or family history of premature CAD (heart attack or sudden cardiac death in a first degree relative less than 60 years of age)
(5) Fire fighters with a Framingham Risk Score gt10 Risk calculator is available at [httphp2010nhlbihinnetatpiiicalculatorasp]
(6) Fire fighters identified in 9431
Negative stress tests should be repeated as clinically indicated or at least every 2 to 5 years
Interpreting stress tests as ldquopositiverdquo or ldquonegativerdquo is beyond the scope of this document However factors that should be taken into consideration should include the individualrsquos exercise capacity symptoms blood pressure response heart rate response EKG changes and the presence of arrhythmias (Gibbon et al 2002)
There are other non-invasive tests to screen for coronary artery disease One of the most promising appears to be coronary artery calcium (CAD) scoring by computed tomography In 2007 an expert committee published an update to their original guidance document The committeersquos consensus was that ldquoit may be reasonable to consider use of CAC measurement in such patients [between 10 and 20 10-year risk of estimated coronary event]helliprdquo The committee did not recommend CAC measurement in low risk patients [lt10 10-year risk of estimated coronary event] or in high risk patients [gt20 10-year risk of estimate coronary event] (Greenland et al 2007]
D22 Cardiology
Resting EKG and Stress Tests
46
Chobanian AV Bakris GL Black HR Cushman WC Green LA Izzo JL Jr Jones DW Materson BJ Oparil S Wright JT Jr Roccella EJ the National High Blood Pressure Education Program Coordinating Committee [2003] The seventh report of the Joint National Committee [JNC-7] on Prevention Detection Evaluation and Treatment of High Blood Pressure JAMA 2892560ndash2571
Gibbons RJ Balady GJ Bricker JT Chaitman BR Fletcher GF Froelicher VF Mark DB McCallister BD Mooss AN OrsquoReilly MG Winters WL Jr [2002] ACCAHA 2002 guideline update for exercise testing summary article a report of the ACCAHA Task Force on Practice Guidelines (Committee to Update the 1997 Exercise Testing guidelines) J Am Coll Cardiol 401531ndash 1540
Greenland et al [2007] ACCFAHA 2007 Clinical Expert Consensus Document on Coronary Artery Calcium Scoring By Computed Tomography in Global Cardiovascular Risk Assessment and in Evaluation of Patients With Chest Pain A Report of the American College of Cardiology Foundation Clinical Expert Consensus Task Force (ACCFAHA Writing Committee to Update the 2000 Expert Consensus Document on Electron Beam Computed Tomography) J Am Coll Cardiol 49378-402
Kales SN Tsismenakis AJ Zhang C Soteriades ES [2009] Blood pressure in fire fighters police officers and other emergency responders Am J Hypertens 2211-20
Schlant RC Adolph RJ DiMarco JP Dreifus LS Dunn MI Fisch C Garson A Jr Haywood LJ Levine HJ Murray JA Noble RJ Ronan JA Jr [1992] Guidelines for electrocardiography A report of the American College of CardiologyAmerican Heart Association Task Force on Assessment of Diagnostic and Therapeutic Cardiovascular Procedures (Committee on Electrocardiography) Circulation 85(3)1221-1228
Soteriades ES Kales SN Liarokapis D Christiani DC [2003] Prospective surveillance of hypertension in firefighters J Clin Hypertens 5315-320
47
ATTACHMENT F
48
1
Current 1582 (2007) language in reference to pregnancy 43 (4) Report to the fire department physician any medical condition that could interfere with the ability of the individual to safely perform essential job tasks such as illness or injury use of prescription or nonprescription drugs and pregnancy 6112 Category B medical conditions shall include the following (1) Pregnancy for its duration A7792 (e) If HIV prophylaxis is to be given the following tests should be done i CBC ii Glucose renal and hepatic chemical function iii Pregnancy test for females B121 Pregnancy and Reproduction Federal regulations as well as many court decisions including the US Supreme Courtrsquos decision in International Union et al v Johnson Controls Inc [499 US 187 111 S Ct 1196 (1991)] have interpreted the requirements of Title VII with respect to pregnancy and reproduction The AHJ should seek the advice of counsel in resolving specific questions concerning these requirements as well as other requirements that can be imposed by state or local laws C211 (4) Review health status with the individual being evaluated Contraindications for evaluations shall be reviewed addressing any changes in the individualrsquos health status since their last medical evaluation that would warrant deferring the evaluation including (g) Pregnancy Recommendations to language enhancement
A female employee who is assigned to regular fire line duty shall report a pregnancy immediately to their respective Supervisor and the fire department physician The employee will then be given the option of a non-hazardous alternative duty position for the duration of her pregnancy (can we say this or is it even appropriate) Any pregnant employee wishing to remain on regular line duty shall be informed of the possible risks and consequences to herself and her fetus that are associated with continued line fire fighting duty Among those risk factors are exposure to teratogens known to have negative effects on the developing fetus such as smoke diesel fumes hazardous chemicals and extreme heat
49
Page 2
appendix It is recommended that the pregnant employee complete a release of liability form signed by herself and her health care provider utilizing NFPArsquos 13 critical tasks as a reference This will inform the health care provider of specific job-related tasks that will need to be performed in order to continue regular line duty These tasks are basic physical standards that any entry level firefighter would have to be able to complete competently The employeersquos health condition will be kept confidential by the department in accordance with HIPAA standards Employees are allowed to remain on active regular duty until they are no longer able to perform their duties in a reasonable manner andor their protective gear no longer fits correctly It is the responsibility of the health care provider to evaluate the pregnant employee If at any time the health care provider feels the pregnant employee can no longer perform the job related tasks this should be reported to the employer by the employee immediately
50
ATTACHMENT G
51
From GLENN BENARICKTo Sawyer SteveSubject RE RE 7743Date Monday August 30 2010 21633 PM
Yes thats my understanding
Glenn P Benarick 211 Winged Elm CircleAiken SC 29803803-644-7093gbenarprodigynet
--- On Mon 83010 Sawyer Steve ltssawyerNFPAorggt wrote
From Sawyer Steve ltssawyerNFPAorggtSubject RE RE 7743To GLENN BENARICK ltgbenarprodigynetgtDate Monday August 30 2010 212 PM
So it should be ldquoorrdquo instead of ldquoandrdquo for now
Steven F Sawyer
Senior Fire Service Specialist
Executive Secretary IFMAFire Service Section
NFPA
1 Batterymarch Park
Quincy MA 02169
6179847423
Fax 6179847056
ssawyernfpaorg
From GLENN BENARICK [mailtogbenarprodigynet] Sent Monday August 30 2010 1202 PMTo Sawyer SteveSubject Fw RE 7743
52
Steve a couple of our docs agree with April Boyer
Glenn P Benarick 211 Winged Elm Circle
Aiken SC 29803
803-644-7093
gbenarprodigynet
--- On Mon 83010 David Prezant ltprezandfdnynycgovgt wrote
From David Prezant ltprezandfdnynycgovgtSubject RE 7743To Thomas R (CDCNIOSHDSHEFS) Hales lttrh1cdcgovgt GLENNBENARICK ltgbenarprodigynetgtCc Sandy Bogucki ltsandyboguckiyaleedugtDate Monday August 30 2010 1004 AM
agree
we should change this to NHANES III rather than Knudson we should alsomodify this to allow not only for predicted cutoffs but all for use of thelower limit of normal cutoff This is important to prevent false-classificationof spirometry as abnormal in older groups and in taller grps The latter ofparticular import to firefighter occupational health surveillance
thanks
David Prezant MDChief Medical Officer Office of Medical AffairsCo-Director WTC Medical Monitoring amp Treatment ProgramsNew York City Fire Department9 Metrotech Center - Rm 4W-1Brooklyn NY 11201Phone 718-999-2696Fax 718-999-0665
Life is full of twists and turns
53
This email may contain confidential information If you are the unintendedrecipient of this email please send it back and delete from your directory
gtgtgt Hales Thomas R (CDCNIOSHDSHEFS) lttrh1cdcgovgt 8302010955 AM gtgtgt
Glen
This seems like a very reasonable comment and illustrates the importance of having clinicians providefeedback on the std Im not familiar with the software program of the various spirometers (NHANES IIIvs KnudsonATS vs both) Given the large role both Dave Prezant and Sandy Bogucki had for thepulmonary section let me forward to them for clarification
Tom
From GLENN BENARICK [mailtogbenarprodigynet] Sent Sunday August 29 2010 456 PMTo Hales Thomas R (CDCNIOSHDSHEFS)Subject FW 7743
Tom is April Boyer correct
Glenn P Benarick 211 Winged Elm Circle
Aiken SC 29803
803-644-7093
gbenarprodigynet
--- On Thu 82610 Sawyer Steve ltssawyerNFPAorggt wrote
From Sawyer Steve ltssawyerNFPAorggtSubject FW 7743To GLENN BENARICK ltgbenarprodigynetgtDate Thursday August 26 2010 925 PM
FYI Do you have any answer She is write
Steven
54
Steven F Sawyer
Senior Fire Service Specialist
Executive Secretary IFMAFire Service Section
NFPA
1 Batterymarch Park
Quincy MA 02169
6179847423
Fax 6179847056
ssawyernfpaorg
From April Boyer [mailtoaboyerbicclinicorg] Sent Thursday August 26 2010 232 PMTo Sawyer SteveCc RobinMWebbmilstateorusSubject 7743
Steven
The spirometry tests cannot be corrected according to both references as the NFPA states because thereferences are contradictory The first part of 7743 states to follow the ATS guidelines and use theKnudsen (we at Basin Immediate Care use the Nhanes III) The second part states to follow the ACOEMguidelines and use the Nhanes III in the occupational setting if available with your unit (which is availableon ours) 7743 does not use the word OR regarding both requirements it uses the word AND whenreferring to the first and second parts thence making 7743 contradictory I realize the NFPA 1582 hasnot been updated since 2007 unless I have just not received an updated version
Our question to you is which part of 7743 do you want us to follow the first or the second part Anyfacility that has an updated computerized spirometry system (as we do) will not be able to follow bothrequired parts for obvious reasons We can either follow the first part of 7743 and use an oldercorrected version of the Knudson by going into our system and changing out of the Nhanes III conversionOR we can follow the second part of 7743 and use the newer corrected version of Nhanes III which ourunit offers too
If you have any questions you may contact me at anytime and I also have many references in regards toboth parts of 7743 if you would like to see them
55
Thank you~
April
Confidentiality NoticeThis message may contain information that isconfidential or privileged
If you are not the intended recipientPlease advise the sender immediately and delete this message
56
ATTACHMENT H
57
NFPA 1582 771(7) Proposed revisions
Why
Preliminary results of two prospective randomized trials on the PSA test were published in 2009 These studies resulted in medical organizations that previously providing guidance to modify their recommendations
Current language
771 Blood Tests Blood tests shall be performed annually and shall include the following
(7) Prostate specific antigen (PSA) after age 40 for positive family history if African American or if otherwise clinically indicated after age 50 for all other male member
Suggested Revision
771 Blood Tests Blood tests shall be performed annually and shall include the following
(7) Prostate specific antigen (PSA) after age 40 for positive family history if African American or if otherwise clinically indicated after age 50 for all other male member
772 Prostate-Specific Antigen (PSA) test At age 50 fire fighters shall have an opportunity to make an informed decision with either the Fire Department physician or their health care provider concerning the PSA test For fire fighters at increased risk of prostate cancer (African-Americans or those with a first degree relative diagnosed with prostate cancer before age 65) shall have the opportunity for this informed decision at age 40
A772 The PSA as a screening test for prostate cancer in asymptomatic men is controversial controversial for two reasons First there is no consensus that PSA screening actually saves lives For example the PSA test may detect small cancers that would never become life threatening Second it is unclear that the benefits of PSA screening outweigh the risks of follow-up diagnostic tests and cancer treatments For example the prostate biopsy used to diagnose prostate cancer may cause bleeding and infection And prostate cancer treatments such as surgery and radiation therapy may cause incontinence (inability to control urine flow) erectile dysfunction (erections inadequate for intercourse) and other complications For these reasons it is important that the benefits and risks of prostate diagnostic procedures and treatment be taken into account when considering the PSA screening test These considerations can be taken account during discussions with the fire department physician or onersquos health care provider
D211 Cancer Screening
Smith R A C J Mettlin K J Davis and H Eyre 2000 ldquoAmerican Cancer Society guidelines for the early detection of cancerrdquo CA J Clin 50(1)34ndash49
Added references
58
Carroll P Albertsen PC Greene K et al [2010] Prostate-specific antigen best practice statement 2009 update Am Urological Assoc Available at httpwwwauanetorgcontentguidelines-and-quality-careclinical-guidelinesmain-reportspsa09pdf Date accessed September 2010
Ferrini R Woolf SH [2009] Screening for prostate cancer in American men American College of Preventive Medicine Practice Policy Statement Available at httpwwwacpmorgprostatehtm Date accessed September 2010
National Cancer Institute [2009] Prostate-specific antigen test National Cancer Institute Fact Sheet Available at httpwwwcancergovcancertopicsfactsheetDetectionPSA Date accessed September 2010
Wolf AMD Wender RC Etzioni RB et al [2010] American Cancer Society guideline for the early detection of prostate cancer Update 2010 Available at httpcaonlineamcancersocorgcgicontentfullcaac20066v1 Date accessed September 2010
59
Address List 9172010
Fire Service Occupational Safety and Health FIX-AAAKenneth Willette
Glenn P Benarick
FIX-AAAChair211 Winged Elm Circle
Aiken SC 29803
NFPA Fire Service SectionAlternate Murrey E Loflin
PhoneCell 803-644-7093
FaxEmail gbenarprodigynet
U 1011992 Murrey E Loflin
FIX-AAASecretary (Alternate)West Virginia University
Fire Service Extension
West virginia State Fire Academy
2600 Old Mill Road
Weston WV 26452-8077
NFPA Fire Service SectionPrincipal Glenn P Benarick
PhoneCell 304-293-8288 304-276-2843
Fax 304-293-2107
Email meloflinmailwvuedu
U 411993
Donald Aldridge
FIX-AAAPrincipalLion Apparel Inc
6450 Poe Avenue Suite 300
Dayton OH 45414
Alternate Andrew G SchwartzPhoneCell 937-415-2801 937-212-0206
Fax 937-913-5545
Email daldridgelionapparelcom
M 111985 David J Barillo
FIX-AAAPrincipalUniversity of Florida College of Medicine
PO Box 100286
Gainesville FL 32610-0286
PhoneCell 352-265-0262
FaxEmail dbarilloearthlinknet
SE 1122000
Lawrence T Bennett
FIX-AAAPrincipalUniverity of Cincinnati
Fire Science Department
2220 Victory Park Way ML 0103
Room 301
Cincinnati OH 45206-2837
PhoneCell 513-556-6583
Fax 513-556-4856
Email lawrencebennettucedu
SE 7232008 Paul Blake
FIX-AAAPrincipalCity of Baytown Fire amp Rescue Services
201 East Wye Drive
Baytown TX 77521
Industrial Emergency Response Working GroupPhoneCell 281-420-5329
Fax 281-420-5367
Email shonblakebaytownorg
E 4171998
Sandy Bogucki
FIX-AAAPrincipalYale University Emergency Medicine
464 Congress Avenue Suite 260
New Haven CT 06519-1315
PhoneCell 203-785-6159
Fax 203-785-3196
Email sandyboguckiyaleedu
SE 711996 Dennis R Childress
FIX-AAAPrincipalOrange County Fire Authority
PO Box 75003
San Clemente CA 92673-0167
California State Firefighters AssociationPhoneCell 949-218-7441
Fax 949-218-7499
Email den4fireaolcom
U 711993
13
Address List 9172010
Fire Service Occupational Safety and Health FIX-AAAKenneth Willette
Dominic J Colletti
FIX-AAAPrincipalHale Products Inc
700 Spring Mill Avenue
Conshohocken PA 19428
Fire Apparatus Manufacturers AssociationAlternate Leroy B Coffman III
PhoneCell 610-940-2437
Fax 610-825-6440
Email dcollettiidexcorpcom
M 4171998 Thomas J Cuff Jr
FIX-AAAPrincipalFiremens Association of the State of New York
127 Shelter Lane
Levittown NY 11756-1218
PhoneCell 516-735-4081 516-351-0942
Fax 516-579-9063
Email tomc621aolcom
U 10101997
Michael L Finkelman
FIX-AAAPrincipal182 Melanie Drive
East Meadow NY 11554
Association of Fire DistrictsState of New YorkPhoneCell 516-579-7570 516-369-8648
Fax 516-542-0593
Email mikexx00aolcom
U 7282006 Stephen N Foley
FIX-AAAPrincipalUS Department of Homeland Security
US Fire Administration
16825 South Seton Avenue
Emmitsburg MD 21727
PhoneCell 301-447-1304
Fax 301-447-1178
Email stephenfoleydhsgov
SE 1042007
Thomas Hillenbrand
FIX-AAAPrincipalUnderwriters Laboratories Inc
333 Pfingsten Road
Northbrook IL 60062-2096
Alternate Steven D CorradoPhoneCell 847-664-2603
Fax 847-313-2603
Email thomasahillenbrandusulcom
RT 7241997 Scott D Kerwood
FIX-AAAPrincipalHutto Fire Rescue
501 Exchange
PO Box 175
Hutto TX 78634
International Association of Fire ChiefsAlternate Brett R Bowman
PhoneCell 512-759-2616 512-413-1404
Fax 512-846-1946
Email sdkerwoodhuttofirerescueorg
E 711995
Jonathan D Kipp
FIX-AAAPrincipalPrimex
3
46 Donovan Street
Concord NH 03301
PhoneCell 603-225-2841
Fax 603-228-3905
Email jkippnhprimexorg
I 111989 Steve Kreis
FIX-AAAPrincipalCity of Phoenix Fire Department
150 South 12th Street
Phoenix AZ 85034-2301
PhoneCell 602-495-5848
Fax 602-262-4429
Email stevelkreisphoenixgov
E 1032002
24
Address List 9172010
Fire Service Occupational Safety and Health FIX-AAAKenneth Willette
Michael A Laton
FIX-AAAPrincipalSperian Protective Apparel
160 Woodstream Way
Fayetteville GA 30214
International Safety Equipment AssociationPhoneCell 770-861-0350
FIX-AAANonvoting MemberNational Institute for Occupational Safety amp Health
4676 Columbia Parkway R-9
Cincinnati OH 45226
Alternate Jay L TarleyPhoneCell 513-841-4583
Fax 513-844-4488
Email thalescdcgov
RT 452001
William R Hamilton
FIX-AAANonvoting MemberUS Department of Labor
Occupational Safety amp Health Administration
200 Constitution Ave NW Room N3609
Washington DC 20210
Alternate Andrew LevinsonPhoneCell 202-693-2077
Fax 202-693-1663
Email hamiltonbilldolgov
E 342009 Andrew Levinson
FIX-AAAAlt to Nonvoting MemberUS Department of Labor
Occupational Safety amp Health Administration
200 Constitution Ave NW Room N3718
Washington DC 20210
Occupational Safety amp Health AdministrationPrincipal William R Hamilton
PhoneCell 202-693-2048
Fax 202-693-1678
Email levinsonandrewdolgov
E 7282006
Jay L Tarley
FIX-AAAAlt to Nonvoting MemberUS Department of Health amp Human Services
National Institute for Occupational Safety amp Health
1095 Willowdale Road MS 1808
Morgantown WV 26505
Principal Thomas R HalesPhoneCell 304-285-5858
Fax 304-285-5774
Email jst9cdcgov
RT 3152007 Kenneth Willette
FIX-AAAStaff LiaisonNational Fire Protection Association
1 Batterymarch Park
Quincy MA
PhoneCell 617-984-7299
Fax 617-984-7056
Email kwillettenfpaorg
792010
68
ATTACHMENT B
9
Technical Committee on Fire Service Occupational Safety and Health
Meeting Minutes May 13 ndash 14 2010
Holiday Inn Inner Harbor MD
Attendees Glenn Benarick Chairman Ken Holland Staff Liaison Michael Finkelman Craig Fry Joe Rivera Stephen Raynis Steve Kreis Dennis Childress Don Stewart Phil Stittleburg David Ross Michael Laton Kim Zagaris Tom Hillenbrand Dominic Colletti Andy Schwartz Brett Bowman Guest David Bernzweig Thursday May 13 NFPA 1500 task groups (Vehicle amp Safety OPS SCBA amp Air Mgt PPEProximity) met to discuss the work they have completed since the last meeting The task groups will present their report to the entire TC on May 14th Not enough 1582 task group members were able to make the meeting so there were no reports or work from those task groups Friday May 14 TC meeting called to order at approximately 0800 by Glenn Benarick TC Chair Ken Holland (NFPA Public Fire Protection Staff) in attendance filling in for Frank Florence Ken made two presentations one on the Codes and Standards Development Process and the other on the general procedures for this Pre-ROP meeting The Staff Liaison remains fluid as Frank is not expected back any time soon
10
One guest in attendance Dave Bernzweig (Columbus OH Fire) Dave is assisting TC with SCBAAir Mgt issues The document revision cycles remain as requested NFPA 1500 amp 1582 Annual 2012 NFPA 1521 amp 1561 Fall 2013 NFPA 1581 1583 1584 Annual 2014 The October 7-9 2010 dates are the primary request for our next meeting Location is San Diego Notice will be sent out as soon as approval is received Discussion on the next revision of 1561 will be held at the October meeting regarding changing the document title to ldquoCommand Safety for Fire Department Operationsrdquo This is a suggestion of the TC Chair Ken Holland conducted a briefing for the TC on how to access and use the committee web page Staff will be posting as much information as possible up on the e-committee page for the entire committee More use will be made of this tool Discussion on monocular vision Dennis Childress presented the current issue in Ventura County CA Further discussionwork may be necessary Don Stewart agreed to take the lead Brief discussion held on pregnancy and the need for fire departments to ensure policies match current law The rep from the Diabetes Association declined the invitation to participate at this meeting due to no discussion of the issue planned She has indicated a desire to attend the October meeting There were no reports from these and all other 1582 task groups It is very important for the 1582 TG Chairs to be ready to report in October The following task group reports will be posted on the ecommittee page PPEProximity New definition of proximity fire fighting
VehicleHighway OPS Discussion on use of vehicle data recorders Collapse Zones Submission from Jay Tarley SCBAAir Mgt New exit strategy for SCBA Discussion on having the low air alarm activate when the bottle volume reaches 600 liters Further discussion to take place on ldquobuddy breathingrdquo
On Day 2 Casey Grant (NFPA Fire Protection Research Foundation) made a presentation on Research Planning for FSOSH Dr Ellen Sogolow (DHSFEMA) also present during this presentation She discussed the role of the AFGRampD activities See ecommittee page for his presentation Chair
11
will be in contact with Mr Grant for future work between the TC and the Foundation Also on Day 2 Ken Willette (Division Manager ndash NFPA Public Fire Protection Division) delivered a presentation on the initiative developed by Kelvin Cochran (US Fire Administrator) to reduce fire fighter injuries and deaths NFPA 1500 is an integral part of this initiative See ecommittee page for presentation The Chair will be coordinating a committee conference call in the coming weeks The purpose will be to review the work which needs to be completed for the October meeting The primary focus of the call will be on 1582 issues NOTE Subsequent to the meeting I have had some discussions with a fire chief in Kentucky on the use of hearing aids The TC especially the doctors need to review the current language in 1582 and decide if revisions are needed Also most of you know that Kelvin Cochran has left the USFA unexpectedly to return to Atlanta as their fire chief I have been in contact with the Acting Administrator Glenn Gaines to inform him that our committee remains focused on the work to reduce fire fighter injuries and deaths I told him that I would keep him informed of our work He indicated that one of his primary goals is to bring fire service organizations together in order to create a safe working environment Of particular interest to him is reducing heart related injuries and deaths Submitted by Glenn Benarick
12
Technical Committee on Fire Service Occupational Safety and Health
Conference Call Meeting Minutes August 30th 2010
Members participating
Glenn Benarick TC Chair
Murrey Loflin Secretary Dr Sandy Bogucki
Thomas Cuff Stephen Foley
Scott Kerwood Tammy Lopes
David Love Dr David Prezant
Joe Rivera David Ross
Mario Rueda Phil Stittleburg
Phil Vorlander Dominic Colletti
Thomas Hillenbrand
Denise Smith Brett Bowman Alternate
Andrew Schwartz Alternate Mike Young Alternate
Dr Thomas Hales Non-Voting Member Ken Holland NFPA Staff Liaison
Casey Grant NFPAResearch Foundation Staff Katie Hathway Guest from ADA
Dr Jim Fleming Guest from Phoenix Fire Dept
The chair welcomed everyone to the conference call in which he hoped
would last only an hour The purpose was to discuss any task groups that had reports for proposed changes to NFPA 1582 for the
committee This is in hopes to ensure the committee is ready for their
pre-ROP meeting in October The following topics were discussed and are in no specific order
Comments from ADA Katie Hathaway and the group went into deep
discussion regarding ones medical history and diagnosis of diabetes
13
and some proposed changesremoval of text based on research
findings The specific proposed changes will be available for the committee at their next meeting Some members on the call felt that
this issue was covered in another law enforcement document which might better serve this issue
Research topics for FSOSH projects Casey Grant offered his time to
answer any questions regarding his presentation from the May meeting in Baltimore There was also discussion about further
involvement of the Research Foundation with this committee and some of the medical requirements within the documents Glenn and Casey
are going to be in contact offline to discuss this further
Prosthetics amp Amputees report Nothing new to report
Heart amp Hypertension report There was discussion about the need for
periodic EKGrsquos that were done both in resting and non-resting states as well as discussion about stress test requirements and frequency of
such tests The hopes were to develop text that would point to annual versus periodic evaluations of EKGrsquos and stress tests
Epilepsy report Nothing new to report
Pregnancy report The initial textlanguage has been provided to the
group through email and e-committee page posting
Coagulation amp Meds report Nothing new to report
Hearing Aid discussion Nothing new to report
The committee also discussed the evaluation and documentation of
PSA results and test requirements for the purposes of consistency The proposed text and changes have been posted on the e-committee
page as well
All of the proposed text changes from the May meeting in Baltimore have been emailed out and posted on the e-committee page If there
are any questions or concerns that something was missed please contact Glenn Steven Sawyer or Ken Holland to ensure they are
resolved
The conference call lasted approximately an hour and was adjourned at 1400 hours
14
ATTACHMENT C
15
2012 ANNUAL REVISION CYCLE
PROCESS STAGE PROCESS STEP DATES
FOR TC DATES
FOR TCC 1 PRELIMINARY 10 Notification of intent to enter cycle 7910 7910
2 REPORT ON
PROPOSALS (ROP)
21 Proposal closing date 112310 112310 22 Final date for ROP meeting 22511 2411 23 Final date for mailing TC ballots 31811 21811 24 Receipt of (TC) ballots by staff liaison 42211 31111 25 Receipt of TC recirculation ballots 5611 31811 26 Final date for TCC meeting 41511 27 Final date for mailing TCC ballots 42211 28 Receipt of TCC ballots 51311 29 Receipt of TCC recirculation ballots 52011 210 Final copy (w ballot statements) to Secretary Standards Council 51311 52711 211 Completion of Reports 52011 6311 212 ROP Published and Posted 62411 62411
3 REPORT ON
COMMENTS
(ROC)
31 Comment closing date 83011 83011 32 Final date for ROC meeting 11411 10711 33 Final date for mailing TC ballots 111811 102111 34 Receipt of (TC) ballots by staff liaison 12211 111111 35 Receipt of TC recirculation ballots 12911 111811 36 Final date for TCC meeting 121611 37 Final date for mailing TCC ballots 122311 38 Receipt of TCC ballots 11312 39 Receipt of TCC recirculation ballots 12012 310 Final copy (w ballot statements) to Secretary Standards Council 122311 12712 311 Completion of Reports 11312 2312 312 ROC Published and Posted 22412 22412
4 TECH SESSION
PREPARATION amp
ISSUANCE OF
CONSENT
DOCUMENTS
41 Notice of Intent to Make a Motion (NITMAM) Closing Date 4612 4612 42 Posting of Filed NITMAM 5412 5412
43 Council Issuance Date for Consent Documents 52912 52912
44 Appeal Closing Date for Consent Documents 61312 61312
5 TECHNICAL
SESSION 50 Association Meeting for Documents with Certified Amending Motions
64-712 64-712
6
APPEALS amp
ISSUANCE OF
DOCUMENTS
WCAMS
61 Appeal closing date for Documents with Certified Amending Motions
62712 62712
62 Council issuance for Documents with Certified Amending Motions 8912 8912
Proposal Closing Dates may vary according to documents and schedules for Revision Cycles may change Please check the NFPA website (wwwnfpaorg) for the most up-to-date information on proposal closing dates and schedules
16
ATTACHMENT D
17
This weekrsquos conference call mentioned the Diabetes chapter written for the ACOEM document Guidance for the Medical Evaluation of the Law Enforcement Officer The task group working on this chapter (led Richard Miller of the Secret Service and our very own Dan Samo) worked with the ADA or over 2-3 years to come up with a consensus document
Please find the Chapter attached ltltDiabetes Guidance Sept 2010pdfgtgt
Regarding Dan Loeberrsquos points
1) Physical Evaluation Form - We could modify the LEO form (see end of the attached Chapter)
2) Duration required for stable regiment
1582 for IDDM Type 1 1 yr
Type 2 6 m
Oral Agents None specifically
ACOEM Police for IDDM Type 1 6m
Type 2 3m
Oral Agents 1m
The police document is much clearer about the decision regarding medical fitness for duty is the responsibility of the police physician with the treating diabetes-expert physician providing the data to the police physician to make an informed decision In this regard the police officer must provide the police physician with downloaded self monitoring glucose data for the 1 3 and 6 month time periods (see section 433)
3) HA1C ndash NFPA lt 8 over 3 month period
ACOEM Police ndash (Section 4333) Specifies the frequency on measurement and if gt8 requires further evaluation
Some other discrepancies End organ complications
NFPA ndash end organ complications (eye kidney heart neuro) ndash restriction
ACOEM Police ndash end organ complication -- requires further evaluation
18
Hypoglycemia (incapacitating ndash defined differently between the two documents (434)
NFPA ndash 0 episodes in past year le1 in past 5 yrs
ACOEM Police ndash 0 episodes in past year le2 in past 3 yrs
Given Dan Samorsquos and Richard Millerrsquos work with the ADALoeber it would be helpful to get their opinions on whether any of the changes requested by Loeber are appropriate for FF with DM
Tom
Thomas Hales MD MPH
Senior Medical Epidemiologist
NIOSH CDC
4676 Columbia Pkwy R-9
Cincinnati OH 45241
(513) 841-4583
trh1cdcgov
19
43 ndash DIABETES MELLITUS
431 ndash INTRODUCTION
The educated and motivated law enforcement officer (LEO) with well-managed diabetes mellitus can be capable of
safe and effective job performance1 However diabetes mellitus may place LEOs at risk for sudden incapacitation
thus jeopardizing their ability to perform critical job functions (These job functions include those listed in Sections
32 333 351 352 36 and 37 and discussed in Appendix A)
Therefore an individualized assessment of the LEOrsquos diabetes should be performed using the following evaluative
criteria to determine whether the individuals condition permits safe and effective job performance Such evaluation
must include the following key elements which are discussed in detail below
history of blood glucose control
knowledge of diabetes and its management
current stability of blood glucose
risk for significant hypoglycemia or hyperglycemia and
presence of diabetic complications
432 ndash OVERVIEW OF MEDICAL EVALUATION
The treating endocrinologist or other physician knowledgeable regarding diabetes management should provide
a narrative report certifying whether the LEO has or has not met the criteria set out in Sections 4321 through
4354 below In addition the physician should include supporting data (see Appendix B for the Physician Evalu-
ation Form)
4321 The LEO is under the care of an endocrinologist or other physician knowledgeable regarding diabetes
management Outpatient and in-patient medical record(s) for the last 3 years or since date of diagnosis
(whichever is shorter) should be reviewed by the treating physician and provided to the police physician
4322 If the LEO has type 1 diabetes the individual has been on a basalbolus regimena or an insulin pump
using analogue insulins for the 6 months prior to evaluation2
4323 If the LEO has type 2 diabetes on insulin the individual has been on a stable medication regimenb
for the 3 months prior to evaluation3 If on oral agents alone the LEO has been on a stable medication regimen
for the month prior to evaluationc
ACOEM Guidance for the Medical Evaluation of Law Enforcement Officers 1
43 ndash DIABETES MELLITUS
aA basalbolus insulin regimen consists of the use of a basal insulin (Glargine NPH) in a once or twice daily regimen to provide between-
meal insulin combined with the use of a short acting insulin (Regular Lispro Aspart or Glulisine) at mealtimes Insulin pumps are small
(beeper sized) battery powered devices that deliver small amounts of short-acting insulin in a constant infusion to meet basal insulin
requirements The wearer selects an additional mealtime bolus to be infused at the time of meals For more information on pumps visit
the manufacturerrsquos web sites ndash wwwMinimedcom wwwcozmorecom wwwanimascorpcom wwwdisetroniccom
bA stable insulin regimen is defined as maintaining the same types of insulin (long acting intermediate acting short or rapid acting)
Changes in insulin dose are part of the appropriate self-management of diabetes and do not disqualify an applicant or incumbent under
this section
cChanges in dose within the evaluation period will be allowed but addition of a new class of medications or insulin should result in a new
period of observation
one month for addition of a sulfonylurea or metformin
two months for the addition of a thiazolidinedione to insulin or a sulfonylurea or
three months for the addition of insulin
20
4324 If the LEO uses an insulin pump documentation is needed as follows
proper understanding and education in the use of the insulin pump
start date for the use of the pump
history of insulin site infectionsd
history of pump cessation and pump malfunction
backup plan for pump malfunction including use of injectable insulin and
frequency of infusion set changes
4325 The LEO has been educated in diabetes and its management and thoroughly informed of and under-
stands the procedures that must be followed to monitor and manage hisher diabetes and what procedures
should be followed if complications arise3
433 ndash QUANTITATIVE GLUCOSE MONITORING
4331 The LEO has documentation of ongoing self-monitoring of blood glucose
4332 This must be done with a glucose meter that stores every reading records date and time of reading
and from which data can be downloaded (Most meters now have this capability)
4333 Monitoring logs must be available covering the time period (1 3 or 6 months) as described in
Sections 4322 and 4323 The frequency of glucose monitoring must follow a schedule acceptable to the
police physician in consultation with the treating physician
Testing schedules are individual What follows is a common pattern but individual patterns may differ
2 ACOEM Guidance for the Medical Evaluation of Law Enforcement Officers
43 ndash DIABETES MELLITUS
dIndividual has not had more than one pump-site infection that caused him or her to miss work or usual daily activities in the preceding 6
months
THERAPEUTIC REGIMEN GLUCOSE TESTING SCHEDULE
Diet alone Once or twice a week
Metformin Thiazolidinediones or Alpha
Glucosidase inhibitors alone or in
combination
Once or twice a week
Sulfonylureas meglitanides nateglinide ndash
alone or in combination with the above group
Twice a day ndash AM and at supper with any
suspected hypoglycemic episodes
Insulin ndash one shot in combination with orals Twice a day ndash AM and at supper with any
suspected hypoglycemic episodes
2 to 3 times AM once a week
Insulin ndash two or more shots Insulin pump 3 to 4 times a day ndash at meals and bedtime
2 to 3 times AM once a week with any
suspected hypoglycemic episodes
21
4334 The LEO has had hemoglobin A1C measured at least 4 times a year (intervals of 2 to 3 months) over
the last 12 months prior to evaluation if diagnosis has been present for more than a year4 If hemoglobin A1C is
gt8 this may signal a problem with the LEOrsquos diabetes management that warrants further assessment5
434 ndash INCAPACITATING EVENTS
4341 The LEO has not had any incapacitating episodes within the past 1 year and no more than 2 episodes
in the past 3 years or since diagnosis of diabetes (whichever is shorter) of
43411 Severe hypoglycemia (loss of consciousness seizures or coma requiring assistance of others or
needing urgent treatment [glucagon injectionIV glucose]) or
43412 Blood sugar lt60 mgdl with unawareness demonstrated in current glucose logs6
435 ndash CHRONIC COMPLICATION SCREENING
4351 Chronic complications of diabetes are associated with increased risk for severe hypoglycemic
episodes and warrant further assessmente
4352 The components of screening for chronic complications are
43521 A complete eye exam by a qualified ophthalmologist or optometrist including a dilated retinal
exam demonstrating no more than mild background diabetic retinopathyf7
43522 Normal vibratory testing with a 128 Hz tuning forkg normal testing with 10 gram Semmes-
Weinstein monofilamentg and normal orthostatic blood pressureh and pulse testing89
ACOEM Guidance for the Medical Evaluation of Law Enforcement Officers 3
43 ndash DIABETES MELLITUS
ePresence of chronic complications of diabetes in and of themselves may not require the implementation of work restrictions
fNo more than one dot blot or flame-shaped hemorrhages or microaneurysm in all four fundus quadrants
gThe Michigan Diabetes Research and Training Center of the University of Michigan Health System recommends the following guidance
(see wwwmedumichedumdrtcprofsdocumentssviMNSI_howtopdf) for conducting vibratory and monofilament testing8
Vibration Sensation Vibration sensation should be performed with the great toe unsupported Vibration sensation will be tested bi-
laterally using a 128 Hz tuning fork placed over the dorsum of the great toe on the boney prominence of the DIP joint Patients whose
eyes are closed will be asked to indicate when they can no longer sense the vibration from the vibrating tuning fork In general the
examiner should be able to feel vibration from the hand-held tuning fork for 5 seconds longer on his distal forefinger than a normal subject
can at the great toe (eg examiners DIP joint of the first finger versus patients toe) If the examiner feels vibration for 10 or more seconds
on his or her finger then vibration is considered decreased A trial should be given when the tuning fork is not vibrating to be certain that
the patient is responding to vibration and not pressure or some other clue Vibration is scored as 1) present if the examiner senses the
vibration on his or her finger for lt10 seconds 2) reduced if sensed for 10 seconds or 3) absent (no vibration detection)
Monofilament Testing For this examination it is important that the patients foot be supported (ie allow the sole of the foot to rest on
a flat warm surface) The filament should initially be pre-stressed (4-6 perpendicular applications to the dorsum of the examiner s first
finger) The filament is then applied to the dorsum of the great toe midway between the nail fold and the DIP joint Do not hold the toe
directly The filament is applied perpendicularly and briefly (lt1 second) with an even pressure When the filament bends the force of
10 grams has been applied The patient whose eyes are closed is asked to respond yes if heshe feels the filament Eight correct responses
out of 10 applications is considered normal 1 to 7 correct responses indicates reduced sensation and no correct answers translates into
absent sensation
hOrthostatic hypotension is a physical finding defined by the American Autonomic Society and the American Academy of Neurology as a
systolic blood pressure decrease of at least 20 mm Hg or a diastolic blood pressure decrease of at least 10 mm Hg within 3 minutes of
standing
22
43523 Normal cardiac physical exam Cardiac stress testing to at least 12 METS is recommended and
should begin based on either the criteria of the American Heart AssociationAmerican College of
Cardiologyi10 or those of the American Diabetes Associationj11
Diabetics who have a normal cardiac stress test will be retested every one to three years based on
individual clinical assessment This assessment should consider
the age of the individual
the number and persistence of coronary artery disease (CAD) risk factors
the severity of CAD risk factors
43524 Microalbumincreatinine ratio 301 measured or calculatedk creatinine clearance
gt60 mlmin12
436 ndash ONGOING EVALUATION AND REQUIREMENTS
4361 Should have medical records and glucose meter logs reviewed periodically Because of the nature of
diabetes it is important that regular medical follow up be provided to the LEO The frequency and content of
the evaluation should be determined on an individual basis by the police physician in consultation with the
treating physicianl
4362 Must advise police physician of any change in type of medication
4363 Must advise police physician of any episodes of significant hypoglycemia or hyperglycemia
Urine microalbumincreatinine ratio _________________
III Treating Physician Statement
The above named individual meets all of the criteria provided on this form
Yes No ndash not recommended for position
No but IS recommended for position (letter of explanation attached)
It is my opinion that the above named individual is well-educated and well-motivated in diabetes self-management and has
achieved a level of diabetes management to be capable of safe and effective job performance as a law enforcement officer
I have reached this opinion after careful review of the above criteria
___________________________________________________________ ___________________________Signature of Physician Date
______________________________________________________________ ___________________________Printed or Typed Name of Physician Telephone Number
10 ACOEM Guidance for the Medical Evaluation of Law Enforcement Officers
43 ndash DIABETES MELLITUS
29
439 ndash REFERENCES
1 American Diabetes Association Diagnosis and classification of diabetes mellitus Diabetes Care 200427 Suppl
1S5-S10 See httpcarediabetesjournalsorgcgicontentfull27suppl_1s5
2 American Diabetes Association Continuous subcutaneous insulin infusion Diabetes Care 200427 Suppl 1S110
See httpcarediabetesjournalsorgcgicontentfull27suppl_1s110
3 Mensing C Boucher J Cypress M et al National standards for diabetes self-management education Diabetes
Care 200528 Suppl 1S72-9 See httpcarediabetesjournalsorgcgicontentfull28suppl_1s72
4 Goldstein DE Little RR Lorenz RA Malone JI Nathan DM Peterson CM American Diabetes Association Tests
of glycemia in diabetes Diabetes Care 200427 Suppl 1S91-3
See httpcarediabetesjournalsorgcgicontentfull27suppl_1s91
5 The Diabetes Control and Complications Trial Research Group Hypoglycemia in the Diabetes Control and
Complications Trial Diabetes 199746(2)271-86 See wwwncbinlmnihgovpubmed9000705 for abstract
6 American Diabetes Association Hypoglycemia and employmentlicensure Diabetes Care 200528 Suppl 1S61
See httpcarediabetesjournalsorgcgicontentfull28suppl_1s61
7 Viswanath K McGavin DD Diabetic Retinopathy Clinical Findings and Management J Comm Eye Health
200316(46)21-4 See wwwcehjournalorg0953-683316jceh_16_46_021html
8 Michigan Diabetes Research and Training Center University of Michigan Health System How to use the Michigan
Neuropathy Screening Instrument See wwwmedumichedumdrtcprofsdocumentssviMNSI_howtopdf
9 Bradley JG Davis KA Orthostatic hypotension Am Fam Physician 200368(12)2393-8
See wwwaafporgafp200312152393html
10 Gibbons RJ Balady GJ Bricker JT et al ACCAHA 2002 guideline update for exercise testing a report of the
American College of CardiologyAmerican Heart Association Task Force on Practice Guidelines (Committee on
Exercise Testing) J Am Coll Cardiol 200240(8)1531-40
See wwwaccorgqualityandscienceclinicalguidelinesexerciseexercise_cleanpdf
11 American Diabetes Association Standards of medical care in diabetes Diabetes Care 200528 Suppl 1S4-S36
Erratum in Diabetes Care 200528(4)990 See httpcarediabetesjournalsorgcgicontentfull28suppl_1s4
12 Molitch ME DeFronzo RA Franz MJ et al American Diabetes Association Nephropathy in diabetes Diabetes
Care 200427 Suppl 1S79-83 See httpcarediabetesjournalsorgcgicontentfull27suppl_1s79
13 Kitabchi AE Umpierrez GE Murphy MB et al American Diabetes Association Hyperglycemic crises in diabetes
Diabetes Care 200427 Suppl 1S94-102 See httpcarediabetesjournalsorgcgicontentfull27suppl_1s94
14 US Centers for Disease Control and Prevention National Diabetes Fact Sheet 2007
See wwwcdcgovdiabetespubspdfndfs_2007pdf
ACOEM Guidance for the Medical Evaluation of Law Enforcement Officers 11
43 ndash DIABETES MELLITUS
30
ATTACHMENT E
31
Typos A6921(2) 7th line down test should be plural 94201 Paragraph 2 target organ damage is used though end organ damage was defined earlier and in the appendix for that paragraph
A94201 Para A (1) d Id suggest deleting the phrases in brackets Im not sure either are predictably true or politically wise
a) tests for left ventricular hypertrophy Unfortunately use of the EKG to detect left ventricular hypertrophy is very insensitive (eg 5 sensitivity) The echocardiogram is the best test for diagnosing left ventricular hypertrophy but [it is relatively expensive and not readily available in small rural communities ] conducting echocardiograms on asymptomatic fire fighters with Stage 1 hypertension should be reserved only for those with long-standing hypertension
In addition
7761 A resting EKG shall be performed as part of the baseline medical evaluation and shall be obtained periodically thereafter
Changing from annually to periodically is noted has the language in the wellness-fitness initiative been changed as well Our previous decision was that we would support the W-F language since there was no compelling evidence to either support or refute it
Thanks
Sandy
32
NFPA 1582‐ HTN Draft 1
Reason for Revision
1) New classification of BP by the Joint National Commission [Chobanian et al 2002]
2) A high prevalence of FF have either HTN (~20) and Pre‐HTN (~20) [Soteriades et al 2003]
3) Among FF studies have shown a strong association between HTN and a number of adverse
cardiovascular events [Kales et al 2009]
4) A large percentage of on‐duty FF fatalities were found to have left ventricular hypertrophy a
complication of HTN at autopsy
Language in 2007 Edition with draft revisions in Red (Track changes)
611 The medical evaluation of a candidate shall include a medical history examination and any laboratory tests required to detect physical or medical condition(s) that could adversely affect hisher ability to safely perform the essential job tasks outlined in 511 A611 The medical history should include the candidates known health problems such as major illnesses surgeries medication use and allergies Symptom review is also important for detecting early signs of illness A medical history should also include a personal health history a family health history a health habit history an immunization history and a reproductive history
An occupational history should also be obtained to collect information about the persons past occupational and environmental exposures
(a) BP should be measured according to the Joint National Commission (JNC) -7 recommendations BP should be measured with a properly calibrated and validated instrument Patients should be seated quietly for at least 5 minutes in a chair with feet on the floor and arm supported at heart level An appropriate-sized cuff (cuff bladder encircling at least 80 of the arm) should be used to ensure accuracy At least 2 measurements should be made Systolic BP is the point at which the first of 2 or more sounds is heard (phase 1) and diastolic BP is the point before the disappearance of sounds (phase 5) [Chobanian et al 2003]
(2) Head eyes ears nose and throat (HEENT)
Formatted Font (Default) Times New RomanFont color Black
33
692 Vascular System 6921 Category A medical conditions shall include the following
(1) Uncontrolled or poorly controlled hypertension
(2) Hypertension with evidence of end organ damage
or not controlled by approved medications
A6921(1) Uncontrolled or poorly controlled hHypertension increases the risk of a sudden cardiac event This sudden cardiac event would cause sudden incapacitation which that is uncontrolled poorly controlled or requires medication likely to interferes with the safe performance of essential job tasks Uncontrolled or poorly controlled hypertension can be defined as the presence of end organ damage (see below) or stage 2 hypertension (BP systolic gt160 mmHg or BP diastolic gt100 mmHg) is an illness that can lead to functional impairment and potential for sudden incapacitation Individuals with pre- stage 1 or stage 2 hypertension should be referred to their primary care physician for evaluation lifestyle modification and treatment [QUESTION FOR GROUP _- WHAT ABOUT HAVING CANDIDATE RETURN IN ONE MONTH UNDER TREATMENT WITH NORMAL BP]
A6921(2)
Chronic hypertension can damage the eye (retinopathy) the kidneys (nephropathy) the vascular system (stroke transient ischemic attack or peripheral artery disease) or the heart (left ventricular hypertrophy and heart failure) These hypertension complications are known as end organ damage The cardiac and vascular complications are associated with an increased risk of sudden incapacitation and sudden cardiac death (Koren et al 1991) Unfortunately the cardiac complications are frequently asymptomatic and valid screening tests are not fast and are not inexpensive Therefore determining who to screen for cardiac complications (such as echocardiogram for LVH or a measurement of left ventricular ejection fraction for heart failure) should be based on the severity and the duration of HTN
76 Physical Examination The annual physical examination shall include each of the following components
(a) BP shall be measured according to the Joint National Commission (JNC)-7 recommendations
A76(1)(a) BP should be measured with a properly calibrated and validated instrument Patients should be seated quietly for at least 5 minutes in a chair with feet on the floor and arm supported at heart level An appropriate-sized cuff (cuff bladder encircling at least 80 of the arm) should be used to ensure accuracy At least 2 measurements should be made Systolic BP is the point at which the first of 2 or more sounds is heard (phase 1) and diastolic BP is the point before the disappearance of sounds (phase 5) [Chobanian et al 2003]
(2) Head eyes ears nose and throat (HEENT)
34
9420 Uncontrolled Hypertension 94201 Physician Evaluation Severe uncontrolled hypertension [defined as systolic pressure greater than 180 mm Hg diastolic pressure greater than 100 mm Hg or mean systolic blood
pressure ( systolic + diastolic) greater than 120 mm Hg] or malignant hypertension (defined as hypertension with the presence of target organ damage) compromises the members ability to safely perform essential job tasks 1 5 7 9 and 13 and the physician shall report the applicable job limitations to the fire department
Members with Pre-hypertention (systolic 120-139 mmHg or diastolic 80-89 mmHg) Stage 1 hypertension (systolic 140-159 mmHg or diastolic 90-99 mmHg) or Stage 2 hypertension (systolic ge160 mmHg or diastolic ge100 mmHg) should be referred to their primary care physician for evaluation lifestyle modification and treatment
(1) Members with Stage I hypertension should be followed-up not only by their primary care physician but also by the FD physician every 3 to 6 months to ensure their blood pressure is under control and to determine whether screening tests for asymptomatic end organ damage are appropriate
(2) Members with Stage 2 hypertension or with end organ damage (retinopathy nephropathy vascular or cardiac complications) compromises the members ability to safely perform essential job tasks 1 5 7 9 and 130 and the physician shall report the applicable job limitations to the fire department
A94201 Severe uncontrolled hypertension is a significant risk factor for the development of coronary artery disease congestive heart failure and stroke Blood pressure increases as a normal response to exercise This response is further exaggerated by the emotional and physical stress of performing these critical tasks while operating in personal protective clothing at extremes of temperature This normal elevation of blood pressure under these response conditions can lead to life-threatening hypertensive emergencies if a members daily blood pressure is already elevated to high levels In addition hypertension is a progressive illness that when uncontrolled ultimately and inevitably leads to target organ damage Target organs that are sensitive to the effects of elevated blood pressure are the central nervous system vision heart major blood vessels and kidneys
Chronic hypertension can damage the eye (retinopathy) the kidneys (nephropathy) the vascular system (stroke transient ischemic attack or peripheral artery disease) or the heart (left ventricular hypertrophy and heart failure) These hypertension complications are known as end organ damage The cardiac and vascular complications are associated with an increased risk of sudden incapacitation and sudden cardiac death (Koren et al 1991) Fortunately with proper evaluation life style modification and treatment these complications can be avoided Life style modification includes weight reduction DASH eating plan reduction in dietary sodium an increase in aerobic physical activity and moderation in alcohol consumption [Chobanian 2003]
Formatted Font (Default) Times New Roman12 pt Font color Black
Formatted Font (Default) Times New Roman12 pt Font color Black
35
A94201 (1) Members with Stage I hypertension whose BP returns to either pre-hypertenion or normal with lifestyle modification andor treatment can return to an annual medical evaluation For members with long-standing Stage I hypertension whose BP has not been reduced additional evaluation for possible end organ damage should be considered This evaluation could include any or all of the following
a) a compete patient history for symptoms of heart failure (eg shortness of breath upon exertion) or transient ischemic attacks (TIAs)
b) dilated eye examination for retinopathy
c) blood creatinine measurement for nephropathy
d) tests for left ventricular hypertrophy Unfortunately use of the resting EKG to detect left ventricular hypertrophy is very insensitive (eg 5 sensitivity) The echocardiogram is the best test for diagnosing left ventricular hypertrophy
A 94201 (2) Due to the high risk of a sudden cardiovascular event members with Stage 2 hypertension should be restricted until their BP can be brought under control Once the BP is brought under control they should be followed in the same manner as a member with Stage I hypertension
Formatted Font (Default) Times New Roman12 pt
36
D22 Cardiology Gibbons R J GJ Balady J W Beasley et al 1997 ACCAHA guidelines for exercise testing a report of American College of CardiologyAmerican Heart Association Task Force on Practice Guidelines (Committee on Exercise Testing) J Am Coll Cardiol 30260ndash311
Gibbons RJ Balady GJ Bricker JT Chaitman BR Fletcher GF Froelicher VF Mark DB McCallister BD Mooss AN OrsquoReilly MG Winters WL Jr [2002] ACCAHA 2002 guideline update for exercise testing summary article a report of the ACCAHA Task Force on Practice Guidelines (Committee to Update the 1997 Exercise Testing guidelines) J Am Coll Cardiol 401531ndash 40
Chobanian AV Bakris GL Black HR Cushman WC Green LA Izzo JL Jr Jones DW Materson BJ Oparil S Wright JT Jr Roccella EJ the National High Blood Pressure Education Program Coordinating Committee [2003] The seventh report of the Joint National Committee [JNC-7] on Prevention Detection Evaluation and Treatment of High Blood Pressure JAMA 2892560ndash2571
Soteriades ES Kales SN Liarokapis D Christiani DC [2003] Prospective surveillance of hypertension in firefighters J Clin Hypertens 5315-320
Kales SN Tsismenakis AJ Zhang C Soteriades ES [2009] Blood pressure in fire fighters police officers and other emergency responders Am J Hypertens 2211-20
37
NFPA 1582‐ HTN Draft 1
Reason for Revision
1) New classification of BP by the Joint National Commission [Chobanian et al 2002]
2) A high prevalence of FF have either HTN (~20) and Pre‐HTN (~20) [Soteriades et al 2003]
3) Among FF studies have shown a strong association between HTN and a number of adverse
cardiovascular events [Kales et al 2009]
4) A large percentage of on‐duty FF fatalities were found to have left ventricular hypertrophy a
complication of HTN at autopsy
Language in 2007 Edition with draft revisions in Red (Track changes)
611 The medical evaluation of a candidate shall include a medical history examination and any laboratory tests required to detect physical or medical condition(s) that could adversely affect hisher ability to safely perform the essential job tasks outlined in 511 A611 The medical history should include the candidates known health problems such as major illnesses surgeries medication use and allergies Symptom review is also important for detecting early signs of illness A medical history should also include a personal health history a family health history a health habit history an immunization history and a reproductive history
An occupational history should also be obtained to collect information about the persons past occupational and environmental exposures
(a) BP should be measured according to the Joint National Commission (JNC) -7 recommendations BP should be measured with a properly calibrated and validated instrument Patients should be seated quietly for at least 5 minutes in a chair with feet on the floor and arm supported at heart level An appropriate-sized cuff (cuff bladder encircling at least 80 of the arm) should be used to ensure accuracy At least 2 measurements should be made Systolic BP is the point at which the first of 2 or more sounds is heard (phase 1) and diastolic BP is the point before the disappearance of sounds (phase 5) [Chobanian et al 2003]
(2) Head eyes ears nose and throat
38
692 Vascular System 6921 Category A medical conditions shall include the following
(1) Uncontrolled or poorly controlled hypertension
(2) Hypertension with evidence of end organ damage
A6921(1) Uncontrolled or poorly controlled hypertension increases the risk of a sudden cardiac event This sudden cardiac event would cause sudden incapacitation which interferes with the safe performance of essential job tasks Uncontrolled or poorly controlled hypertension can be defined as the presence of end organ damage (see below) or stage 2 hypertension (BP systolic gt160 mmHg or BP diastolic gt100 mmHg) Individuals with pre- stage 1 or stage 2 hypertension should be referred to their primary care physician for evaluation lifestyle modification and treatment [QUESTION FOR GROUP _- WHAT ABOUT HAVING CANDIDATE RETURN IN ONE MONTH UNDER TREATMENT WITH NORMAL BP]
A6921(2)Chronic hypertension can damage the eye (retinopathy) the kidneys (nephropathy) the vascular system (stroke transient ischemic attack or peripheral artery disease) or the heart (left ventricular hypertrophy and heart failure) These hypertension complications are known as end organ damage The cardiac and vascular complications are associated with an increased risk of sudden incapacitation and sudden cardiac death (Koren et al 1991) Unfortunately the cardiac complications are frequently asymptomatic and valid screening tests are not fast and are not inexpensive Therefore determining who to screen for cardiac complications (such as echocardiogram for LVH or a measurement of left ventricular ejection fraction for heart failure) should be based on the severity and the duration of HTN
76 Physical Examination The annual physical examination shall include each of the following components
(a) BP shall be measured according to the Joint National Commission (JNC)-7 recommendations
A76(1)(a) BP should be measured with a properly calibrated and validated instrument Patients should be seated quietly for at least 5 minutes in a chair with feet on the floor and arm supported at heart level An appropriate-sized cuff (cuff bladder encircling at least 80 of the arm) should be used to ensure accuracy At least 2 measurements should be made Systolic BP is the point at which the first of 2 or more sounds is heard (phase 1) and diastolic BP is the point before the disappearance of sounds (phase 5) [Chobanian et al 2003]
(2) Head eyes ears nose and throat9420 Hypertension 94201 Physician Evaluation Members with Pre-hypertention (systolic 120-139 mmHg or diastolic 80-89 mmHg) Stage 1 hypertension (systolic 140-159 mmHg or diastolic 90-99 mmHg) or Stage 2 hypertension (systolic ge160 mmHg or diastolic ge100 mmHg) should be referred to their primary care physician for evaluation lifestyle modification and treatment
39
(1) Members with Stage I hypertension should be followed-up not only by their primary care physician but also by the FD physician every 3 to 6 months to ensure their blood pressure is under control and to determine whether screening tests for asymptomatic end organ damage are appropriate
(2) Members with Stage 2 hypertension or with end organ damage (retinopathy nephropathy vascular or cardiac complications) compromises the members ability to safely perform essential job tasks 1 5 7 9 and 130 and the physician shall report the applicable job limitations to the fire department
A94201 Chronic hypertension can damage the eye (retinopathy) the kidneys (nephropathy) the vascular system (stroke transient ischemic attack or peripheral artery disease) or the heart (left ventricular hypertrophy and heart failure) These hypertension complications are known as end organ damage The cardiac and vascular complications are associated with an increased risk of sudden incapacitation and sudden cardiac death (Koren et al 1991) Fortunately with proper evaluation life style modification and treatment these complications can be avoided Life style modification includes weight reduction DASH eating plan reduction in dietary sodium an increase in aerobic physical activity and moderation in alcohol consumption [Chobanian 2003]
A94201 (1) Members with Stage I hypertension whose BP returns to either pre-hypertenion or normal with lifestyle modification andor treatment can return to an annual medical evaluation For members with long-standing Stage I hypertension whose BP has not been reduced additional evaluation for possible end organ damage should be considered This evaluation could include any or all of the following
a) a compete patient history for symptoms of heart failure (eg shortness of breath upon exertion) or transient ischemic attacks (TIAs)
b) dilated eye examination for retinopathy
c) blood creatinine measurement for nephropathy
d) tests for left ventricular hypertrophy Unfortunately use of the resting EKG to detect left ventricular hypertrophy is very insensitive (eg 5 sensitivity) The echocardiogram is the best test for diagnosing left ventricular hypertrophy
A 94201 (2) Due to the high risk of a sudden cardiovascular event members with Stage 2 hypertension should be restricted until their BP can be brought under control Once the BP is brought under control they should be followed in the same manner as a member with Stage I hypertension
D22 Cardiology
40
Hypertension
Gibbons RJ Balady GJ Bricker JT Chaitman BR Fletcher GF Froelicher VF Mark DB McCallister BD Mooss AN OrsquoReilly MG Winters WL Jr [2002] ACCAHA 2002 guideline update for exercise testing summary article a report of the ACCAHA Task Force on Practice Guidelines (Committee to Update the 1997 Exercise Testing guidelines) J Am Coll Cardiol 401531ndash 40
Chobanian AV Bakris GL Black HR Cushman WC Green LA Izzo JL Jr Jones DW Materson BJ Oparil S Wright JT Jr Roccella EJ the National High Blood Pressure Education Program Coordinating Committee [2003] The seventh report of the Joint National Committee [JNC-7] on Prevention Detection Evaluation and Treatment of High Blood Pressure JAMA 2892560ndash2571
Soteriades ES Kales SN Liarokapis D Christiani DC [2003] Prospective surveillance of hypertension in firefighters J Clin Hypertens 5315-320
Kales SN Tsismenakis AJ Zhang C Soteriades ES [2009] Blood pressure in fire fighters police officers and other emergency responders Am J Hypertens 2211-20
41
NFPA 1582‐ Draft Revisions for CVDHTN
EKG and stress tests
Reason for Revision
1) Change requirement for annual resting EKG to periodically to be more consistent with ACCAHA
recommendation (Schlant et al 1992)
2) Add language to clarify what constitutes a positive ST
3) Make criteria for conducting diagnostic ST in asymptomatic patients consistent with the
ACCAHA
Language in 2007 Edition with draft revisions in Red (Track changes)
776 Electrocardiograms (EKG)) and Stress Tests 7761 A resting EKG shall be performed as part of the baseline medical evaluation and shall be obtained periodically (every 1 to 5 years) annually thereafter
A7761 A baseline resting EKGs shall be conducted Follow-up resting EKGs should be conducted as clinically indicated but at a minimum of every 1 to 5 years The frequency of these follow-up resting EKGs should increase as a members age increases or with increasing number andor severity of coronary heart disease risk factors Members above the age of 40 should have annual resting EKGs (Schlant et al 1992)
7762 The fire department physician or other qualified medical evaluator shall compare EKGs obtained during yearly evaluations with baseline and subsequent EKGs
7763 Stress testing EKG with or without echocardiography or radionuclide scanning shall be performed as clinically indicated by history or symptoms
A7761 Baseline electrocardiography should be conducted (Periodic resting electrocardiograms have not been shown to be useful but can be reasonable as a members agefactors increase)
A7763 No firm guidelines for stress testingelectrocardiography in asymptomatic individuals have been developed Stress testingelectrocardiography as a screening tool is used as part of an evaluation of aerobic capacity during the annual occupational fitness evaluation Submaximal stress testingelectrocardiography testing to 85 percent is commonly used as part of this screening
Submaximal stress electrocardiography testing should not be used for diagnostic purposes Cardiology evaluation with maximal stress testingelectrocardiography together with imaging techniques (eg echocardiography technetium Tc99m sestamibi study andor coronary angiography) is necessary for diagnosticprognostic purposes for the following
42
(1) Fire fighters with positive or questionably positive changes on screening submaximal stress tests
(2) Fire fighters with new onset chest pain or other symptoms suggestive of coronary artery disease (CAD)
(3) Fire fighters with diabetes mellitus who
(a) are gt35 years old or
(b) have type I diabetes for more than 15 years or
(c) have type II diabetes for more than 10 years or
(d) have any other CHD risk factor (see below) or
(e) have the presence of microvascular disease (proliferative retinopathy)
(4) Fire fighters over the age of 45 (for men) and 55 (for women) with onetwo or more risk factors for CAD Risk factors for CAD include hypercholesterolemia (total cholesterol greater than 240 mgdL) hypertension (systolic gt140 mmHg or diastolic gt90 mmHg) smoking or family history of premature CAD (heart attack or sudden cardiac death in a first degree relative less than 60 years of age)
as defined below if stress electrocardiography with imaging is negative then repeat as clinically indicated or at least every 5 years
(5) Fire fighters with a Framingham Risk Score gt10 Risk calculator is available at [httphp2010nhlbihinnetatpiiicalculatorasp]
(6) Fire fighters identified in 9431
Negative stress tests should be repeated as clinically indicated or at least every 2 to 5 years
Interpreting stress tests as ldquopositiverdquo or ldquonegativerdquo is beyond the scope of this document However factors that should be taken into consideration should include the individualrsquos exercise capacity symptoms blood pressure response heart rate response EKG changes and the presence of arrhythmias (Gibbon et al 2002)
Risk factors for CAD include hypercholesterolemia (total cholesterol greater than 240 mgdL) hypertension (systolic greater than 140 andor diastolic greater than 90) smoking diabetes mellitus or family history of premature CAD (heart attack or sudden cardiac death in a first degree relative less than 60 years of age)
There are other non-invasive tests to screen for coronary artery disease One of the most promising appears to be coronary artery calcium (CAD) scoring by computed tomography In 2007 an expert committee published an update to their original guidance document The committeersquos consensus was that ldquoit may be reasonable to consider use of CAC measurement in such patients [between 10 and 20 10-year risk of estimated coronary event]helliprdquo The committee did not recommend CAC measurement in low risk patients [lt10 10-year risk of estimated coronary event] or in high risk patients [gt20 10-year risk of estimate coronary event] (Greenland et al 2007]
43
D22 Cardiology
Chobanian AV Bakris GL Black HR Cushman WC Green LA Izzo JL Jr Jones DW Materson BJ Oparil S Wright JT Jr Roccella EJ the National High Blood Pressure Education Program Coordinating Committee [2003] The seventh report of the Joint National Committee [JNC-7] on Prevention Detection Evaluation and Treatment of High Blood Pressure JAMA 2892560ndash2571
Gibbons RJ Balady GJ Bricker JT Chaitman BR Fletcher GF Froelicher VF Mark DB McCallister BD Mooss AN OrsquoReilly MG Winters WL Jr [2002] ACCAHA 2002 guideline update for exercise testing summary article a report of the ACCAHA Task Force on Practice Guidelines (Committee to Update the 1997 Exercise Testing guidelines) J Am Coll Cardiol 401531ndash 1540
Greenland et al [2007] ACCFAHA 2007 Clinical Expert Consensus Document on Coronary Artery Calcium Scoring By Computed Tomography in Global Cardiovascular Risk Assessment and in Evaluation of Patients With Chest Pain A Report of the American College of Cardiology Foundation Clinical Expert Consensus Task Force (ACCFAHA Writing Committee to Update the 2000 Expert Consensus Document on Electron Beam Computed Tomography) J Am Coll Cardiol 49378-402
Kales SN Tsismenakis AJ Zhang C Soteriades ES [2009] Blood pressure in fire fighters police officers and other emergency responders Am J Hypertens 2211-20
Schlant RC Adolph RJ DiMarco JP Dreifus LS Dunn MI Fisch C Garson A Jr Haywood LJ Levine HJ Murray JA Noble RJ Ronan JA Jr [1992] Guidelines for electrocardiography A report of the American College of CardiologyAmerican Heart Association Task Force on Assessment of Diagnostic and Therapeutic Cardiovascular Procedures (Committee on Electrocardiography) Circulation 85(3)1221-1228
Soteriades ES Kales SN Liarokapis D Christiani DC [2003] Prospective surveillance of hypertension in firefighters J Clin Hypertens 5315-320
Formatted Font Italic
Formatted Line spacing single
Formatted Font Italic
Formatted Font Italic
44
NFPA 1582‐ Draft Revisions for CVDHTN
EKG and stress tests
Reason for Revision
1) Change requirement for annual resting EKG to periodically to be more consistent with ACCAHA
recommendation (Schlant et al 1992)
2) Add language to clarify what constitutes a positive ST
3) Make criteria for conducting diagnostic ST in asymptomatic patients consistent with the
ACCAHA
Language in 2007 Edition with draft revisions in Red (Track changes)
776 Electrocardiograms (EKG) and Stress Tests 7761 A resting EKG shall be performed as part of the baseline medical evaluation and shall be obtained periodically (every 1 to 5 years) thereafter
A7761 A baseline resting EKGs shall be conducted Follow-up resting EKGs should be conducted as clinically indicated but at a minimum of every 1 to 5 years The frequency of these follow-up resting EKGs should increase as a members age increases or with increasing number andor severity of coronary heart disease risk factors Members above the age of 40 should have annual resting EKGs (Schlant et al 1992)
7762 The fire department physician or other qualified medical evaluator shall compare baseline and subsequent EKGs
7763 Stress testing with or without echocardiography or radionuclide scanning shall be performed as clinically indicated by history or symptoms
A7763 No firm guidelines for stress testing in asymptomatic individuals have been developed Stress testing as a screening tool is used as part of an evaluation of aerobic capacity during the annual occupational fitness evaluation Submaximal stress testing testing to 85 percent is commonly used as part of this screening
Submaximal stress testing should not be used for diagnostic purposes Cardiology evaluation with maximal stress testing together with imaging techniques (eg echocardiography technetium Tc99m sestamibi study) is necessary for diagnosticprognostic purposes for the following
(1) Fire fighters with positive or questionably positive changes on screening submaximal stress tests
(2) Fire fighters with new onset chest pain or other symptoms suggestive of coronary artery disease (CAD)
45
(3) Fire fighters with diabetes mellitus who
(a) are gt35 years old or
(b) have type I diabetes for more than 15 years or
(c) have type II diabetes for more than 10 years or
(d) have any other CHD risk factor (see below) or
(e) have the presence of microvascular disease (proliferative retinopathy)
(4) Fire fighters over the age of 45 (for men) and 55 (for women) with one or more risk factors for CAD Risk factors for CAD include hypercholesterolemia (total cholesterol greater than 240 mgdL) hypertension (systolic gt140 mmHg or diastolic gt90 mmHg) smoking or family history of premature CAD (heart attack or sudden cardiac death in a first degree relative less than 60 years of age)
(5) Fire fighters with a Framingham Risk Score gt10 Risk calculator is available at [httphp2010nhlbihinnetatpiiicalculatorasp]
(6) Fire fighters identified in 9431
Negative stress tests should be repeated as clinically indicated or at least every 2 to 5 years
Interpreting stress tests as ldquopositiverdquo or ldquonegativerdquo is beyond the scope of this document However factors that should be taken into consideration should include the individualrsquos exercise capacity symptoms blood pressure response heart rate response EKG changes and the presence of arrhythmias (Gibbon et al 2002)
There are other non-invasive tests to screen for coronary artery disease One of the most promising appears to be coronary artery calcium (CAD) scoring by computed tomography In 2007 an expert committee published an update to their original guidance document The committeersquos consensus was that ldquoit may be reasonable to consider use of CAC measurement in such patients [between 10 and 20 10-year risk of estimated coronary event]helliprdquo The committee did not recommend CAC measurement in low risk patients [lt10 10-year risk of estimated coronary event] or in high risk patients [gt20 10-year risk of estimate coronary event] (Greenland et al 2007]
D22 Cardiology
Resting EKG and Stress Tests
46
Chobanian AV Bakris GL Black HR Cushman WC Green LA Izzo JL Jr Jones DW Materson BJ Oparil S Wright JT Jr Roccella EJ the National High Blood Pressure Education Program Coordinating Committee [2003] The seventh report of the Joint National Committee [JNC-7] on Prevention Detection Evaluation and Treatment of High Blood Pressure JAMA 2892560ndash2571
Gibbons RJ Balady GJ Bricker JT Chaitman BR Fletcher GF Froelicher VF Mark DB McCallister BD Mooss AN OrsquoReilly MG Winters WL Jr [2002] ACCAHA 2002 guideline update for exercise testing summary article a report of the ACCAHA Task Force on Practice Guidelines (Committee to Update the 1997 Exercise Testing guidelines) J Am Coll Cardiol 401531ndash 1540
Greenland et al [2007] ACCFAHA 2007 Clinical Expert Consensus Document on Coronary Artery Calcium Scoring By Computed Tomography in Global Cardiovascular Risk Assessment and in Evaluation of Patients With Chest Pain A Report of the American College of Cardiology Foundation Clinical Expert Consensus Task Force (ACCFAHA Writing Committee to Update the 2000 Expert Consensus Document on Electron Beam Computed Tomography) J Am Coll Cardiol 49378-402
Kales SN Tsismenakis AJ Zhang C Soteriades ES [2009] Blood pressure in fire fighters police officers and other emergency responders Am J Hypertens 2211-20
Schlant RC Adolph RJ DiMarco JP Dreifus LS Dunn MI Fisch C Garson A Jr Haywood LJ Levine HJ Murray JA Noble RJ Ronan JA Jr [1992] Guidelines for electrocardiography A report of the American College of CardiologyAmerican Heart Association Task Force on Assessment of Diagnostic and Therapeutic Cardiovascular Procedures (Committee on Electrocardiography) Circulation 85(3)1221-1228
Soteriades ES Kales SN Liarokapis D Christiani DC [2003] Prospective surveillance of hypertension in firefighters J Clin Hypertens 5315-320
47
ATTACHMENT F
48
1
Current 1582 (2007) language in reference to pregnancy 43 (4) Report to the fire department physician any medical condition that could interfere with the ability of the individual to safely perform essential job tasks such as illness or injury use of prescription or nonprescription drugs and pregnancy 6112 Category B medical conditions shall include the following (1) Pregnancy for its duration A7792 (e) If HIV prophylaxis is to be given the following tests should be done i CBC ii Glucose renal and hepatic chemical function iii Pregnancy test for females B121 Pregnancy and Reproduction Federal regulations as well as many court decisions including the US Supreme Courtrsquos decision in International Union et al v Johnson Controls Inc [499 US 187 111 S Ct 1196 (1991)] have interpreted the requirements of Title VII with respect to pregnancy and reproduction The AHJ should seek the advice of counsel in resolving specific questions concerning these requirements as well as other requirements that can be imposed by state or local laws C211 (4) Review health status with the individual being evaluated Contraindications for evaluations shall be reviewed addressing any changes in the individualrsquos health status since their last medical evaluation that would warrant deferring the evaluation including (g) Pregnancy Recommendations to language enhancement
A female employee who is assigned to regular fire line duty shall report a pregnancy immediately to their respective Supervisor and the fire department physician The employee will then be given the option of a non-hazardous alternative duty position for the duration of her pregnancy (can we say this or is it even appropriate) Any pregnant employee wishing to remain on regular line duty shall be informed of the possible risks and consequences to herself and her fetus that are associated with continued line fire fighting duty Among those risk factors are exposure to teratogens known to have negative effects on the developing fetus such as smoke diesel fumes hazardous chemicals and extreme heat
49
Page 2
appendix It is recommended that the pregnant employee complete a release of liability form signed by herself and her health care provider utilizing NFPArsquos 13 critical tasks as a reference This will inform the health care provider of specific job-related tasks that will need to be performed in order to continue regular line duty These tasks are basic physical standards that any entry level firefighter would have to be able to complete competently The employeersquos health condition will be kept confidential by the department in accordance with HIPAA standards Employees are allowed to remain on active regular duty until they are no longer able to perform their duties in a reasonable manner andor their protective gear no longer fits correctly It is the responsibility of the health care provider to evaluate the pregnant employee If at any time the health care provider feels the pregnant employee can no longer perform the job related tasks this should be reported to the employer by the employee immediately
50
ATTACHMENT G
51
From GLENN BENARICKTo Sawyer SteveSubject RE RE 7743Date Monday August 30 2010 21633 PM
Yes thats my understanding
Glenn P Benarick 211 Winged Elm CircleAiken SC 29803803-644-7093gbenarprodigynet
--- On Mon 83010 Sawyer Steve ltssawyerNFPAorggt wrote
From Sawyer Steve ltssawyerNFPAorggtSubject RE RE 7743To GLENN BENARICK ltgbenarprodigynetgtDate Monday August 30 2010 212 PM
So it should be ldquoorrdquo instead of ldquoandrdquo for now
Steven F Sawyer
Senior Fire Service Specialist
Executive Secretary IFMAFire Service Section
NFPA
1 Batterymarch Park
Quincy MA 02169
6179847423
Fax 6179847056
ssawyernfpaorg
From GLENN BENARICK [mailtogbenarprodigynet] Sent Monday August 30 2010 1202 PMTo Sawyer SteveSubject Fw RE 7743
52
Steve a couple of our docs agree with April Boyer
Glenn P Benarick 211 Winged Elm Circle
Aiken SC 29803
803-644-7093
gbenarprodigynet
--- On Mon 83010 David Prezant ltprezandfdnynycgovgt wrote
From David Prezant ltprezandfdnynycgovgtSubject RE 7743To Thomas R (CDCNIOSHDSHEFS) Hales lttrh1cdcgovgt GLENNBENARICK ltgbenarprodigynetgtCc Sandy Bogucki ltsandyboguckiyaleedugtDate Monday August 30 2010 1004 AM
agree
we should change this to NHANES III rather than Knudson we should alsomodify this to allow not only for predicted cutoffs but all for use of thelower limit of normal cutoff This is important to prevent false-classificationof spirometry as abnormal in older groups and in taller grps The latter ofparticular import to firefighter occupational health surveillance
thanks
David Prezant MDChief Medical Officer Office of Medical AffairsCo-Director WTC Medical Monitoring amp Treatment ProgramsNew York City Fire Department9 Metrotech Center - Rm 4W-1Brooklyn NY 11201Phone 718-999-2696Fax 718-999-0665
Life is full of twists and turns
53
This email may contain confidential information If you are the unintendedrecipient of this email please send it back and delete from your directory
gtgtgt Hales Thomas R (CDCNIOSHDSHEFS) lttrh1cdcgovgt 8302010955 AM gtgtgt
Glen
This seems like a very reasonable comment and illustrates the importance of having clinicians providefeedback on the std Im not familiar with the software program of the various spirometers (NHANES IIIvs KnudsonATS vs both) Given the large role both Dave Prezant and Sandy Bogucki had for thepulmonary section let me forward to them for clarification
Tom
From GLENN BENARICK [mailtogbenarprodigynet] Sent Sunday August 29 2010 456 PMTo Hales Thomas R (CDCNIOSHDSHEFS)Subject FW 7743
Tom is April Boyer correct
Glenn P Benarick 211 Winged Elm Circle
Aiken SC 29803
803-644-7093
gbenarprodigynet
--- On Thu 82610 Sawyer Steve ltssawyerNFPAorggt wrote
From Sawyer Steve ltssawyerNFPAorggtSubject FW 7743To GLENN BENARICK ltgbenarprodigynetgtDate Thursday August 26 2010 925 PM
FYI Do you have any answer She is write
Steven
54
Steven F Sawyer
Senior Fire Service Specialist
Executive Secretary IFMAFire Service Section
NFPA
1 Batterymarch Park
Quincy MA 02169
6179847423
Fax 6179847056
ssawyernfpaorg
From April Boyer [mailtoaboyerbicclinicorg] Sent Thursday August 26 2010 232 PMTo Sawyer SteveCc RobinMWebbmilstateorusSubject 7743
Steven
The spirometry tests cannot be corrected according to both references as the NFPA states because thereferences are contradictory The first part of 7743 states to follow the ATS guidelines and use theKnudsen (we at Basin Immediate Care use the Nhanes III) The second part states to follow the ACOEMguidelines and use the Nhanes III in the occupational setting if available with your unit (which is availableon ours) 7743 does not use the word OR regarding both requirements it uses the word AND whenreferring to the first and second parts thence making 7743 contradictory I realize the NFPA 1582 hasnot been updated since 2007 unless I have just not received an updated version
Our question to you is which part of 7743 do you want us to follow the first or the second part Anyfacility that has an updated computerized spirometry system (as we do) will not be able to follow bothrequired parts for obvious reasons We can either follow the first part of 7743 and use an oldercorrected version of the Knudson by going into our system and changing out of the Nhanes III conversionOR we can follow the second part of 7743 and use the newer corrected version of Nhanes III which ourunit offers too
If you have any questions you may contact me at anytime and I also have many references in regards toboth parts of 7743 if you would like to see them
55
Thank you~
April
Confidentiality NoticeThis message may contain information that isconfidential or privileged
If you are not the intended recipientPlease advise the sender immediately and delete this message
56
ATTACHMENT H
57
NFPA 1582 771(7) Proposed revisions
Why
Preliminary results of two prospective randomized trials on the PSA test were published in 2009 These studies resulted in medical organizations that previously providing guidance to modify their recommendations
Current language
771 Blood Tests Blood tests shall be performed annually and shall include the following
(7) Prostate specific antigen (PSA) after age 40 for positive family history if African American or if otherwise clinically indicated after age 50 for all other male member
Suggested Revision
771 Blood Tests Blood tests shall be performed annually and shall include the following
(7) Prostate specific antigen (PSA) after age 40 for positive family history if African American or if otherwise clinically indicated after age 50 for all other male member
772 Prostate-Specific Antigen (PSA) test At age 50 fire fighters shall have an opportunity to make an informed decision with either the Fire Department physician or their health care provider concerning the PSA test For fire fighters at increased risk of prostate cancer (African-Americans or those with a first degree relative diagnosed with prostate cancer before age 65) shall have the opportunity for this informed decision at age 40
A772 The PSA as a screening test for prostate cancer in asymptomatic men is controversial controversial for two reasons First there is no consensus that PSA screening actually saves lives For example the PSA test may detect small cancers that would never become life threatening Second it is unclear that the benefits of PSA screening outweigh the risks of follow-up diagnostic tests and cancer treatments For example the prostate biopsy used to diagnose prostate cancer may cause bleeding and infection And prostate cancer treatments such as surgery and radiation therapy may cause incontinence (inability to control urine flow) erectile dysfunction (erections inadequate for intercourse) and other complications For these reasons it is important that the benefits and risks of prostate diagnostic procedures and treatment be taken into account when considering the PSA screening test These considerations can be taken account during discussions with the fire department physician or onersquos health care provider
D211 Cancer Screening
Smith R A C J Mettlin K J Davis and H Eyre 2000 ldquoAmerican Cancer Society guidelines for the early detection of cancerrdquo CA J Clin 50(1)34ndash49
Added references
58
Carroll P Albertsen PC Greene K et al [2010] Prostate-specific antigen best practice statement 2009 update Am Urological Assoc Available at httpwwwauanetorgcontentguidelines-and-quality-careclinical-guidelinesmain-reportspsa09pdf Date accessed September 2010
Ferrini R Woolf SH [2009] Screening for prostate cancer in American men American College of Preventive Medicine Practice Policy Statement Available at httpwwwacpmorgprostatehtm Date accessed September 2010
National Cancer Institute [2009] Prostate-specific antigen test National Cancer Institute Fact Sheet Available at httpwwwcancergovcancertopicsfactsheetDetectionPSA Date accessed September 2010
Wolf AMD Wender RC Etzioni RB et al [2010] American Cancer Society guideline for the early detection of prostate cancer Update 2010 Available at httpcaonlineamcancersocorgcgicontentfullcaac20066v1 Date accessed September 2010
59
Address List 9172010
Fire Service Occupational Safety and Health FIX-AAAKenneth Willette
Dominic J Colletti
FIX-AAAPrincipalHale Products Inc
700 Spring Mill Avenue
Conshohocken PA 19428
Fire Apparatus Manufacturers AssociationAlternate Leroy B Coffman III
PhoneCell 610-940-2437
Fax 610-825-6440
Email dcollettiidexcorpcom
M 4171998 Thomas J Cuff Jr
FIX-AAAPrincipalFiremens Association of the State of New York
127 Shelter Lane
Levittown NY 11756-1218
PhoneCell 516-735-4081 516-351-0942
Fax 516-579-9063
Email tomc621aolcom
U 10101997
Michael L Finkelman
FIX-AAAPrincipal182 Melanie Drive
East Meadow NY 11554
Association of Fire DistrictsState of New YorkPhoneCell 516-579-7570 516-369-8648
Fax 516-542-0593
Email mikexx00aolcom
U 7282006 Stephen N Foley
FIX-AAAPrincipalUS Department of Homeland Security
US Fire Administration
16825 South Seton Avenue
Emmitsburg MD 21727
PhoneCell 301-447-1304
Fax 301-447-1178
Email stephenfoleydhsgov
SE 1042007
Thomas Hillenbrand
FIX-AAAPrincipalUnderwriters Laboratories Inc
333 Pfingsten Road
Northbrook IL 60062-2096
Alternate Steven D CorradoPhoneCell 847-664-2603
Fax 847-313-2603
Email thomasahillenbrandusulcom
RT 7241997 Scott D Kerwood
FIX-AAAPrincipalHutto Fire Rescue
501 Exchange
PO Box 175
Hutto TX 78634
International Association of Fire ChiefsAlternate Brett R Bowman
PhoneCell 512-759-2616 512-413-1404
Fax 512-846-1946
Email sdkerwoodhuttofirerescueorg
E 711995
Jonathan D Kipp
FIX-AAAPrincipalPrimex
3
46 Donovan Street
Concord NH 03301
PhoneCell 603-225-2841
Fax 603-228-3905
Email jkippnhprimexorg
I 111989 Steve Kreis
FIX-AAAPrincipalCity of Phoenix Fire Department
150 South 12th Street
Phoenix AZ 85034-2301
PhoneCell 602-495-5848
Fax 602-262-4429
Email stevelkreisphoenixgov
E 1032002
24
Address List 9172010
Fire Service Occupational Safety and Health FIX-AAAKenneth Willette
Michael A Laton
FIX-AAAPrincipalSperian Protective Apparel
160 Woodstream Way
Fayetteville GA 30214
International Safety Equipment AssociationPhoneCell 770-861-0350
FIX-AAANonvoting MemberNational Institute for Occupational Safety amp Health
4676 Columbia Parkway R-9
Cincinnati OH 45226
Alternate Jay L TarleyPhoneCell 513-841-4583
Fax 513-844-4488
Email thalescdcgov
RT 452001
William R Hamilton
FIX-AAANonvoting MemberUS Department of Labor
Occupational Safety amp Health Administration
200 Constitution Ave NW Room N3609
Washington DC 20210
Alternate Andrew LevinsonPhoneCell 202-693-2077
Fax 202-693-1663
Email hamiltonbilldolgov
E 342009 Andrew Levinson
FIX-AAAAlt to Nonvoting MemberUS Department of Labor
Occupational Safety amp Health Administration
200 Constitution Ave NW Room N3718
Washington DC 20210
Occupational Safety amp Health AdministrationPrincipal William R Hamilton
PhoneCell 202-693-2048
Fax 202-693-1678
Email levinsonandrewdolgov
E 7282006
Jay L Tarley
FIX-AAAAlt to Nonvoting MemberUS Department of Health amp Human Services
National Institute for Occupational Safety amp Health
1095 Willowdale Road MS 1808
Morgantown WV 26505
Principal Thomas R HalesPhoneCell 304-285-5858
Fax 304-285-5774
Email jst9cdcgov
RT 3152007 Kenneth Willette
FIX-AAAStaff LiaisonNational Fire Protection Association
1 Batterymarch Park
Quincy MA
PhoneCell 617-984-7299
Fax 617-984-7056
Email kwillettenfpaorg
792010
68
ATTACHMENT B
9
Technical Committee on Fire Service Occupational Safety and Health
Meeting Minutes May 13 ndash 14 2010
Holiday Inn Inner Harbor MD
Attendees Glenn Benarick Chairman Ken Holland Staff Liaison Michael Finkelman Craig Fry Joe Rivera Stephen Raynis Steve Kreis Dennis Childress Don Stewart Phil Stittleburg David Ross Michael Laton Kim Zagaris Tom Hillenbrand Dominic Colletti Andy Schwartz Brett Bowman Guest David Bernzweig Thursday May 13 NFPA 1500 task groups (Vehicle amp Safety OPS SCBA amp Air Mgt PPEProximity) met to discuss the work they have completed since the last meeting The task groups will present their report to the entire TC on May 14th Not enough 1582 task group members were able to make the meeting so there were no reports or work from those task groups Friday May 14 TC meeting called to order at approximately 0800 by Glenn Benarick TC Chair Ken Holland (NFPA Public Fire Protection Staff) in attendance filling in for Frank Florence Ken made two presentations one on the Codes and Standards Development Process and the other on the general procedures for this Pre-ROP meeting The Staff Liaison remains fluid as Frank is not expected back any time soon
10
One guest in attendance Dave Bernzweig (Columbus OH Fire) Dave is assisting TC with SCBAAir Mgt issues The document revision cycles remain as requested NFPA 1500 amp 1582 Annual 2012 NFPA 1521 amp 1561 Fall 2013 NFPA 1581 1583 1584 Annual 2014 The October 7-9 2010 dates are the primary request for our next meeting Location is San Diego Notice will be sent out as soon as approval is received Discussion on the next revision of 1561 will be held at the October meeting regarding changing the document title to ldquoCommand Safety for Fire Department Operationsrdquo This is a suggestion of the TC Chair Ken Holland conducted a briefing for the TC on how to access and use the committee web page Staff will be posting as much information as possible up on the e-committee page for the entire committee More use will be made of this tool Discussion on monocular vision Dennis Childress presented the current issue in Ventura County CA Further discussionwork may be necessary Don Stewart agreed to take the lead Brief discussion held on pregnancy and the need for fire departments to ensure policies match current law The rep from the Diabetes Association declined the invitation to participate at this meeting due to no discussion of the issue planned She has indicated a desire to attend the October meeting There were no reports from these and all other 1582 task groups It is very important for the 1582 TG Chairs to be ready to report in October The following task group reports will be posted on the ecommittee page PPEProximity New definition of proximity fire fighting
VehicleHighway OPS Discussion on use of vehicle data recorders Collapse Zones Submission from Jay Tarley SCBAAir Mgt New exit strategy for SCBA Discussion on having the low air alarm activate when the bottle volume reaches 600 liters Further discussion to take place on ldquobuddy breathingrdquo
On Day 2 Casey Grant (NFPA Fire Protection Research Foundation) made a presentation on Research Planning for FSOSH Dr Ellen Sogolow (DHSFEMA) also present during this presentation She discussed the role of the AFGRampD activities See ecommittee page for his presentation Chair
11
will be in contact with Mr Grant for future work between the TC and the Foundation Also on Day 2 Ken Willette (Division Manager ndash NFPA Public Fire Protection Division) delivered a presentation on the initiative developed by Kelvin Cochran (US Fire Administrator) to reduce fire fighter injuries and deaths NFPA 1500 is an integral part of this initiative See ecommittee page for presentation The Chair will be coordinating a committee conference call in the coming weeks The purpose will be to review the work which needs to be completed for the October meeting The primary focus of the call will be on 1582 issues NOTE Subsequent to the meeting I have had some discussions with a fire chief in Kentucky on the use of hearing aids The TC especially the doctors need to review the current language in 1582 and decide if revisions are needed Also most of you know that Kelvin Cochran has left the USFA unexpectedly to return to Atlanta as their fire chief I have been in contact with the Acting Administrator Glenn Gaines to inform him that our committee remains focused on the work to reduce fire fighter injuries and deaths I told him that I would keep him informed of our work He indicated that one of his primary goals is to bring fire service organizations together in order to create a safe working environment Of particular interest to him is reducing heart related injuries and deaths Submitted by Glenn Benarick
12
Technical Committee on Fire Service Occupational Safety and Health
Conference Call Meeting Minutes August 30th 2010
Members participating
Glenn Benarick TC Chair
Murrey Loflin Secretary Dr Sandy Bogucki
Thomas Cuff Stephen Foley
Scott Kerwood Tammy Lopes
David Love Dr David Prezant
Joe Rivera David Ross
Mario Rueda Phil Stittleburg
Phil Vorlander Dominic Colletti
Thomas Hillenbrand
Denise Smith Brett Bowman Alternate
Andrew Schwartz Alternate Mike Young Alternate
Dr Thomas Hales Non-Voting Member Ken Holland NFPA Staff Liaison
Casey Grant NFPAResearch Foundation Staff Katie Hathway Guest from ADA
Dr Jim Fleming Guest from Phoenix Fire Dept
The chair welcomed everyone to the conference call in which he hoped
would last only an hour The purpose was to discuss any task groups that had reports for proposed changes to NFPA 1582 for the
committee This is in hopes to ensure the committee is ready for their
pre-ROP meeting in October The following topics were discussed and are in no specific order
Comments from ADA Katie Hathaway and the group went into deep
discussion regarding ones medical history and diagnosis of diabetes
13
and some proposed changesremoval of text based on research
findings The specific proposed changes will be available for the committee at their next meeting Some members on the call felt that
this issue was covered in another law enforcement document which might better serve this issue
Research topics for FSOSH projects Casey Grant offered his time to
answer any questions regarding his presentation from the May meeting in Baltimore There was also discussion about further
involvement of the Research Foundation with this committee and some of the medical requirements within the documents Glenn and Casey
are going to be in contact offline to discuss this further
Prosthetics amp Amputees report Nothing new to report
Heart amp Hypertension report There was discussion about the need for
periodic EKGrsquos that were done both in resting and non-resting states as well as discussion about stress test requirements and frequency of
such tests The hopes were to develop text that would point to annual versus periodic evaluations of EKGrsquos and stress tests
Epilepsy report Nothing new to report
Pregnancy report The initial textlanguage has been provided to the
group through email and e-committee page posting
Coagulation amp Meds report Nothing new to report
Hearing Aid discussion Nothing new to report
The committee also discussed the evaluation and documentation of
PSA results and test requirements for the purposes of consistency The proposed text and changes have been posted on the e-committee
page as well
All of the proposed text changes from the May meeting in Baltimore have been emailed out and posted on the e-committee page If there
are any questions or concerns that something was missed please contact Glenn Steven Sawyer or Ken Holland to ensure they are
resolved
The conference call lasted approximately an hour and was adjourned at 1400 hours
14
ATTACHMENT C
15
2012 ANNUAL REVISION CYCLE
PROCESS STAGE PROCESS STEP DATES
FOR TC DATES
FOR TCC 1 PRELIMINARY 10 Notification of intent to enter cycle 7910 7910
2 REPORT ON
PROPOSALS (ROP)
21 Proposal closing date 112310 112310 22 Final date for ROP meeting 22511 2411 23 Final date for mailing TC ballots 31811 21811 24 Receipt of (TC) ballots by staff liaison 42211 31111 25 Receipt of TC recirculation ballots 5611 31811 26 Final date for TCC meeting 41511 27 Final date for mailing TCC ballots 42211 28 Receipt of TCC ballots 51311 29 Receipt of TCC recirculation ballots 52011 210 Final copy (w ballot statements) to Secretary Standards Council 51311 52711 211 Completion of Reports 52011 6311 212 ROP Published and Posted 62411 62411
3 REPORT ON
COMMENTS
(ROC)
31 Comment closing date 83011 83011 32 Final date for ROC meeting 11411 10711 33 Final date for mailing TC ballots 111811 102111 34 Receipt of (TC) ballots by staff liaison 12211 111111 35 Receipt of TC recirculation ballots 12911 111811 36 Final date for TCC meeting 121611 37 Final date for mailing TCC ballots 122311 38 Receipt of TCC ballots 11312 39 Receipt of TCC recirculation ballots 12012 310 Final copy (w ballot statements) to Secretary Standards Council 122311 12712 311 Completion of Reports 11312 2312 312 ROC Published and Posted 22412 22412
4 TECH SESSION
PREPARATION amp
ISSUANCE OF
CONSENT
DOCUMENTS
41 Notice of Intent to Make a Motion (NITMAM) Closing Date 4612 4612 42 Posting of Filed NITMAM 5412 5412
43 Council Issuance Date for Consent Documents 52912 52912
44 Appeal Closing Date for Consent Documents 61312 61312
5 TECHNICAL
SESSION 50 Association Meeting for Documents with Certified Amending Motions
64-712 64-712
6
APPEALS amp
ISSUANCE OF
DOCUMENTS
WCAMS
61 Appeal closing date for Documents with Certified Amending Motions
62712 62712
62 Council issuance for Documents with Certified Amending Motions 8912 8912
Proposal Closing Dates may vary according to documents and schedules for Revision Cycles may change Please check the NFPA website (wwwnfpaorg) for the most up-to-date information on proposal closing dates and schedules
16
ATTACHMENT D
17
This weekrsquos conference call mentioned the Diabetes chapter written for the ACOEM document Guidance for the Medical Evaluation of the Law Enforcement Officer The task group working on this chapter (led Richard Miller of the Secret Service and our very own Dan Samo) worked with the ADA or over 2-3 years to come up with a consensus document
Please find the Chapter attached ltltDiabetes Guidance Sept 2010pdfgtgt
Regarding Dan Loeberrsquos points
1) Physical Evaluation Form - We could modify the LEO form (see end of the attached Chapter)
2) Duration required for stable regiment
1582 for IDDM Type 1 1 yr
Type 2 6 m
Oral Agents None specifically
ACOEM Police for IDDM Type 1 6m
Type 2 3m
Oral Agents 1m
The police document is much clearer about the decision regarding medical fitness for duty is the responsibility of the police physician with the treating diabetes-expert physician providing the data to the police physician to make an informed decision In this regard the police officer must provide the police physician with downloaded self monitoring glucose data for the 1 3 and 6 month time periods (see section 433)
3) HA1C ndash NFPA lt 8 over 3 month period
ACOEM Police ndash (Section 4333) Specifies the frequency on measurement and if gt8 requires further evaluation
Some other discrepancies End organ complications
NFPA ndash end organ complications (eye kidney heart neuro) ndash restriction
ACOEM Police ndash end organ complication -- requires further evaluation
18
Hypoglycemia (incapacitating ndash defined differently between the two documents (434)
NFPA ndash 0 episodes in past year le1 in past 5 yrs
ACOEM Police ndash 0 episodes in past year le2 in past 3 yrs
Given Dan Samorsquos and Richard Millerrsquos work with the ADALoeber it would be helpful to get their opinions on whether any of the changes requested by Loeber are appropriate for FF with DM
Tom
Thomas Hales MD MPH
Senior Medical Epidemiologist
NIOSH CDC
4676 Columbia Pkwy R-9
Cincinnati OH 45241
(513) 841-4583
trh1cdcgov
19
43 ndash DIABETES MELLITUS
431 ndash INTRODUCTION
The educated and motivated law enforcement officer (LEO) with well-managed diabetes mellitus can be capable of
safe and effective job performance1 However diabetes mellitus may place LEOs at risk for sudden incapacitation
thus jeopardizing their ability to perform critical job functions (These job functions include those listed in Sections
32 333 351 352 36 and 37 and discussed in Appendix A)
Therefore an individualized assessment of the LEOrsquos diabetes should be performed using the following evaluative
criteria to determine whether the individuals condition permits safe and effective job performance Such evaluation
must include the following key elements which are discussed in detail below
history of blood glucose control
knowledge of diabetes and its management
current stability of blood glucose
risk for significant hypoglycemia or hyperglycemia and
presence of diabetic complications
432 ndash OVERVIEW OF MEDICAL EVALUATION
The treating endocrinologist or other physician knowledgeable regarding diabetes management should provide
a narrative report certifying whether the LEO has or has not met the criteria set out in Sections 4321 through
4354 below In addition the physician should include supporting data (see Appendix B for the Physician Evalu-
ation Form)
4321 The LEO is under the care of an endocrinologist or other physician knowledgeable regarding diabetes
management Outpatient and in-patient medical record(s) for the last 3 years or since date of diagnosis
(whichever is shorter) should be reviewed by the treating physician and provided to the police physician
4322 If the LEO has type 1 diabetes the individual has been on a basalbolus regimena or an insulin pump
using analogue insulins for the 6 months prior to evaluation2
4323 If the LEO has type 2 diabetes on insulin the individual has been on a stable medication regimenb
for the 3 months prior to evaluation3 If on oral agents alone the LEO has been on a stable medication regimen
for the month prior to evaluationc
ACOEM Guidance for the Medical Evaluation of Law Enforcement Officers 1
43 ndash DIABETES MELLITUS
aA basalbolus insulin regimen consists of the use of a basal insulin (Glargine NPH) in a once or twice daily regimen to provide between-
meal insulin combined with the use of a short acting insulin (Regular Lispro Aspart or Glulisine) at mealtimes Insulin pumps are small
(beeper sized) battery powered devices that deliver small amounts of short-acting insulin in a constant infusion to meet basal insulin
requirements The wearer selects an additional mealtime bolus to be infused at the time of meals For more information on pumps visit
the manufacturerrsquos web sites ndash wwwMinimedcom wwwcozmorecom wwwanimascorpcom wwwdisetroniccom
bA stable insulin regimen is defined as maintaining the same types of insulin (long acting intermediate acting short or rapid acting)
Changes in insulin dose are part of the appropriate self-management of diabetes and do not disqualify an applicant or incumbent under
this section
cChanges in dose within the evaluation period will be allowed but addition of a new class of medications or insulin should result in a new
period of observation
one month for addition of a sulfonylurea or metformin
two months for the addition of a thiazolidinedione to insulin or a sulfonylurea or
three months for the addition of insulin
20
4324 If the LEO uses an insulin pump documentation is needed as follows
proper understanding and education in the use of the insulin pump
start date for the use of the pump
history of insulin site infectionsd
history of pump cessation and pump malfunction
backup plan for pump malfunction including use of injectable insulin and
frequency of infusion set changes
4325 The LEO has been educated in diabetes and its management and thoroughly informed of and under-
stands the procedures that must be followed to monitor and manage hisher diabetes and what procedures
should be followed if complications arise3
433 ndash QUANTITATIVE GLUCOSE MONITORING
4331 The LEO has documentation of ongoing self-monitoring of blood glucose
4332 This must be done with a glucose meter that stores every reading records date and time of reading
and from which data can be downloaded (Most meters now have this capability)
4333 Monitoring logs must be available covering the time period (1 3 or 6 months) as described in
Sections 4322 and 4323 The frequency of glucose monitoring must follow a schedule acceptable to the
police physician in consultation with the treating physician
Testing schedules are individual What follows is a common pattern but individual patterns may differ
2 ACOEM Guidance for the Medical Evaluation of Law Enforcement Officers
43 ndash DIABETES MELLITUS
dIndividual has not had more than one pump-site infection that caused him or her to miss work or usual daily activities in the preceding 6
months
THERAPEUTIC REGIMEN GLUCOSE TESTING SCHEDULE
Diet alone Once or twice a week
Metformin Thiazolidinediones or Alpha
Glucosidase inhibitors alone or in
combination
Once or twice a week
Sulfonylureas meglitanides nateglinide ndash
alone or in combination with the above group
Twice a day ndash AM and at supper with any
suspected hypoglycemic episodes
Insulin ndash one shot in combination with orals Twice a day ndash AM and at supper with any
suspected hypoglycemic episodes
2 to 3 times AM once a week
Insulin ndash two or more shots Insulin pump 3 to 4 times a day ndash at meals and bedtime
2 to 3 times AM once a week with any
suspected hypoglycemic episodes
21
4334 The LEO has had hemoglobin A1C measured at least 4 times a year (intervals of 2 to 3 months) over
the last 12 months prior to evaluation if diagnosis has been present for more than a year4 If hemoglobin A1C is
gt8 this may signal a problem with the LEOrsquos diabetes management that warrants further assessment5
434 ndash INCAPACITATING EVENTS
4341 The LEO has not had any incapacitating episodes within the past 1 year and no more than 2 episodes
in the past 3 years or since diagnosis of diabetes (whichever is shorter) of
43411 Severe hypoglycemia (loss of consciousness seizures or coma requiring assistance of others or
needing urgent treatment [glucagon injectionIV glucose]) or
43412 Blood sugar lt60 mgdl with unawareness demonstrated in current glucose logs6
435 ndash CHRONIC COMPLICATION SCREENING
4351 Chronic complications of diabetes are associated with increased risk for severe hypoglycemic
episodes and warrant further assessmente
4352 The components of screening for chronic complications are
43521 A complete eye exam by a qualified ophthalmologist or optometrist including a dilated retinal
exam demonstrating no more than mild background diabetic retinopathyf7
43522 Normal vibratory testing with a 128 Hz tuning forkg normal testing with 10 gram Semmes-
Weinstein monofilamentg and normal orthostatic blood pressureh and pulse testing89
ACOEM Guidance for the Medical Evaluation of Law Enforcement Officers 3
43 ndash DIABETES MELLITUS
ePresence of chronic complications of diabetes in and of themselves may not require the implementation of work restrictions
fNo more than one dot blot or flame-shaped hemorrhages or microaneurysm in all four fundus quadrants
gThe Michigan Diabetes Research and Training Center of the University of Michigan Health System recommends the following guidance
(see wwwmedumichedumdrtcprofsdocumentssviMNSI_howtopdf) for conducting vibratory and monofilament testing8
Vibration Sensation Vibration sensation should be performed with the great toe unsupported Vibration sensation will be tested bi-
laterally using a 128 Hz tuning fork placed over the dorsum of the great toe on the boney prominence of the DIP joint Patients whose
eyes are closed will be asked to indicate when they can no longer sense the vibration from the vibrating tuning fork In general the
examiner should be able to feel vibration from the hand-held tuning fork for 5 seconds longer on his distal forefinger than a normal subject
can at the great toe (eg examiners DIP joint of the first finger versus patients toe) If the examiner feels vibration for 10 or more seconds
on his or her finger then vibration is considered decreased A trial should be given when the tuning fork is not vibrating to be certain that
the patient is responding to vibration and not pressure or some other clue Vibration is scored as 1) present if the examiner senses the
vibration on his or her finger for lt10 seconds 2) reduced if sensed for 10 seconds or 3) absent (no vibration detection)
Monofilament Testing For this examination it is important that the patients foot be supported (ie allow the sole of the foot to rest on
a flat warm surface) The filament should initially be pre-stressed (4-6 perpendicular applications to the dorsum of the examiner s first
finger) The filament is then applied to the dorsum of the great toe midway between the nail fold and the DIP joint Do not hold the toe
directly The filament is applied perpendicularly and briefly (lt1 second) with an even pressure When the filament bends the force of
10 grams has been applied The patient whose eyes are closed is asked to respond yes if heshe feels the filament Eight correct responses
out of 10 applications is considered normal 1 to 7 correct responses indicates reduced sensation and no correct answers translates into
absent sensation
hOrthostatic hypotension is a physical finding defined by the American Autonomic Society and the American Academy of Neurology as a
systolic blood pressure decrease of at least 20 mm Hg or a diastolic blood pressure decrease of at least 10 mm Hg within 3 minutes of
standing
22
43523 Normal cardiac physical exam Cardiac stress testing to at least 12 METS is recommended and
should begin based on either the criteria of the American Heart AssociationAmerican College of
Cardiologyi10 or those of the American Diabetes Associationj11
Diabetics who have a normal cardiac stress test will be retested every one to three years based on
individual clinical assessment This assessment should consider
the age of the individual
the number and persistence of coronary artery disease (CAD) risk factors
the severity of CAD risk factors
43524 Microalbumincreatinine ratio 301 measured or calculatedk creatinine clearance
gt60 mlmin12
436 ndash ONGOING EVALUATION AND REQUIREMENTS
4361 Should have medical records and glucose meter logs reviewed periodically Because of the nature of
diabetes it is important that regular medical follow up be provided to the LEO The frequency and content of
the evaluation should be determined on an individual basis by the police physician in consultation with the
treating physicianl
4362 Must advise police physician of any change in type of medication
4363 Must advise police physician of any episodes of significant hypoglycemia or hyperglycemia
Urine microalbumincreatinine ratio _________________
III Treating Physician Statement
The above named individual meets all of the criteria provided on this form
Yes No ndash not recommended for position
No but IS recommended for position (letter of explanation attached)
It is my opinion that the above named individual is well-educated and well-motivated in diabetes self-management and has
achieved a level of diabetes management to be capable of safe and effective job performance as a law enforcement officer
I have reached this opinion after careful review of the above criteria
___________________________________________________________ ___________________________Signature of Physician Date
______________________________________________________________ ___________________________Printed or Typed Name of Physician Telephone Number
10 ACOEM Guidance for the Medical Evaluation of Law Enforcement Officers
43 ndash DIABETES MELLITUS
29
439 ndash REFERENCES
1 American Diabetes Association Diagnosis and classification of diabetes mellitus Diabetes Care 200427 Suppl
1S5-S10 See httpcarediabetesjournalsorgcgicontentfull27suppl_1s5
2 American Diabetes Association Continuous subcutaneous insulin infusion Diabetes Care 200427 Suppl 1S110
See httpcarediabetesjournalsorgcgicontentfull27suppl_1s110
3 Mensing C Boucher J Cypress M et al National standards for diabetes self-management education Diabetes
Care 200528 Suppl 1S72-9 See httpcarediabetesjournalsorgcgicontentfull28suppl_1s72
4 Goldstein DE Little RR Lorenz RA Malone JI Nathan DM Peterson CM American Diabetes Association Tests
of glycemia in diabetes Diabetes Care 200427 Suppl 1S91-3
See httpcarediabetesjournalsorgcgicontentfull27suppl_1s91
5 The Diabetes Control and Complications Trial Research Group Hypoglycemia in the Diabetes Control and
Complications Trial Diabetes 199746(2)271-86 See wwwncbinlmnihgovpubmed9000705 for abstract
6 American Diabetes Association Hypoglycemia and employmentlicensure Diabetes Care 200528 Suppl 1S61
See httpcarediabetesjournalsorgcgicontentfull28suppl_1s61
7 Viswanath K McGavin DD Diabetic Retinopathy Clinical Findings and Management J Comm Eye Health
200316(46)21-4 See wwwcehjournalorg0953-683316jceh_16_46_021html
8 Michigan Diabetes Research and Training Center University of Michigan Health System How to use the Michigan
Neuropathy Screening Instrument See wwwmedumichedumdrtcprofsdocumentssviMNSI_howtopdf
9 Bradley JG Davis KA Orthostatic hypotension Am Fam Physician 200368(12)2393-8
See wwwaafporgafp200312152393html
10 Gibbons RJ Balady GJ Bricker JT et al ACCAHA 2002 guideline update for exercise testing a report of the
American College of CardiologyAmerican Heart Association Task Force on Practice Guidelines (Committee on
Exercise Testing) J Am Coll Cardiol 200240(8)1531-40
See wwwaccorgqualityandscienceclinicalguidelinesexerciseexercise_cleanpdf
11 American Diabetes Association Standards of medical care in diabetes Diabetes Care 200528 Suppl 1S4-S36
Erratum in Diabetes Care 200528(4)990 See httpcarediabetesjournalsorgcgicontentfull28suppl_1s4
12 Molitch ME DeFronzo RA Franz MJ et al American Diabetes Association Nephropathy in diabetes Diabetes
Care 200427 Suppl 1S79-83 See httpcarediabetesjournalsorgcgicontentfull27suppl_1s79
13 Kitabchi AE Umpierrez GE Murphy MB et al American Diabetes Association Hyperglycemic crises in diabetes
Diabetes Care 200427 Suppl 1S94-102 See httpcarediabetesjournalsorgcgicontentfull27suppl_1s94
14 US Centers for Disease Control and Prevention National Diabetes Fact Sheet 2007
See wwwcdcgovdiabetespubspdfndfs_2007pdf
ACOEM Guidance for the Medical Evaluation of Law Enforcement Officers 11
43 ndash DIABETES MELLITUS
30
ATTACHMENT E
31
Typos A6921(2) 7th line down test should be plural 94201 Paragraph 2 target organ damage is used though end organ damage was defined earlier and in the appendix for that paragraph
A94201 Para A (1) d Id suggest deleting the phrases in brackets Im not sure either are predictably true or politically wise
a) tests for left ventricular hypertrophy Unfortunately use of the EKG to detect left ventricular hypertrophy is very insensitive (eg 5 sensitivity) The echocardiogram is the best test for diagnosing left ventricular hypertrophy but [it is relatively expensive and not readily available in small rural communities ] conducting echocardiograms on asymptomatic fire fighters with Stage 1 hypertension should be reserved only for those with long-standing hypertension
In addition
7761 A resting EKG shall be performed as part of the baseline medical evaluation and shall be obtained periodically thereafter
Changing from annually to periodically is noted has the language in the wellness-fitness initiative been changed as well Our previous decision was that we would support the W-F language since there was no compelling evidence to either support or refute it
Thanks
Sandy
32
NFPA 1582‐ HTN Draft 1
Reason for Revision
1) New classification of BP by the Joint National Commission [Chobanian et al 2002]
2) A high prevalence of FF have either HTN (~20) and Pre‐HTN (~20) [Soteriades et al 2003]
3) Among FF studies have shown a strong association between HTN and a number of adverse
cardiovascular events [Kales et al 2009]
4) A large percentage of on‐duty FF fatalities were found to have left ventricular hypertrophy a
complication of HTN at autopsy
Language in 2007 Edition with draft revisions in Red (Track changes)
611 The medical evaluation of a candidate shall include a medical history examination and any laboratory tests required to detect physical or medical condition(s) that could adversely affect hisher ability to safely perform the essential job tasks outlined in 511 A611 The medical history should include the candidates known health problems such as major illnesses surgeries medication use and allergies Symptom review is also important for detecting early signs of illness A medical history should also include a personal health history a family health history a health habit history an immunization history and a reproductive history
An occupational history should also be obtained to collect information about the persons past occupational and environmental exposures
(a) BP should be measured according to the Joint National Commission (JNC) -7 recommendations BP should be measured with a properly calibrated and validated instrument Patients should be seated quietly for at least 5 minutes in a chair with feet on the floor and arm supported at heart level An appropriate-sized cuff (cuff bladder encircling at least 80 of the arm) should be used to ensure accuracy At least 2 measurements should be made Systolic BP is the point at which the first of 2 or more sounds is heard (phase 1) and diastolic BP is the point before the disappearance of sounds (phase 5) [Chobanian et al 2003]
(2) Head eyes ears nose and throat (HEENT)
Formatted Font (Default) Times New RomanFont color Black
33
692 Vascular System 6921 Category A medical conditions shall include the following
(1) Uncontrolled or poorly controlled hypertension
(2) Hypertension with evidence of end organ damage
or not controlled by approved medications
A6921(1) Uncontrolled or poorly controlled hHypertension increases the risk of a sudden cardiac event This sudden cardiac event would cause sudden incapacitation which that is uncontrolled poorly controlled or requires medication likely to interferes with the safe performance of essential job tasks Uncontrolled or poorly controlled hypertension can be defined as the presence of end organ damage (see below) or stage 2 hypertension (BP systolic gt160 mmHg or BP diastolic gt100 mmHg) is an illness that can lead to functional impairment and potential for sudden incapacitation Individuals with pre- stage 1 or stage 2 hypertension should be referred to their primary care physician for evaluation lifestyle modification and treatment [QUESTION FOR GROUP _- WHAT ABOUT HAVING CANDIDATE RETURN IN ONE MONTH UNDER TREATMENT WITH NORMAL BP]
A6921(2)
Chronic hypertension can damage the eye (retinopathy) the kidneys (nephropathy) the vascular system (stroke transient ischemic attack or peripheral artery disease) or the heart (left ventricular hypertrophy and heart failure) These hypertension complications are known as end organ damage The cardiac and vascular complications are associated with an increased risk of sudden incapacitation and sudden cardiac death (Koren et al 1991) Unfortunately the cardiac complications are frequently asymptomatic and valid screening tests are not fast and are not inexpensive Therefore determining who to screen for cardiac complications (such as echocardiogram for LVH or a measurement of left ventricular ejection fraction for heart failure) should be based on the severity and the duration of HTN
76 Physical Examination The annual physical examination shall include each of the following components
(a) BP shall be measured according to the Joint National Commission (JNC)-7 recommendations
A76(1)(a) BP should be measured with a properly calibrated and validated instrument Patients should be seated quietly for at least 5 minutes in a chair with feet on the floor and arm supported at heart level An appropriate-sized cuff (cuff bladder encircling at least 80 of the arm) should be used to ensure accuracy At least 2 measurements should be made Systolic BP is the point at which the first of 2 or more sounds is heard (phase 1) and diastolic BP is the point before the disappearance of sounds (phase 5) [Chobanian et al 2003]
(2) Head eyes ears nose and throat (HEENT)
34
9420 Uncontrolled Hypertension 94201 Physician Evaluation Severe uncontrolled hypertension [defined as systolic pressure greater than 180 mm Hg diastolic pressure greater than 100 mm Hg or mean systolic blood
pressure ( systolic + diastolic) greater than 120 mm Hg] or malignant hypertension (defined as hypertension with the presence of target organ damage) compromises the members ability to safely perform essential job tasks 1 5 7 9 and 13 and the physician shall report the applicable job limitations to the fire department
Members with Pre-hypertention (systolic 120-139 mmHg or diastolic 80-89 mmHg) Stage 1 hypertension (systolic 140-159 mmHg or diastolic 90-99 mmHg) or Stage 2 hypertension (systolic ge160 mmHg or diastolic ge100 mmHg) should be referred to their primary care physician for evaluation lifestyle modification and treatment
(1) Members with Stage I hypertension should be followed-up not only by their primary care physician but also by the FD physician every 3 to 6 months to ensure their blood pressure is under control and to determine whether screening tests for asymptomatic end organ damage are appropriate
(2) Members with Stage 2 hypertension or with end organ damage (retinopathy nephropathy vascular or cardiac complications) compromises the members ability to safely perform essential job tasks 1 5 7 9 and 130 and the physician shall report the applicable job limitations to the fire department
A94201 Severe uncontrolled hypertension is a significant risk factor for the development of coronary artery disease congestive heart failure and stroke Blood pressure increases as a normal response to exercise This response is further exaggerated by the emotional and physical stress of performing these critical tasks while operating in personal protective clothing at extremes of temperature This normal elevation of blood pressure under these response conditions can lead to life-threatening hypertensive emergencies if a members daily blood pressure is already elevated to high levels In addition hypertension is a progressive illness that when uncontrolled ultimately and inevitably leads to target organ damage Target organs that are sensitive to the effects of elevated blood pressure are the central nervous system vision heart major blood vessels and kidneys
Chronic hypertension can damage the eye (retinopathy) the kidneys (nephropathy) the vascular system (stroke transient ischemic attack or peripheral artery disease) or the heart (left ventricular hypertrophy and heart failure) These hypertension complications are known as end organ damage The cardiac and vascular complications are associated with an increased risk of sudden incapacitation and sudden cardiac death (Koren et al 1991) Fortunately with proper evaluation life style modification and treatment these complications can be avoided Life style modification includes weight reduction DASH eating plan reduction in dietary sodium an increase in aerobic physical activity and moderation in alcohol consumption [Chobanian 2003]
Formatted Font (Default) Times New Roman12 pt Font color Black
Formatted Font (Default) Times New Roman12 pt Font color Black
35
A94201 (1) Members with Stage I hypertension whose BP returns to either pre-hypertenion or normal with lifestyle modification andor treatment can return to an annual medical evaluation For members with long-standing Stage I hypertension whose BP has not been reduced additional evaluation for possible end organ damage should be considered This evaluation could include any or all of the following
a) a compete patient history for symptoms of heart failure (eg shortness of breath upon exertion) or transient ischemic attacks (TIAs)
b) dilated eye examination for retinopathy
c) blood creatinine measurement for nephropathy
d) tests for left ventricular hypertrophy Unfortunately use of the resting EKG to detect left ventricular hypertrophy is very insensitive (eg 5 sensitivity) The echocardiogram is the best test for diagnosing left ventricular hypertrophy
A 94201 (2) Due to the high risk of a sudden cardiovascular event members with Stage 2 hypertension should be restricted until their BP can be brought under control Once the BP is brought under control they should be followed in the same manner as a member with Stage I hypertension
Formatted Font (Default) Times New Roman12 pt
36
D22 Cardiology Gibbons R J GJ Balady J W Beasley et al 1997 ACCAHA guidelines for exercise testing a report of American College of CardiologyAmerican Heart Association Task Force on Practice Guidelines (Committee on Exercise Testing) J Am Coll Cardiol 30260ndash311
Gibbons RJ Balady GJ Bricker JT Chaitman BR Fletcher GF Froelicher VF Mark DB McCallister BD Mooss AN OrsquoReilly MG Winters WL Jr [2002] ACCAHA 2002 guideline update for exercise testing summary article a report of the ACCAHA Task Force on Practice Guidelines (Committee to Update the 1997 Exercise Testing guidelines) J Am Coll Cardiol 401531ndash 40
Chobanian AV Bakris GL Black HR Cushman WC Green LA Izzo JL Jr Jones DW Materson BJ Oparil S Wright JT Jr Roccella EJ the National High Blood Pressure Education Program Coordinating Committee [2003] The seventh report of the Joint National Committee [JNC-7] on Prevention Detection Evaluation and Treatment of High Blood Pressure JAMA 2892560ndash2571
Soteriades ES Kales SN Liarokapis D Christiani DC [2003] Prospective surveillance of hypertension in firefighters J Clin Hypertens 5315-320
Kales SN Tsismenakis AJ Zhang C Soteriades ES [2009] Blood pressure in fire fighters police officers and other emergency responders Am J Hypertens 2211-20
37
NFPA 1582‐ HTN Draft 1
Reason for Revision
1) New classification of BP by the Joint National Commission [Chobanian et al 2002]
2) A high prevalence of FF have either HTN (~20) and Pre‐HTN (~20) [Soteriades et al 2003]
3) Among FF studies have shown a strong association between HTN and a number of adverse
cardiovascular events [Kales et al 2009]
4) A large percentage of on‐duty FF fatalities were found to have left ventricular hypertrophy a
complication of HTN at autopsy
Language in 2007 Edition with draft revisions in Red (Track changes)
611 The medical evaluation of a candidate shall include a medical history examination and any laboratory tests required to detect physical or medical condition(s) that could adversely affect hisher ability to safely perform the essential job tasks outlined in 511 A611 The medical history should include the candidates known health problems such as major illnesses surgeries medication use and allergies Symptom review is also important for detecting early signs of illness A medical history should also include a personal health history a family health history a health habit history an immunization history and a reproductive history
An occupational history should also be obtained to collect information about the persons past occupational and environmental exposures
(a) BP should be measured according to the Joint National Commission (JNC) -7 recommendations BP should be measured with a properly calibrated and validated instrument Patients should be seated quietly for at least 5 minutes in a chair with feet on the floor and arm supported at heart level An appropriate-sized cuff (cuff bladder encircling at least 80 of the arm) should be used to ensure accuracy At least 2 measurements should be made Systolic BP is the point at which the first of 2 or more sounds is heard (phase 1) and diastolic BP is the point before the disappearance of sounds (phase 5) [Chobanian et al 2003]
(2) Head eyes ears nose and throat
38
692 Vascular System 6921 Category A medical conditions shall include the following
(1) Uncontrolled or poorly controlled hypertension
(2) Hypertension with evidence of end organ damage
A6921(1) Uncontrolled or poorly controlled hypertension increases the risk of a sudden cardiac event This sudden cardiac event would cause sudden incapacitation which interferes with the safe performance of essential job tasks Uncontrolled or poorly controlled hypertension can be defined as the presence of end organ damage (see below) or stage 2 hypertension (BP systolic gt160 mmHg or BP diastolic gt100 mmHg) Individuals with pre- stage 1 or stage 2 hypertension should be referred to their primary care physician for evaluation lifestyle modification and treatment [QUESTION FOR GROUP _- WHAT ABOUT HAVING CANDIDATE RETURN IN ONE MONTH UNDER TREATMENT WITH NORMAL BP]
A6921(2)Chronic hypertension can damage the eye (retinopathy) the kidneys (nephropathy) the vascular system (stroke transient ischemic attack or peripheral artery disease) or the heart (left ventricular hypertrophy and heart failure) These hypertension complications are known as end organ damage The cardiac and vascular complications are associated with an increased risk of sudden incapacitation and sudden cardiac death (Koren et al 1991) Unfortunately the cardiac complications are frequently asymptomatic and valid screening tests are not fast and are not inexpensive Therefore determining who to screen for cardiac complications (such as echocardiogram for LVH or a measurement of left ventricular ejection fraction for heart failure) should be based on the severity and the duration of HTN
76 Physical Examination The annual physical examination shall include each of the following components
(a) BP shall be measured according to the Joint National Commission (JNC)-7 recommendations
A76(1)(a) BP should be measured with a properly calibrated and validated instrument Patients should be seated quietly for at least 5 minutes in a chair with feet on the floor and arm supported at heart level An appropriate-sized cuff (cuff bladder encircling at least 80 of the arm) should be used to ensure accuracy At least 2 measurements should be made Systolic BP is the point at which the first of 2 or more sounds is heard (phase 1) and diastolic BP is the point before the disappearance of sounds (phase 5) [Chobanian et al 2003]
(2) Head eyes ears nose and throat9420 Hypertension 94201 Physician Evaluation Members with Pre-hypertention (systolic 120-139 mmHg or diastolic 80-89 mmHg) Stage 1 hypertension (systolic 140-159 mmHg or diastolic 90-99 mmHg) or Stage 2 hypertension (systolic ge160 mmHg or diastolic ge100 mmHg) should be referred to their primary care physician for evaluation lifestyle modification and treatment
39
(1) Members with Stage I hypertension should be followed-up not only by their primary care physician but also by the FD physician every 3 to 6 months to ensure their blood pressure is under control and to determine whether screening tests for asymptomatic end organ damage are appropriate
(2) Members with Stage 2 hypertension or with end organ damage (retinopathy nephropathy vascular or cardiac complications) compromises the members ability to safely perform essential job tasks 1 5 7 9 and 130 and the physician shall report the applicable job limitations to the fire department
A94201 Chronic hypertension can damage the eye (retinopathy) the kidneys (nephropathy) the vascular system (stroke transient ischemic attack or peripheral artery disease) or the heart (left ventricular hypertrophy and heart failure) These hypertension complications are known as end organ damage The cardiac and vascular complications are associated with an increased risk of sudden incapacitation and sudden cardiac death (Koren et al 1991) Fortunately with proper evaluation life style modification and treatment these complications can be avoided Life style modification includes weight reduction DASH eating plan reduction in dietary sodium an increase in aerobic physical activity and moderation in alcohol consumption [Chobanian 2003]
A94201 (1) Members with Stage I hypertension whose BP returns to either pre-hypertenion or normal with lifestyle modification andor treatment can return to an annual medical evaluation For members with long-standing Stage I hypertension whose BP has not been reduced additional evaluation for possible end organ damage should be considered This evaluation could include any or all of the following
a) a compete patient history for symptoms of heart failure (eg shortness of breath upon exertion) or transient ischemic attacks (TIAs)
b) dilated eye examination for retinopathy
c) blood creatinine measurement for nephropathy
d) tests for left ventricular hypertrophy Unfortunately use of the resting EKG to detect left ventricular hypertrophy is very insensitive (eg 5 sensitivity) The echocardiogram is the best test for diagnosing left ventricular hypertrophy
A 94201 (2) Due to the high risk of a sudden cardiovascular event members with Stage 2 hypertension should be restricted until their BP can be brought under control Once the BP is brought under control they should be followed in the same manner as a member with Stage I hypertension
D22 Cardiology
40
Hypertension
Gibbons RJ Balady GJ Bricker JT Chaitman BR Fletcher GF Froelicher VF Mark DB McCallister BD Mooss AN OrsquoReilly MG Winters WL Jr [2002] ACCAHA 2002 guideline update for exercise testing summary article a report of the ACCAHA Task Force on Practice Guidelines (Committee to Update the 1997 Exercise Testing guidelines) J Am Coll Cardiol 401531ndash 40
Chobanian AV Bakris GL Black HR Cushman WC Green LA Izzo JL Jr Jones DW Materson BJ Oparil S Wright JT Jr Roccella EJ the National High Blood Pressure Education Program Coordinating Committee [2003] The seventh report of the Joint National Committee [JNC-7] on Prevention Detection Evaluation and Treatment of High Blood Pressure JAMA 2892560ndash2571
Soteriades ES Kales SN Liarokapis D Christiani DC [2003] Prospective surveillance of hypertension in firefighters J Clin Hypertens 5315-320
Kales SN Tsismenakis AJ Zhang C Soteriades ES [2009] Blood pressure in fire fighters police officers and other emergency responders Am J Hypertens 2211-20
41
NFPA 1582‐ Draft Revisions for CVDHTN
EKG and stress tests
Reason for Revision
1) Change requirement for annual resting EKG to periodically to be more consistent with ACCAHA
recommendation (Schlant et al 1992)
2) Add language to clarify what constitutes a positive ST
3) Make criteria for conducting diagnostic ST in asymptomatic patients consistent with the
ACCAHA
Language in 2007 Edition with draft revisions in Red (Track changes)
776 Electrocardiograms (EKG)) and Stress Tests 7761 A resting EKG shall be performed as part of the baseline medical evaluation and shall be obtained periodically (every 1 to 5 years) annually thereafter
A7761 A baseline resting EKGs shall be conducted Follow-up resting EKGs should be conducted as clinically indicated but at a minimum of every 1 to 5 years The frequency of these follow-up resting EKGs should increase as a members age increases or with increasing number andor severity of coronary heart disease risk factors Members above the age of 40 should have annual resting EKGs (Schlant et al 1992)
7762 The fire department physician or other qualified medical evaluator shall compare EKGs obtained during yearly evaluations with baseline and subsequent EKGs
7763 Stress testing EKG with or without echocardiography or radionuclide scanning shall be performed as clinically indicated by history or symptoms
A7761 Baseline electrocardiography should be conducted (Periodic resting electrocardiograms have not been shown to be useful but can be reasonable as a members agefactors increase)
A7763 No firm guidelines for stress testingelectrocardiography in asymptomatic individuals have been developed Stress testingelectrocardiography as a screening tool is used as part of an evaluation of aerobic capacity during the annual occupational fitness evaluation Submaximal stress testingelectrocardiography testing to 85 percent is commonly used as part of this screening
Submaximal stress electrocardiography testing should not be used for diagnostic purposes Cardiology evaluation with maximal stress testingelectrocardiography together with imaging techniques (eg echocardiography technetium Tc99m sestamibi study andor coronary angiography) is necessary for diagnosticprognostic purposes for the following
42
(1) Fire fighters with positive or questionably positive changes on screening submaximal stress tests
(2) Fire fighters with new onset chest pain or other symptoms suggestive of coronary artery disease (CAD)
(3) Fire fighters with diabetes mellitus who
(a) are gt35 years old or
(b) have type I diabetes for more than 15 years or
(c) have type II diabetes for more than 10 years or
(d) have any other CHD risk factor (see below) or
(e) have the presence of microvascular disease (proliferative retinopathy)
(4) Fire fighters over the age of 45 (for men) and 55 (for women) with onetwo or more risk factors for CAD Risk factors for CAD include hypercholesterolemia (total cholesterol greater than 240 mgdL) hypertension (systolic gt140 mmHg or diastolic gt90 mmHg) smoking or family history of premature CAD (heart attack or sudden cardiac death in a first degree relative less than 60 years of age)
as defined below if stress electrocardiography with imaging is negative then repeat as clinically indicated or at least every 5 years
(5) Fire fighters with a Framingham Risk Score gt10 Risk calculator is available at [httphp2010nhlbihinnetatpiiicalculatorasp]
(6) Fire fighters identified in 9431
Negative stress tests should be repeated as clinically indicated or at least every 2 to 5 years
Interpreting stress tests as ldquopositiverdquo or ldquonegativerdquo is beyond the scope of this document However factors that should be taken into consideration should include the individualrsquos exercise capacity symptoms blood pressure response heart rate response EKG changes and the presence of arrhythmias (Gibbon et al 2002)
Risk factors for CAD include hypercholesterolemia (total cholesterol greater than 240 mgdL) hypertension (systolic greater than 140 andor diastolic greater than 90) smoking diabetes mellitus or family history of premature CAD (heart attack or sudden cardiac death in a first degree relative less than 60 years of age)
There are other non-invasive tests to screen for coronary artery disease One of the most promising appears to be coronary artery calcium (CAD) scoring by computed tomography In 2007 an expert committee published an update to their original guidance document The committeersquos consensus was that ldquoit may be reasonable to consider use of CAC measurement in such patients [between 10 and 20 10-year risk of estimated coronary event]helliprdquo The committee did not recommend CAC measurement in low risk patients [lt10 10-year risk of estimated coronary event] or in high risk patients [gt20 10-year risk of estimate coronary event] (Greenland et al 2007]
43
D22 Cardiology
Chobanian AV Bakris GL Black HR Cushman WC Green LA Izzo JL Jr Jones DW Materson BJ Oparil S Wright JT Jr Roccella EJ the National High Blood Pressure Education Program Coordinating Committee [2003] The seventh report of the Joint National Committee [JNC-7] on Prevention Detection Evaluation and Treatment of High Blood Pressure JAMA 2892560ndash2571
Gibbons RJ Balady GJ Bricker JT Chaitman BR Fletcher GF Froelicher VF Mark DB McCallister BD Mooss AN OrsquoReilly MG Winters WL Jr [2002] ACCAHA 2002 guideline update for exercise testing summary article a report of the ACCAHA Task Force on Practice Guidelines (Committee to Update the 1997 Exercise Testing guidelines) J Am Coll Cardiol 401531ndash 1540
Greenland et al [2007] ACCFAHA 2007 Clinical Expert Consensus Document on Coronary Artery Calcium Scoring By Computed Tomography in Global Cardiovascular Risk Assessment and in Evaluation of Patients With Chest Pain A Report of the American College of Cardiology Foundation Clinical Expert Consensus Task Force (ACCFAHA Writing Committee to Update the 2000 Expert Consensus Document on Electron Beam Computed Tomography) J Am Coll Cardiol 49378-402
Kales SN Tsismenakis AJ Zhang C Soteriades ES [2009] Blood pressure in fire fighters police officers and other emergency responders Am J Hypertens 2211-20
Schlant RC Adolph RJ DiMarco JP Dreifus LS Dunn MI Fisch C Garson A Jr Haywood LJ Levine HJ Murray JA Noble RJ Ronan JA Jr [1992] Guidelines for electrocardiography A report of the American College of CardiologyAmerican Heart Association Task Force on Assessment of Diagnostic and Therapeutic Cardiovascular Procedures (Committee on Electrocardiography) Circulation 85(3)1221-1228
Soteriades ES Kales SN Liarokapis D Christiani DC [2003] Prospective surveillance of hypertension in firefighters J Clin Hypertens 5315-320
Formatted Font Italic
Formatted Line spacing single
Formatted Font Italic
Formatted Font Italic
44
NFPA 1582‐ Draft Revisions for CVDHTN
EKG and stress tests
Reason for Revision
1) Change requirement for annual resting EKG to periodically to be more consistent with ACCAHA
recommendation (Schlant et al 1992)
2) Add language to clarify what constitutes a positive ST
3) Make criteria for conducting diagnostic ST in asymptomatic patients consistent with the
ACCAHA
Language in 2007 Edition with draft revisions in Red (Track changes)
776 Electrocardiograms (EKG) and Stress Tests 7761 A resting EKG shall be performed as part of the baseline medical evaluation and shall be obtained periodically (every 1 to 5 years) thereafter
A7761 A baseline resting EKGs shall be conducted Follow-up resting EKGs should be conducted as clinically indicated but at a minimum of every 1 to 5 years The frequency of these follow-up resting EKGs should increase as a members age increases or with increasing number andor severity of coronary heart disease risk factors Members above the age of 40 should have annual resting EKGs (Schlant et al 1992)
7762 The fire department physician or other qualified medical evaluator shall compare baseline and subsequent EKGs
7763 Stress testing with or without echocardiography or radionuclide scanning shall be performed as clinically indicated by history or symptoms
A7763 No firm guidelines for stress testing in asymptomatic individuals have been developed Stress testing as a screening tool is used as part of an evaluation of aerobic capacity during the annual occupational fitness evaluation Submaximal stress testing testing to 85 percent is commonly used as part of this screening
Submaximal stress testing should not be used for diagnostic purposes Cardiology evaluation with maximal stress testing together with imaging techniques (eg echocardiography technetium Tc99m sestamibi study) is necessary for diagnosticprognostic purposes for the following
(1) Fire fighters with positive or questionably positive changes on screening submaximal stress tests
(2) Fire fighters with new onset chest pain or other symptoms suggestive of coronary artery disease (CAD)
45
(3) Fire fighters with diabetes mellitus who
(a) are gt35 years old or
(b) have type I diabetes for more than 15 years or
(c) have type II diabetes for more than 10 years or
(d) have any other CHD risk factor (see below) or
(e) have the presence of microvascular disease (proliferative retinopathy)
(4) Fire fighters over the age of 45 (for men) and 55 (for women) with one or more risk factors for CAD Risk factors for CAD include hypercholesterolemia (total cholesterol greater than 240 mgdL) hypertension (systolic gt140 mmHg or diastolic gt90 mmHg) smoking or family history of premature CAD (heart attack or sudden cardiac death in a first degree relative less than 60 years of age)
(5) Fire fighters with a Framingham Risk Score gt10 Risk calculator is available at [httphp2010nhlbihinnetatpiiicalculatorasp]
(6) Fire fighters identified in 9431
Negative stress tests should be repeated as clinically indicated or at least every 2 to 5 years
Interpreting stress tests as ldquopositiverdquo or ldquonegativerdquo is beyond the scope of this document However factors that should be taken into consideration should include the individualrsquos exercise capacity symptoms blood pressure response heart rate response EKG changes and the presence of arrhythmias (Gibbon et al 2002)
There are other non-invasive tests to screen for coronary artery disease One of the most promising appears to be coronary artery calcium (CAD) scoring by computed tomography In 2007 an expert committee published an update to their original guidance document The committeersquos consensus was that ldquoit may be reasonable to consider use of CAC measurement in such patients [between 10 and 20 10-year risk of estimated coronary event]helliprdquo The committee did not recommend CAC measurement in low risk patients [lt10 10-year risk of estimated coronary event] or in high risk patients [gt20 10-year risk of estimate coronary event] (Greenland et al 2007]
D22 Cardiology
Resting EKG and Stress Tests
46
Chobanian AV Bakris GL Black HR Cushman WC Green LA Izzo JL Jr Jones DW Materson BJ Oparil S Wright JT Jr Roccella EJ the National High Blood Pressure Education Program Coordinating Committee [2003] The seventh report of the Joint National Committee [JNC-7] on Prevention Detection Evaluation and Treatment of High Blood Pressure JAMA 2892560ndash2571
Gibbons RJ Balady GJ Bricker JT Chaitman BR Fletcher GF Froelicher VF Mark DB McCallister BD Mooss AN OrsquoReilly MG Winters WL Jr [2002] ACCAHA 2002 guideline update for exercise testing summary article a report of the ACCAHA Task Force on Practice Guidelines (Committee to Update the 1997 Exercise Testing guidelines) J Am Coll Cardiol 401531ndash 1540
Greenland et al [2007] ACCFAHA 2007 Clinical Expert Consensus Document on Coronary Artery Calcium Scoring By Computed Tomography in Global Cardiovascular Risk Assessment and in Evaluation of Patients With Chest Pain A Report of the American College of Cardiology Foundation Clinical Expert Consensus Task Force (ACCFAHA Writing Committee to Update the 2000 Expert Consensus Document on Electron Beam Computed Tomography) J Am Coll Cardiol 49378-402
Kales SN Tsismenakis AJ Zhang C Soteriades ES [2009] Blood pressure in fire fighters police officers and other emergency responders Am J Hypertens 2211-20
Schlant RC Adolph RJ DiMarco JP Dreifus LS Dunn MI Fisch C Garson A Jr Haywood LJ Levine HJ Murray JA Noble RJ Ronan JA Jr [1992] Guidelines for electrocardiography A report of the American College of CardiologyAmerican Heart Association Task Force on Assessment of Diagnostic and Therapeutic Cardiovascular Procedures (Committee on Electrocardiography) Circulation 85(3)1221-1228
Soteriades ES Kales SN Liarokapis D Christiani DC [2003] Prospective surveillance of hypertension in firefighters J Clin Hypertens 5315-320
47
ATTACHMENT F
48
1
Current 1582 (2007) language in reference to pregnancy 43 (4) Report to the fire department physician any medical condition that could interfere with the ability of the individual to safely perform essential job tasks such as illness or injury use of prescription or nonprescription drugs and pregnancy 6112 Category B medical conditions shall include the following (1) Pregnancy for its duration A7792 (e) If HIV prophylaxis is to be given the following tests should be done i CBC ii Glucose renal and hepatic chemical function iii Pregnancy test for females B121 Pregnancy and Reproduction Federal regulations as well as many court decisions including the US Supreme Courtrsquos decision in International Union et al v Johnson Controls Inc [499 US 187 111 S Ct 1196 (1991)] have interpreted the requirements of Title VII with respect to pregnancy and reproduction The AHJ should seek the advice of counsel in resolving specific questions concerning these requirements as well as other requirements that can be imposed by state or local laws C211 (4) Review health status with the individual being evaluated Contraindications for evaluations shall be reviewed addressing any changes in the individualrsquos health status since their last medical evaluation that would warrant deferring the evaluation including (g) Pregnancy Recommendations to language enhancement
A female employee who is assigned to regular fire line duty shall report a pregnancy immediately to their respective Supervisor and the fire department physician The employee will then be given the option of a non-hazardous alternative duty position for the duration of her pregnancy (can we say this or is it even appropriate) Any pregnant employee wishing to remain on regular line duty shall be informed of the possible risks and consequences to herself and her fetus that are associated with continued line fire fighting duty Among those risk factors are exposure to teratogens known to have negative effects on the developing fetus such as smoke diesel fumes hazardous chemicals and extreme heat
49
Page 2
appendix It is recommended that the pregnant employee complete a release of liability form signed by herself and her health care provider utilizing NFPArsquos 13 critical tasks as a reference This will inform the health care provider of specific job-related tasks that will need to be performed in order to continue regular line duty These tasks are basic physical standards that any entry level firefighter would have to be able to complete competently The employeersquos health condition will be kept confidential by the department in accordance with HIPAA standards Employees are allowed to remain on active regular duty until they are no longer able to perform their duties in a reasonable manner andor their protective gear no longer fits correctly It is the responsibility of the health care provider to evaluate the pregnant employee If at any time the health care provider feels the pregnant employee can no longer perform the job related tasks this should be reported to the employer by the employee immediately
50
ATTACHMENT G
51
From GLENN BENARICKTo Sawyer SteveSubject RE RE 7743Date Monday August 30 2010 21633 PM
Yes thats my understanding
Glenn P Benarick 211 Winged Elm CircleAiken SC 29803803-644-7093gbenarprodigynet
--- On Mon 83010 Sawyer Steve ltssawyerNFPAorggt wrote
From Sawyer Steve ltssawyerNFPAorggtSubject RE RE 7743To GLENN BENARICK ltgbenarprodigynetgtDate Monday August 30 2010 212 PM
So it should be ldquoorrdquo instead of ldquoandrdquo for now
Steven F Sawyer
Senior Fire Service Specialist
Executive Secretary IFMAFire Service Section
NFPA
1 Batterymarch Park
Quincy MA 02169
6179847423
Fax 6179847056
ssawyernfpaorg
From GLENN BENARICK [mailtogbenarprodigynet] Sent Monday August 30 2010 1202 PMTo Sawyer SteveSubject Fw RE 7743
52
Steve a couple of our docs agree with April Boyer
Glenn P Benarick 211 Winged Elm Circle
Aiken SC 29803
803-644-7093
gbenarprodigynet
--- On Mon 83010 David Prezant ltprezandfdnynycgovgt wrote
From David Prezant ltprezandfdnynycgovgtSubject RE 7743To Thomas R (CDCNIOSHDSHEFS) Hales lttrh1cdcgovgt GLENNBENARICK ltgbenarprodigynetgtCc Sandy Bogucki ltsandyboguckiyaleedugtDate Monday August 30 2010 1004 AM
agree
we should change this to NHANES III rather than Knudson we should alsomodify this to allow not only for predicted cutoffs but all for use of thelower limit of normal cutoff This is important to prevent false-classificationof spirometry as abnormal in older groups and in taller grps The latter ofparticular import to firefighter occupational health surveillance
thanks
David Prezant MDChief Medical Officer Office of Medical AffairsCo-Director WTC Medical Monitoring amp Treatment ProgramsNew York City Fire Department9 Metrotech Center - Rm 4W-1Brooklyn NY 11201Phone 718-999-2696Fax 718-999-0665
Life is full of twists and turns
53
This email may contain confidential information If you are the unintendedrecipient of this email please send it back and delete from your directory
gtgtgt Hales Thomas R (CDCNIOSHDSHEFS) lttrh1cdcgovgt 8302010955 AM gtgtgt
Glen
This seems like a very reasonable comment and illustrates the importance of having clinicians providefeedback on the std Im not familiar with the software program of the various spirometers (NHANES IIIvs KnudsonATS vs both) Given the large role both Dave Prezant and Sandy Bogucki had for thepulmonary section let me forward to them for clarification
Tom
From GLENN BENARICK [mailtogbenarprodigynet] Sent Sunday August 29 2010 456 PMTo Hales Thomas R (CDCNIOSHDSHEFS)Subject FW 7743
Tom is April Boyer correct
Glenn P Benarick 211 Winged Elm Circle
Aiken SC 29803
803-644-7093
gbenarprodigynet
--- On Thu 82610 Sawyer Steve ltssawyerNFPAorggt wrote
From Sawyer Steve ltssawyerNFPAorggtSubject FW 7743To GLENN BENARICK ltgbenarprodigynetgtDate Thursday August 26 2010 925 PM
FYI Do you have any answer She is write
Steven
54
Steven F Sawyer
Senior Fire Service Specialist
Executive Secretary IFMAFire Service Section
NFPA
1 Batterymarch Park
Quincy MA 02169
6179847423
Fax 6179847056
ssawyernfpaorg
From April Boyer [mailtoaboyerbicclinicorg] Sent Thursday August 26 2010 232 PMTo Sawyer SteveCc RobinMWebbmilstateorusSubject 7743
Steven
The spirometry tests cannot be corrected according to both references as the NFPA states because thereferences are contradictory The first part of 7743 states to follow the ATS guidelines and use theKnudsen (we at Basin Immediate Care use the Nhanes III) The second part states to follow the ACOEMguidelines and use the Nhanes III in the occupational setting if available with your unit (which is availableon ours) 7743 does not use the word OR regarding both requirements it uses the word AND whenreferring to the first and second parts thence making 7743 contradictory I realize the NFPA 1582 hasnot been updated since 2007 unless I have just not received an updated version
Our question to you is which part of 7743 do you want us to follow the first or the second part Anyfacility that has an updated computerized spirometry system (as we do) will not be able to follow bothrequired parts for obvious reasons We can either follow the first part of 7743 and use an oldercorrected version of the Knudson by going into our system and changing out of the Nhanes III conversionOR we can follow the second part of 7743 and use the newer corrected version of Nhanes III which ourunit offers too
If you have any questions you may contact me at anytime and I also have many references in regards toboth parts of 7743 if you would like to see them
55
Thank you~
April
Confidentiality NoticeThis message may contain information that isconfidential or privileged
If you are not the intended recipientPlease advise the sender immediately and delete this message
56
ATTACHMENT H
57
NFPA 1582 771(7) Proposed revisions
Why
Preliminary results of two prospective randomized trials on the PSA test were published in 2009 These studies resulted in medical organizations that previously providing guidance to modify their recommendations
Current language
771 Blood Tests Blood tests shall be performed annually and shall include the following
(7) Prostate specific antigen (PSA) after age 40 for positive family history if African American or if otherwise clinically indicated after age 50 for all other male member
Suggested Revision
771 Blood Tests Blood tests shall be performed annually and shall include the following
(7) Prostate specific antigen (PSA) after age 40 for positive family history if African American or if otherwise clinically indicated after age 50 for all other male member
772 Prostate-Specific Antigen (PSA) test At age 50 fire fighters shall have an opportunity to make an informed decision with either the Fire Department physician or their health care provider concerning the PSA test For fire fighters at increased risk of prostate cancer (African-Americans or those with a first degree relative diagnosed with prostate cancer before age 65) shall have the opportunity for this informed decision at age 40
A772 The PSA as a screening test for prostate cancer in asymptomatic men is controversial controversial for two reasons First there is no consensus that PSA screening actually saves lives For example the PSA test may detect small cancers that would never become life threatening Second it is unclear that the benefits of PSA screening outweigh the risks of follow-up diagnostic tests and cancer treatments For example the prostate biopsy used to diagnose prostate cancer may cause bleeding and infection And prostate cancer treatments such as surgery and radiation therapy may cause incontinence (inability to control urine flow) erectile dysfunction (erections inadequate for intercourse) and other complications For these reasons it is important that the benefits and risks of prostate diagnostic procedures and treatment be taken into account when considering the PSA screening test These considerations can be taken account during discussions with the fire department physician or onersquos health care provider
D211 Cancer Screening
Smith R A C J Mettlin K J Davis and H Eyre 2000 ldquoAmerican Cancer Society guidelines for the early detection of cancerrdquo CA J Clin 50(1)34ndash49
Added references
58
Carroll P Albertsen PC Greene K et al [2010] Prostate-specific antigen best practice statement 2009 update Am Urological Assoc Available at httpwwwauanetorgcontentguidelines-and-quality-careclinical-guidelinesmain-reportspsa09pdf Date accessed September 2010
Ferrini R Woolf SH [2009] Screening for prostate cancer in American men American College of Preventive Medicine Practice Policy Statement Available at httpwwwacpmorgprostatehtm Date accessed September 2010
National Cancer Institute [2009] Prostate-specific antigen test National Cancer Institute Fact Sheet Available at httpwwwcancergovcancertopicsfactsheetDetectionPSA Date accessed September 2010
Wolf AMD Wender RC Etzioni RB et al [2010] American Cancer Society guideline for the early detection of prostate cancer Update 2010 Available at httpcaonlineamcancersocorgcgicontentfullcaac20066v1 Date accessed September 2010
59
Address List 9172010
Fire Service Occupational Safety and Health FIX-AAAKenneth Willette
Michael A Laton
FIX-AAAPrincipalSperian Protective Apparel
160 Woodstream Way
Fayetteville GA 30214
International Safety Equipment AssociationPhoneCell 770-861-0350
FIX-AAANonvoting MemberNational Institute for Occupational Safety amp Health
4676 Columbia Parkway R-9
Cincinnati OH 45226
Alternate Jay L TarleyPhoneCell 513-841-4583
Fax 513-844-4488
Email thalescdcgov
RT 452001
William R Hamilton
FIX-AAANonvoting MemberUS Department of Labor
Occupational Safety amp Health Administration
200 Constitution Ave NW Room N3609
Washington DC 20210
Alternate Andrew LevinsonPhoneCell 202-693-2077
Fax 202-693-1663
Email hamiltonbilldolgov
E 342009 Andrew Levinson
FIX-AAAAlt to Nonvoting MemberUS Department of Labor
Occupational Safety amp Health Administration
200 Constitution Ave NW Room N3718
Washington DC 20210
Occupational Safety amp Health AdministrationPrincipal William R Hamilton
PhoneCell 202-693-2048
Fax 202-693-1678
Email levinsonandrewdolgov
E 7282006
Jay L Tarley
FIX-AAAAlt to Nonvoting MemberUS Department of Health amp Human Services
National Institute for Occupational Safety amp Health
1095 Willowdale Road MS 1808
Morgantown WV 26505
Principal Thomas R HalesPhoneCell 304-285-5858
Fax 304-285-5774
Email jst9cdcgov
RT 3152007 Kenneth Willette
FIX-AAAStaff LiaisonNational Fire Protection Association
1 Batterymarch Park
Quincy MA
PhoneCell 617-984-7299
Fax 617-984-7056
Email kwillettenfpaorg
792010
68
ATTACHMENT B
9
Technical Committee on Fire Service Occupational Safety and Health
Meeting Minutes May 13 ndash 14 2010
Holiday Inn Inner Harbor MD
Attendees Glenn Benarick Chairman Ken Holland Staff Liaison Michael Finkelman Craig Fry Joe Rivera Stephen Raynis Steve Kreis Dennis Childress Don Stewart Phil Stittleburg David Ross Michael Laton Kim Zagaris Tom Hillenbrand Dominic Colletti Andy Schwartz Brett Bowman Guest David Bernzweig Thursday May 13 NFPA 1500 task groups (Vehicle amp Safety OPS SCBA amp Air Mgt PPEProximity) met to discuss the work they have completed since the last meeting The task groups will present their report to the entire TC on May 14th Not enough 1582 task group members were able to make the meeting so there were no reports or work from those task groups Friday May 14 TC meeting called to order at approximately 0800 by Glenn Benarick TC Chair Ken Holland (NFPA Public Fire Protection Staff) in attendance filling in for Frank Florence Ken made two presentations one on the Codes and Standards Development Process and the other on the general procedures for this Pre-ROP meeting The Staff Liaison remains fluid as Frank is not expected back any time soon
10
One guest in attendance Dave Bernzweig (Columbus OH Fire) Dave is assisting TC with SCBAAir Mgt issues The document revision cycles remain as requested NFPA 1500 amp 1582 Annual 2012 NFPA 1521 amp 1561 Fall 2013 NFPA 1581 1583 1584 Annual 2014 The October 7-9 2010 dates are the primary request for our next meeting Location is San Diego Notice will be sent out as soon as approval is received Discussion on the next revision of 1561 will be held at the October meeting regarding changing the document title to ldquoCommand Safety for Fire Department Operationsrdquo This is a suggestion of the TC Chair Ken Holland conducted a briefing for the TC on how to access and use the committee web page Staff will be posting as much information as possible up on the e-committee page for the entire committee More use will be made of this tool Discussion on monocular vision Dennis Childress presented the current issue in Ventura County CA Further discussionwork may be necessary Don Stewart agreed to take the lead Brief discussion held on pregnancy and the need for fire departments to ensure policies match current law The rep from the Diabetes Association declined the invitation to participate at this meeting due to no discussion of the issue planned She has indicated a desire to attend the October meeting There were no reports from these and all other 1582 task groups It is very important for the 1582 TG Chairs to be ready to report in October The following task group reports will be posted on the ecommittee page PPEProximity New definition of proximity fire fighting
VehicleHighway OPS Discussion on use of vehicle data recorders Collapse Zones Submission from Jay Tarley SCBAAir Mgt New exit strategy for SCBA Discussion on having the low air alarm activate when the bottle volume reaches 600 liters Further discussion to take place on ldquobuddy breathingrdquo
On Day 2 Casey Grant (NFPA Fire Protection Research Foundation) made a presentation on Research Planning for FSOSH Dr Ellen Sogolow (DHSFEMA) also present during this presentation She discussed the role of the AFGRampD activities See ecommittee page for his presentation Chair
11
will be in contact with Mr Grant for future work between the TC and the Foundation Also on Day 2 Ken Willette (Division Manager ndash NFPA Public Fire Protection Division) delivered a presentation on the initiative developed by Kelvin Cochran (US Fire Administrator) to reduce fire fighter injuries and deaths NFPA 1500 is an integral part of this initiative See ecommittee page for presentation The Chair will be coordinating a committee conference call in the coming weeks The purpose will be to review the work which needs to be completed for the October meeting The primary focus of the call will be on 1582 issues NOTE Subsequent to the meeting I have had some discussions with a fire chief in Kentucky on the use of hearing aids The TC especially the doctors need to review the current language in 1582 and decide if revisions are needed Also most of you know that Kelvin Cochran has left the USFA unexpectedly to return to Atlanta as their fire chief I have been in contact with the Acting Administrator Glenn Gaines to inform him that our committee remains focused on the work to reduce fire fighter injuries and deaths I told him that I would keep him informed of our work He indicated that one of his primary goals is to bring fire service organizations together in order to create a safe working environment Of particular interest to him is reducing heart related injuries and deaths Submitted by Glenn Benarick
12
Technical Committee on Fire Service Occupational Safety and Health
Conference Call Meeting Minutes August 30th 2010
Members participating
Glenn Benarick TC Chair
Murrey Loflin Secretary Dr Sandy Bogucki
Thomas Cuff Stephen Foley
Scott Kerwood Tammy Lopes
David Love Dr David Prezant
Joe Rivera David Ross
Mario Rueda Phil Stittleburg
Phil Vorlander Dominic Colletti
Thomas Hillenbrand
Denise Smith Brett Bowman Alternate
Andrew Schwartz Alternate Mike Young Alternate
Dr Thomas Hales Non-Voting Member Ken Holland NFPA Staff Liaison
Casey Grant NFPAResearch Foundation Staff Katie Hathway Guest from ADA
Dr Jim Fleming Guest from Phoenix Fire Dept
The chair welcomed everyone to the conference call in which he hoped
would last only an hour The purpose was to discuss any task groups that had reports for proposed changes to NFPA 1582 for the
committee This is in hopes to ensure the committee is ready for their
pre-ROP meeting in October The following topics were discussed and are in no specific order
Comments from ADA Katie Hathaway and the group went into deep
discussion regarding ones medical history and diagnosis of diabetes
13
and some proposed changesremoval of text based on research
findings The specific proposed changes will be available for the committee at their next meeting Some members on the call felt that
this issue was covered in another law enforcement document which might better serve this issue
Research topics for FSOSH projects Casey Grant offered his time to
answer any questions regarding his presentation from the May meeting in Baltimore There was also discussion about further
involvement of the Research Foundation with this committee and some of the medical requirements within the documents Glenn and Casey
are going to be in contact offline to discuss this further
Prosthetics amp Amputees report Nothing new to report
Heart amp Hypertension report There was discussion about the need for
periodic EKGrsquos that were done both in resting and non-resting states as well as discussion about stress test requirements and frequency of
such tests The hopes were to develop text that would point to annual versus periodic evaluations of EKGrsquos and stress tests
Epilepsy report Nothing new to report
Pregnancy report The initial textlanguage has been provided to the
group through email and e-committee page posting
Coagulation amp Meds report Nothing new to report
Hearing Aid discussion Nothing new to report
The committee also discussed the evaluation and documentation of
PSA results and test requirements for the purposes of consistency The proposed text and changes have been posted on the e-committee
page as well
All of the proposed text changes from the May meeting in Baltimore have been emailed out and posted on the e-committee page If there
are any questions or concerns that something was missed please contact Glenn Steven Sawyer or Ken Holland to ensure they are
resolved
The conference call lasted approximately an hour and was adjourned at 1400 hours
14
ATTACHMENT C
15
2012 ANNUAL REVISION CYCLE
PROCESS STAGE PROCESS STEP DATES
FOR TC DATES
FOR TCC 1 PRELIMINARY 10 Notification of intent to enter cycle 7910 7910
2 REPORT ON
PROPOSALS (ROP)
21 Proposal closing date 112310 112310 22 Final date for ROP meeting 22511 2411 23 Final date for mailing TC ballots 31811 21811 24 Receipt of (TC) ballots by staff liaison 42211 31111 25 Receipt of TC recirculation ballots 5611 31811 26 Final date for TCC meeting 41511 27 Final date for mailing TCC ballots 42211 28 Receipt of TCC ballots 51311 29 Receipt of TCC recirculation ballots 52011 210 Final copy (w ballot statements) to Secretary Standards Council 51311 52711 211 Completion of Reports 52011 6311 212 ROP Published and Posted 62411 62411
3 REPORT ON
COMMENTS
(ROC)
31 Comment closing date 83011 83011 32 Final date for ROC meeting 11411 10711 33 Final date for mailing TC ballots 111811 102111 34 Receipt of (TC) ballots by staff liaison 12211 111111 35 Receipt of TC recirculation ballots 12911 111811 36 Final date for TCC meeting 121611 37 Final date for mailing TCC ballots 122311 38 Receipt of TCC ballots 11312 39 Receipt of TCC recirculation ballots 12012 310 Final copy (w ballot statements) to Secretary Standards Council 122311 12712 311 Completion of Reports 11312 2312 312 ROC Published and Posted 22412 22412
4 TECH SESSION
PREPARATION amp
ISSUANCE OF
CONSENT
DOCUMENTS
41 Notice of Intent to Make a Motion (NITMAM) Closing Date 4612 4612 42 Posting of Filed NITMAM 5412 5412
43 Council Issuance Date for Consent Documents 52912 52912
44 Appeal Closing Date for Consent Documents 61312 61312
5 TECHNICAL
SESSION 50 Association Meeting for Documents with Certified Amending Motions
64-712 64-712
6
APPEALS amp
ISSUANCE OF
DOCUMENTS
WCAMS
61 Appeal closing date for Documents with Certified Amending Motions
62712 62712
62 Council issuance for Documents with Certified Amending Motions 8912 8912
Proposal Closing Dates may vary according to documents and schedules for Revision Cycles may change Please check the NFPA website (wwwnfpaorg) for the most up-to-date information on proposal closing dates and schedules
16
ATTACHMENT D
17
This weekrsquos conference call mentioned the Diabetes chapter written for the ACOEM document Guidance for the Medical Evaluation of the Law Enforcement Officer The task group working on this chapter (led Richard Miller of the Secret Service and our very own Dan Samo) worked with the ADA or over 2-3 years to come up with a consensus document
Please find the Chapter attached ltltDiabetes Guidance Sept 2010pdfgtgt
Regarding Dan Loeberrsquos points
1) Physical Evaluation Form - We could modify the LEO form (see end of the attached Chapter)
2) Duration required for stable regiment
1582 for IDDM Type 1 1 yr
Type 2 6 m
Oral Agents None specifically
ACOEM Police for IDDM Type 1 6m
Type 2 3m
Oral Agents 1m
The police document is much clearer about the decision regarding medical fitness for duty is the responsibility of the police physician with the treating diabetes-expert physician providing the data to the police physician to make an informed decision In this regard the police officer must provide the police physician with downloaded self monitoring glucose data for the 1 3 and 6 month time periods (see section 433)
3) HA1C ndash NFPA lt 8 over 3 month period
ACOEM Police ndash (Section 4333) Specifies the frequency on measurement and if gt8 requires further evaluation
Some other discrepancies End organ complications
NFPA ndash end organ complications (eye kidney heart neuro) ndash restriction
ACOEM Police ndash end organ complication -- requires further evaluation
18
Hypoglycemia (incapacitating ndash defined differently between the two documents (434)
NFPA ndash 0 episodes in past year le1 in past 5 yrs
ACOEM Police ndash 0 episodes in past year le2 in past 3 yrs
Given Dan Samorsquos and Richard Millerrsquos work with the ADALoeber it would be helpful to get their opinions on whether any of the changes requested by Loeber are appropriate for FF with DM
Tom
Thomas Hales MD MPH
Senior Medical Epidemiologist
NIOSH CDC
4676 Columbia Pkwy R-9
Cincinnati OH 45241
(513) 841-4583
trh1cdcgov
19
43 ndash DIABETES MELLITUS
431 ndash INTRODUCTION
The educated and motivated law enforcement officer (LEO) with well-managed diabetes mellitus can be capable of
safe and effective job performance1 However diabetes mellitus may place LEOs at risk for sudden incapacitation
thus jeopardizing their ability to perform critical job functions (These job functions include those listed in Sections
32 333 351 352 36 and 37 and discussed in Appendix A)
Therefore an individualized assessment of the LEOrsquos diabetes should be performed using the following evaluative
criteria to determine whether the individuals condition permits safe and effective job performance Such evaluation
must include the following key elements which are discussed in detail below
history of blood glucose control
knowledge of diabetes and its management
current stability of blood glucose
risk for significant hypoglycemia or hyperglycemia and
presence of diabetic complications
432 ndash OVERVIEW OF MEDICAL EVALUATION
The treating endocrinologist or other physician knowledgeable regarding diabetes management should provide
a narrative report certifying whether the LEO has or has not met the criteria set out in Sections 4321 through
4354 below In addition the physician should include supporting data (see Appendix B for the Physician Evalu-
ation Form)
4321 The LEO is under the care of an endocrinologist or other physician knowledgeable regarding diabetes
management Outpatient and in-patient medical record(s) for the last 3 years or since date of diagnosis
(whichever is shorter) should be reviewed by the treating physician and provided to the police physician
4322 If the LEO has type 1 diabetes the individual has been on a basalbolus regimena or an insulin pump
using analogue insulins for the 6 months prior to evaluation2
4323 If the LEO has type 2 diabetes on insulin the individual has been on a stable medication regimenb
for the 3 months prior to evaluation3 If on oral agents alone the LEO has been on a stable medication regimen
for the month prior to evaluationc
ACOEM Guidance for the Medical Evaluation of Law Enforcement Officers 1
43 ndash DIABETES MELLITUS
aA basalbolus insulin regimen consists of the use of a basal insulin (Glargine NPH) in a once or twice daily regimen to provide between-
meal insulin combined with the use of a short acting insulin (Regular Lispro Aspart or Glulisine) at mealtimes Insulin pumps are small
(beeper sized) battery powered devices that deliver small amounts of short-acting insulin in a constant infusion to meet basal insulin
requirements The wearer selects an additional mealtime bolus to be infused at the time of meals For more information on pumps visit
the manufacturerrsquos web sites ndash wwwMinimedcom wwwcozmorecom wwwanimascorpcom wwwdisetroniccom
bA stable insulin regimen is defined as maintaining the same types of insulin (long acting intermediate acting short or rapid acting)
Changes in insulin dose are part of the appropriate self-management of diabetes and do not disqualify an applicant or incumbent under
this section
cChanges in dose within the evaluation period will be allowed but addition of a new class of medications or insulin should result in a new
period of observation
one month for addition of a sulfonylurea or metformin
two months for the addition of a thiazolidinedione to insulin or a sulfonylurea or
three months for the addition of insulin
20
4324 If the LEO uses an insulin pump documentation is needed as follows
proper understanding and education in the use of the insulin pump
start date for the use of the pump
history of insulin site infectionsd
history of pump cessation and pump malfunction
backup plan for pump malfunction including use of injectable insulin and
frequency of infusion set changes
4325 The LEO has been educated in diabetes and its management and thoroughly informed of and under-
stands the procedures that must be followed to monitor and manage hisher diabetes and what procedures
should be followed if complications arise3
433 ndash QUANTITATIVE GLUCOSE MONITORING
4331 The LEO has documentation of ongoing self-monitoring of blood glucose
4332 This must be done with a glucose meter that stores every reading records date and time of reading
and from which data can be downloaded (Most meters now have this capability)
4333 Monitoring logs must be available covering the time period (1 3 or 6 months) as described in
Sections 4322 and 4323 The frequency of glucose monitoring must follow a schedule acceptable to the
police physician in consultation with the treating physician
Testing schedules are individual What follows is a common pattern but individual patterns may differ
2 ACOEM Guidance for the Medical Evaluation of Law Enforcement Officers
43 ndash DIABETES MELLITUS
dIndividual has not had more than one pump-site infection that caused him or her to miss work or usual daily activities in the preceding 6
months
THERAPEUTIC REGIMEN GLUCOSE TESTING SCHEDULE
Diet alone Once or twice a week
Metformin Thiazolidinediones or Alpha
Glucosidase inhibitors alone or in
combination
Once or twice a week
Sulfonylureas meglitanides nateglinide ndash
alone or in combination with the above group
Twice a day ndash AM and at supper with any
suspected hypoglycemic episodes
Insulin ndash one shot in combination with orals Twice a day ndash AM and at supper with any
suspected hypoglycemic episodes
2 to 3 times AM once a week
Insulin ndash two or more shots Insulin pump 3 to 4 times a day ndash at meals and bedtime
2 to 3 times AM once a week with any
suspected hypoglycemic episodes
21
4334 The LEO has had hemoglobin A1C measured at least 4 times a year (intervals of 2 to 3 months) over
the last 12 months prior to evaluation if diagnosis has been present for more than a year4 If hemoglobin A1C is
gt8 this may signal a problem with the LEOrsquos diabetes management that warrants further assessment5
434 ndash INCAPACITATING EVENTS
4341 The LEO has not had any incapacitating episodes within the past 1 year and no more than 2 episodes
in the past 3 years or since diagnosis of diabetes (whichever is shorter) of
43411 Severe hypoglycemia (loss of consciousness seizures or coma requiring assistance of others or
needing urgent treatment [glucagon injectionIV glucose]) or
43412 Blood sugar lt60 mgdl with unawareness demonstrated in current glucose logs6
435 ndash CHRONIC COMPLICATION SCREENING
4351 Chronic complications of diabetes are associated with increased risk for severe hypoglycemic
episodes and warrant further assessmente
4352 The components of screening for chronic complications are
43521 A complete eye exam by a qualified ophthalmologist or optometrist including a dilated retinal
exam demonstrating no more than mild background diabetic retinopathyf7
43522 Normal vibratory testing with a 128 Hz tuning forkg normal testing with 10 gram Semmes-
Weinstein monofilamentg and normal orthostatic blood pressureh and pulse testing89
ACOEM Guidance for the Medical Evaluation of Law Enforcement Officers 3
43 ndash DIABETES MELLITUS
ePresence of chronic complications of diabetes in and of themselves may not require the implementation of work restrictions
fNo more than one dot blot or flame-shaped hemorrhages or microaneurysm in all four fundus quadrants
gThe Michigan Diabetes Research and Training Center of the University of Michigan Health System recommends the following guidance
(see wwwmedumichedumdrtcprofsdocumentssviMNSI_howtopdf) for conducting vibratory and monofilament testing8
Vibration Sensation Vibration sensation should be performed with the great toe unsupported Vibration sensation will be tested bi-
laterally using a 128 Hz tuning fork placed over the dorsum of the great toe on the boney prominence of the DIP joint Patients whose
eyes are closed will be asked to indicate when they can no longer sense the vibration from the vibrating tuning fork In general the
examiner should be able to feel vibration from the hand-held tuning fork for 5 seconds longer on his distal forefinger than a normal subject
can at the great toe (eg examiners DIP joint of the first finger versus patients toe) If the examiner feels vibration for 10 or more seconds
on his or her finger then vibration is considered decreased A trial should be given when the tuning fork is not vibrating to be certain that
the patient is responding to vibration and not pressure or some other clue Vibration is scored as 1) present if the examiner senses the
vibration on his or her finger for lt10 seconds 2) reduced if sensed for 10 seconds or 3) absent (no vibration detection)
Monofilament Testing For this examination it is important that the patients foot be supported (ie allow the sole of the foot to rest on
a flat warm surface) The filament should initially be pre-stressed (4-6 perpendicular applications to the dorsum of the examiner s first
finger) The filament is then applied to the dorsum of the great toe midway between the nail fold and the DIP joint Do not hold the toe
directly The filament is applied perpendicularly and briefly (lt1 second) with an even pressure When the filament bends the force of
10 grams has been applied The patient whose eyes are closed is asked to respond yes if heshe feels the filament Eight correct responses
out of 10 applications is considered normal 1 to 7 correct responses indicates reduced sensation and no correct answers translates into
absent sensation
hOrthostatic hypotension is a physical finding defined by the American Autonomic Society and the American Academy of Neurology as a
systolic blood pressure decrease of at least 20 mm Hg or a diastolic blood pressure decrease of at least 10 mm Hg within 3 minutes of
standing
22
43523 Normal cardiac physical exam Cardiac stress testing to at least 12 METS is recommended and
should begin based on either the criteria of the American Heart AssociationAmerican College of
Cardiologyi10 or those of the American Diabetes Associationj11
Diabetics who have a normal cardiac stress test will be retested every one to three years based on
individual clinical assessment This assessment should consider
the age of the individual
the number and persistence of coronary artery disease (CAD) risk factors
the severity of CAD risk factors
43524 Microalbumincreatinine ratio 301 measured or calculatedk creatinine clearance
gt60 mlmin12
436 ndash ONGOING EVALUATION AND REQUIREMENTS
4361 Should have medical records and glucose meter logs reviewed periodically Because of the nature of
diabetes it is important that regular medical follow up be provided to the LEO The frequency and content of
the evaluation should be determined on an individual basis by the police physician in consultation with the
treating physicianl
4362 Must advise police physician of any change in type of medication
4363 Must advise police physician of any episodes of significant hypoglycemia or hyperglycemia
Urine microalbumincreatinine ratio _________________
III Treating Physician Statement
The above named individual meets all of the criteria provided on this form
Yes No ndash not recommended for position
No but IS recommended for position (letter of explanation attached)
It is my opinion that the above named individual is well-educated and well-motivated in diabetes self-management and has
achieved a level of diabetes management to be capable of safe and effective job performance as a law enforcement officer
I have reached this opinion after careful review of the above criteria
___________________________________________________________ ___________________________Signature of Physician Date
______________________________________________________________ ___________________________Printed or Typed Name of Physician Telephone Number
10 ACOEM Guidance for the Medical Evaluation of Law Enforcement Officers
43 ndash DIABETES MELLITUS
29
439 ndash REFERENCES
1 American Diabetes Association Diagnosis and classification of diabetes mellitus Diabetes Care 200427 Suppl
1S5-S10 See httpcarediabetesjournalsorgcgicontentfull27suppl_1s5
2 American Diabetes Association Continuous subcutaneous insulin infusion Diabetes Care 200427 Suppl 1S110
See httpcarediabetesjournalsorgcgicontentfull27suppl_1s110
3 Mensing C Boucher J Cypress M et al National standards for diabetes self-management education Diabetes
Care 200528 Suppl 1S72-9 See httpcarediabetesjournalsorgcgicontentfull28suppl_1s72
4 Goldstein DE Little RR Lorenz RA Malone JI Nathan DM Peterson CM American Diabetes Association Tests
of glycemia in diabetes Diabetes Care 200427 Suppl 1S91-3
See httpcarediabetesjournalsorgcgicontentfull27suppl_1s91
5 The Diabetes Control and Complications Trial Research Group Hypoglycemia in the Diabetes Control and
Complications Trial Diabetes 199746(2)271-86 See wwwncbinlmnihgovpubmed9000705 for abstract
6 American Diabetes Association Hypoglycemia and employmentlicensure Diabetes Care 200528 Suppl 1S61
See httpcarediabetesjournalsorgcgicontentfull28suppl_1s61
7 Viswanath K McGavin DD Diabetic Retinopathy Clinical Findings and Management J Comm Eye Health
200316(46)21-4 See wwwcehjournalorg0953-683316jceh_16_46_021html
8 Michigan Diabetes Research and Training Center University of Michigan Health System How to use the Michigan
Neuropathy Screening Instrument See wwwmedumichedumdrtcprofsdocumentssviMNSI_howtopdf
9 Bradley JG Davis KA Orthostatic hypotension Am Fam Physician 200368(12)2393-8
See wwwaafporgafp200312152393html
10 Gibbons RJ Balady GJ Bricker JT et al ACCAHA 2002 guideline update for exercise testing a report of the
American College of CardiologyAmerican Heart Association Task Force on Practice Guidelines (Committee on
Exercise Testing) J Am Coll Cardiol 200240(8)1531-40
See wwwaccorgqualityandscienceclinicalguidelinesexerciseexercise_cleanpdf
11 American Diabetes Association Standards of medical care in diabetes Diabetes Care 200528 Suppl 1S4-S36
Erratum in Diabetes Care 200528(4)990 See httpcarediabetesjournalsorgcgicontentfull28suppl_1s4
12 Molitch ME DeFronzo RA Franz MJ et al American Diabetes Association Nephropathy in diabetes Diabetes
Care 200427 Suppl 1S79-83 See httpcarediabetesjournalsorgcgicontentfull27suppl_1s79
13 Kitabchi AE Umpierrez GE Murphy MB et al American Diabetes Association Hyperglycemic crises in diabetes
Diabetes Care 200427 Suppl 1S94-102 See httpcarediabetesjournalsorgcgicontentfull27suppl_1s94
14 US Centers for Disease Control and Prevention National Diabetes Fact Sheet 2007
See wwwcdcgovdiabetespubspdfndfs_2007pdf
ACOEM Guidance for the Medical Evaluation of Law Enforcement Officers 11
43 ndash DIABETES MELLITUS
30
ATTACHMENT E
31
Typos A6921(2) 7th line down test should be plural 94201 Paragraph 2 target organ damage is used though end organ damage was defined earlier and in the appendix for that paragraph
A94201 Para A (1) d Id suggest deleting the phrases in brackets Im not sure either are predictably true or politically wise
a) tests for left ventricular hypertrophy Unfortunately use of the EKG to detect left ventricular hypertrophy is very insensitive (eg 5 sensitivity) The echocardiogram is the best test for diagnosing left ventricular hypertrophy but [it is relatively expensive and not readily available in small rural communities ] conducting echocardiograms on asymptomatic fire fighters with Stage 1 hypertension should be reserved only for those with long-standing hypertension
In addition
7761 A resting EKG shall be performed as part of the baseline medical evaluation and shall be obtained periodically thereafter
Changing from annually to periodically is noted has the language in the wellness-fitness initiative been changed as well Our previous decision was that we would support the W-F language since there was no compelling evidence to either support or refute it
Thanks
Sandy
32
NFPA 1582‐ HTN Draft 1
Reason for Revision
1) New classification of BP by the Joint National Commission [Chobanian et al 2002]
2) A high prevalence of FF have either HTN (~20) and Pre‐HTN (~20) [Soteriades et al 2003]
3) Among FF studies have shown a strong association between HTN and a number of adverse
cardiovascular events [Kales et al 2009]
4) A large percentage of on‐duty FF fatalities were found to have left ventricular hypertrophy a
complication of HTN at autopsy
Language in 2007 Edition with draft revisions in Red (Track changes)
611 The medical evaluation of a candidate shall include a medical history examination and any laboratory tests required to detect physical or medical condition(s) that could adversely affect hisher ability to safely perform the essential job tasks outlined in 511 A611 The medical history should include the candidates known health problems such as major illnesses surgeries medication use and allergies Symptom review is also important for detecting early signs of illness A medical history should also include a personal health history a family health history a health habit history an immunization history and a reproductive history
An occupational history should also be obtained to collect information about the persons past occupational and environmental exposures
(a) BP should be measured according to the Joint National Commission (JNC) -7 recommendations BP should be measured with a properly calibrated and validated instrument Patients should be seated quietly for at least 5 minutes in a chair with feet on the floor and arm supported at heart level An appropriate-sized cuff (cuff bladder encircling at least 80 of the arm) should be used to ensure accuracy At least 2 measurements should be made Systolic BP is the point at which the first of 2 or more sounds is heard (phase 1) and diastolic BP is the point before the disappearance of sounds (phase 5) [Chobanian et al 2003]
(2) Head eyes ears nose and throat (HEENT)
Formatted Font (Default) Times New RomanFont color Black
33
692 Vascular System 6921 Category A medical conditions shall include the following
(1) Uncontrolled or poorly controlled hypertension
(2) Hypertension with evidence of end organ damage
or not controlled by approved medications
A6921(1) Uncontrolled or poorly controlled hHypertension increases the risk of a sudden cardiac event This sudden cardiac event would cause sudden incapacitation which that is uncontrolled poorly controlled or requires medication likely to interferes with the safe performance of essential job tasks Uncontrolled or poorly controlled hypertension can be defined as the presence of end organ damage (see below) or stage 2 hypertension (BP systolic gt160 mmHg or BP diastolic gt100 mmHg) is an illness that can lead to functional impairment and potential for sudden incapacitation Individuals with pre- stage 1 or stage 2 hypertension should be referred to their primary care physician for evaluation lifestyle modification and treatment [QUESTION FOR GROUP _- WHAT ABOUT HAVING CANDIDATE RETURN IN ONE MONTH UNDER TREATMENT WITH NORMAL BP]
A6921(2)
Chronic hypertension can damage the eye (retinopathy) the kidneys (nephropathy) the vascular system (stroke transient ischemic attack or peripheral artery disease) or the heart (left ventricular hypertrophy and heart failure) These hypertension complications are known as end organ damage The cardiac and vascular complications are associated with an increased risk of sudden incapacitation and sudden cardiac death (Koren et al 1991) Unfortunately the cardiac complications are frequently asymptomatic and valid screening tests are not fast and are not inexpensive Therefore determining who to screen for cardiac complications (such as echocardiogram for LVH or a measurement of left ventricular ejection fraction for heart failure) should be based on the severity and the duration of HTN
76 Physical Examination The annual physical examination shall include each of the following components
(a) BP shall be measured according to the Joint National Commission (JNC)-7 recommendations
A76(1)(a) BP should be measured with a properly calibrated and validated instrument Patients should be seated quietly for at least 5 minutes in a chair with feet on the floor and arm supported at heart level An appropriate-sized cuff (cuff bladder encircling at least 80 of the arm) should be used to ensure accuracy At least 2 measurements should be made Systolic BP is the point at which the first of 2 or more sounds is heard (phase 1) and diastolic BP is the point before the disappearance of sounds (phase 5) [Chobanian et al 2003]
(2) Head eyes ears nose and throat (HEENT)
34
9420 Uncontrolled Hypertension 94201 Physician Evaluation Severe uncontrolled hypertension [defined as systolic pressure greater than 180 mm Hg diastolic pressure greater than 100 mm Hg or mean systolic blood
pressure ( systolic + diastolic) greater than 120 mm Hg] or malignant hypertension (defined as hypertension with the presence of target organ damage) compromises the members ability to safely perform essential job tasks 1 5 7 9 and 13 and the physician shall report the applicable job limitations to the fire department
Members with Pre-hypertention (systolic 120-139 mmHg or diastolic 80-89 mmHg) Stage 1 hypertension (systolic 140-159 mmHg or diastolic 90-99 mmHg) or Stage 2 hypertension (systolic ge160 mmHg or diastolic ge100 mmHg) should be referred to their primary care physician for evaluation lifestyle modification and treatment
(1) Members with Stage I hypertension should be followed-up not only by their primary care physician but also by the FD physician every 3 to 6 months to ensure their blood pressure is under control and to determine whether screening tests for asymptomatic end organ damage are appropriate
(2) Members with Stage 2 hypertension or with end organ damage (retinopathy nephropathy vascular or cardiac complications) compromises the members ability to safely perform essential job tasks 1 5 7 9 and 130 and the physician shall report the applicable job limitations to the fire department
A94201 Severe uncontrolled hypertension is a significant risk factor for the development of coronary artery disease congestive heart failure and stroke Blood pressure increases as a normal response to exercise This response is further exaggerated by the emotional and physical stress of performing these critical tasks while operating in personal protective clothing at extremes of temperature This normal elevation of blood pressure under these response conditions can lead to life-threatening hypertensive emergencies if a members daily blood pressure is already elevated to high levels In addition hypertension is a progressive illness that when uncontrolled ultimately and inevitably leads to target organ damage Target organs that are sensitive to the effects of elevated blood pressure are the central nervous system vision heart major blood vessels and kidneys
Chronic hypertension can damage the eye (retinopathy) the kidneys (nephropathy) the vascular system (stroke transient ischemic attack or peripheral artery disease) or the heart (left ventricular hypertrophy and heart failure) These hypertension complications are known as end organ damage The cardiac and vascular complications are associated with an increased risk of sudden incapacitation and sudden cardiac death (Koren et al 1991) Fortunately with proper evaluation life style modification and treatment these complications can be avoided Life style modification includes weight reduction DASH eating plan reduction in dietary sodium an increase in aerobic physical activity and moderation in alcohol consumption [Chobanian 2003]
Formatted Font (Default) Times New Roman12 pt Font color Black
Formatted Font (Default) Times New Roman12 pt Font color Black
35
A94201 (1) Members with Stage I hypertension whose BP returns to either pre-hypertenion or normal with lifestyle modification andor treatment can return to an annual medical evaluation For members with long-standing Stage I hypertension whose BP has not been reduced additional evaluation for possible end organ damage should be considered This evaluation could include any or all of the following
a) a compete patient history for symptoms of heart failure (eg shortness of breath upon exertion) or transient ischemic attacks (TIAs)
b) dilated eye examination for retinopathy
c) blood creatinine measurement for nephropathy
d) tests for left ventricular hypertrophy Unfortunately use of the resting EKG to detect left ventricular hypertrophy is very insensitive (eg 5 sensitivity) The echocardiogram is the best test for diagnosing left ventricular hypertrophy
A 94201 (2) Due to the high risk of a sudden cardiovascular event members with Stage 2 hypertension should be restricted until their BP can be brought under control Once the BP is brought under control they should be followed in the same manner as a member with Stage I hypertension
Formatted Font (Default) Times New Roman12 pt
36
D22 Cardiology Gibbons R J GJ Balady J W Beasley et al 1997 ACCAHA guidelines for exercise testing a report of American College of CardiologyAmerican Heart Association Task Force on Practice Guidelines (Committee on Exercise Testing) J Am Coll Cardiol 30260ndash311
Gibbons RJ Balady GJ Bricker JT Chaitman BR Fletcher GF Froelicher VF Mark DB McCallister BD Mooss AN OrsquoReilly MG Winters WL Jr [2002] ACCAHA 2002 guideline update for exercise testing summary article a report of the ACCAHA Task Force on Practice Guidelines (Committee to Update the 1997 Exercise Testing guidelines) J Am Coll Cardiol 401531ndash 40
Chobanian AV Bakris GL Black HR Cushman WC Green LA Izzo JL Jr Jones DW Materson BJ Oparil S Wright JT Jr Roccella EJ the National High Blood Pressure Education Program Coordinating Committee [2003] The seventh report of the Joint National Committee [JNC-7] on Prevention Detection Evaluation and Treatment of High Blood Pressure JAMA 2892560ndash2571
Soteriades ES Kales SN Liarokapis D Christiani DC [2003] Prospective surveillance of hypertension in firefighters J Clin Hypertens 5315-320
Kales SN Tsismenakis AJ Zhang C Soteriades ES [2009] Blood pressure in fire fighters police officers and other emergency responders Am J Hypertens 2211-20
37
NFPA 1582‐ HTN Draft 1
Reason for Revision
1) New classification of BP by the Joint National Commission [Chobanian et al 2002]
2) A high prevalence of FF have either HTN (~20) and Pre‐HTN (~20) [Soteriades et al 2003]
3) Among FF studies have shown a strong association between HTN and a number of adverse
cardiovascular events [Kales et al 2009]
4) A large percentage of on‐duty FF fatalities were found to have left ventricular hypertrophy a
complication of HTN at autopsy
Language in 2007 Edition with draft revisions in Red (Track changes)
611 The medical evaluation of a candidate shall include a medical history examination and any laboratory tests required to detect physical or medical condition(s) that could adversely affect hisher ability to safely perform the essential job tasks outlined in 511 A611 The medical history should include the candidates known health problems such as major illnesses surgeries medication use and allergies Symptom review is also important for detecting early signs of illness A medical history should also include a personal health history a family health history a health habit history an immunization history and a reproductive history
An occupational history should also be obtained to collect information about the persons past occupational and environmental exposures
(a) BP should be measured according to the Joint National Commission (JNC) -7 recommendations BP should be measured with a properly calibrated and validated instrument Patients should be seated quietly for at least 5 minutes in a chair with feet on the floor and arm supported at heart level An appropriate-sized cuff (cuff bladder encircling at least 80 of the arm) should be used to ensure accuracy At least 2 measurements should be made Systolic BP is the point at which the first of 2 or more sounds is heard (phase 1) and diastolic BP is the point before the disappearance of sounds (phase 5) [Chobanian et al 2003]
(2) Head eyes ears nose and throat
38
692 Vascular System 6921 Category A medical conditions shall include the following
(1) Uncontrolled or poorly controlled hypertension
(2) Hypertension with evidence of end organ damage
A6921(1) Uncontrolled or poorly controlled hypertension increases the risk of a sudden cardiac event This sudden cardiac event would cause sudden incapacitation which interferes with the safe performance of essential job tasks Uncontrolled or poorly controlled hypertension can be defined as the presence of end organ damage (see below) or stage 2 hypertension (BP systolic gt160 mmHg or BP diastolic gt100 mmHg) Individuals with pre- stage 1 or stage 2 hypertension should be referred to their primary care physician for evaluation lifestyle modification and treatment [QUESTION FOR GROUP _- WHAT ABOUT HAVING CANDIDATE RETURN IN ONE MONTH UNDER TREATMENT WITH NORMAL BP]
A6921(2)Chronic hypertension can damage the eye (retinopathy) the kidneys (nephropathy) the vascular system (stroke transient ischemic attack or peripheral artery disease) or the heart (left ventricular hypertrophy and heart failure) These hypertension complications are known as end organ damage The cardiac and vascular complications are associated with an increased risk of sudden incapacitation and sudden cardiac death (Koren et al 1991) Unfortunately the cardiac complications are frequently asymptomatic and valid screening tests are not fast and are not inexpensive Therefore determining who to screen for cardiac complications (such as echocardiogram for LVH or a measurement of left ventricular ejection fraction for heart failure) should be based on the severity and the duration of HTN
76 Physical Examination The annual physical examination shall include each of the following components
(a) BP shall be measured according to the Joint National Commission (JNC)-7 recommendations
A76(1)(a) BP should be measured with a properly calibrated and validated instrument Patients should be seated quietly for at least 5 minutes in a chair with feet on the floor and arm supported at heart level An appropriate-sized cuff (cuff bladder encircling at least 80 of the arm) should be used to ensure accuracy At least 2 measurements should be made Systolic BP is the point at which the first of 2 or more sounds is heard (phase 1) and diastolic BP is the point before the disappearance of sounds (phase 5) [Chobanian et al 2003]
(2) Head eyes ears nose and throat9420 Hypertension 94201 Physician Evaluation Members with Pre-hypertention (systolic 120-139 mmHg or diastolic 80-89 mmHg) Stage 1 hypertension (systolic 140-159 mmHg or diastolic 90-99 mmHg) or Stage 2 hypertension (systolic ge160 mmHg or diastolic ge100 mmHg) should be referred to their primary care physician for evaluation lifestyle modification and treatment
39
(1) Members with Stage I hypertension should be followed-up not only by their primary care physician but also by the FD physician every 3 to 6 months to ensure their blood pressure is under control and to determine whether screening tests for asymptomatic end organ damage are appropriate
(2) Members with Stage 2 hypertension or with end organ damage (retinopathy nephropathy vascular or cardiac complications) compromises the members ability to safely perform essential job tasks 1 5 7 9 and 130 and the physician shall report the applicable job limitations to the fire department
A94201 Chronic hypertension can damage the eye (retinopathy) the kidneys (nephropathy) the vascular system (stroke transient ischemic attack or peripheral artery disease) or the heart (left ventricular hypertrophy and heart failure) These hypertension complications are known as end organ damage The cardiac and vascular complications are associated with an increased risk of sudden incapacitation and sudden cardiac death (Koren et al 1991) Fortunately with proper evaluation life style modification and treatment these complications can be avoided Life style modification includes weight reduction DASH eating plan reduction in dietary sodium an increase in aerobic physical activity and moderation in alcohol consumption [Chobanian 2003]
A94201 (1) Members with Stage I hypertension whose BP returns to either pre-hypertenion or normal with lifestyle modification andor treatment can return to an annual medical evaluation For members with long-standing Stage I hypertension whose BP has not been reduced additional evaluation for possible end organ damage should be considered This evaluation could include any or all of the following
a) a compete patient history for symptoms of heart failure (eg shortness of breath upon exertion) or transient ischemic attacks (TIAs)
b) dilated eye examination for retinopathy
c) blood creatinine measurement for nephropathy
d) tests for left ventricular hypertrophy Unfortunately use of the resting EKG to detect left ventricular hypertrophy is very insensitive (eg 5 sensitivity) The echocardiogram is the best test for diagnosing left ventricular hypertrophy
A 94201 (2) Due to the high risk of a sudden cardiovascular event members with Stage 2 hypertension should be restricted until their BP can be brought under control Once the BP is brought under control they should be followed in the same manner as a member with Stage I hypertension
D22 Cardiology
40
Hypertension
Gibbons RJ Balady GJ Bricker JT Chaitman BR Fletcher GF Froelicher VF Mark DB McCallister BD Mooss AN OrsquoReilly MG Winters WL Jr [2002] ACCAHA 2002 guideline update for exercise testing summary article a report of the ACCAHA Task Force on Practice Guidelines (Committee to Update the 1997 Exercise Testing guidelines) J Am Coll Cardiol 401531ndash 40
Chobanian AV Bakris GL Black HR Cushman WC Green LA Izzo JL Jr Jones DW Materson BJ Oparil S Wright JT Jr Roccella EJ the National High Blood Pressure Education Program Coordinating Committee [2003] The seventh report of the Joint National Committee [JNC-7] on Prevention Detection Evaluation and Treatment of High Blood Pressure JAMA 2892560ndash2571
Soteriades ES Kales SN Liarokapis D Christiani DC [2003] Prospective surveillance of hypertension in firefighters J Clin Hypertens 5315-320
Kales SN Tsismenakis AJ Zhang C Soteriades ES [2009] Blood pressure in fire fighters police officers and other emergency responders Am J Hypertens 2211-20
41
NFPA 1582‐ Draft Revisions for CVDHTN
EKG and stress tests
Reason for Revision
1) Change requirement for annual resting EKG to periodically to be more consistent with ACCAHA
recommendation (Schlant et al 1992)
2) Add language to clarify what constitutes a positive ST
3) Make criteria for conducting diagnostic ST in asymptomatic patients consistent with the
ACCAHA
Language in 2007 Edition with draft revisions in Red (Track changes)
776 Electrocardiograms (EKG)) and Stress Tests 7761 A resting EKG shall be performed as part of the baseline medical evaluation and shall be obtained periodically (every 1 to 5 years) annually thereafter
A7761 A baseline resting EKGs shall be conducted Follow-up resting EKGs should be conducted as clinically indicated but at a minimum of every 1 to 5 years The frequency of these follow-up resting EKGs should increase as a members age increases or with increasing number andor severity of coronary heart disease risk factors Members above the age of 40 should have annual resting EKGs (Schlant et al 1992)
7762 The fire department physician or other qualified medical evaluator shall compare EKGs obtained during yearly evaluations with baseline and subsequent EKGs
7763 Stress testing EKG with or without echocardiography or radionuclide scanning shall be performed as clinically indicated by history or symptoms
A7761 Baseline electrocardiography should be conducted (Periodic resting electrocardiograms have not been shown to be useful but can be reasonable as a members agefactors increase)
A7763 No firm guidelines for stress testingelectrocardiography in asymptomatic individuals have been developed Stress testingelectrocardiography as a screening tool is used as part of an evaluation of aerobic capacity during the annual occupational fitness evaluation Submaximal stress testingelectrocardiography testing to 85 percent is commonly used as part of this screening
Submaximal stress electrocardiography testing should not be used for diagnostic purposes Cardiology evaluation with maximal stress testingelectrocardiography together with imaging techniques (eg echocardiography technetium Tc99m sestamibi study andor coronary angiography) is necessary for diagnosticprognostic purposes for the following
42
(1) Fire fighters with positive or questionably positive changes on screening submaximal stress tests
(2) Fire fighters with new onset chest pain or other symptoms suggestive of coronary artery disease (CAD)
(3) Fire fighters with diabetes mellitus who
(a) are gt35 years old or
(b) have type I diabetes for more than 15 years or
(c) have type II diabetes for more than 10 years or
(d) have any other CHD risk factor (see below) or
(e) have the presence of microvascular disease (proliferative retinopathy)
(4) Fire fighters over the age of 45 (for men) and 55 (for women) with onetwo or more risk factors for CAD Risk factors for CAD include hypercholesterolemia (total cholesterol greater than 240 mgdL) hypertension (systolic gt140 mmHg or diastolic gt90 mmHg) smoking or family history of premature CAD (heart attack or sudden cardiac death in a first degree relative less than 60 years of age)
as defined below if stress electrocardiography with imaging is negative then repeat as clinically indicated or at least every 5 years
(5) Fire fighters with a Framingham Risk Score gt10 Risk calculator is available at [httphp2010nhlbihinnetatpiiicalculatorasp]
(6) Fire fighters identified in 9431
Negative stress tests should be repeated as clinically indicated or at least every 2 to 5 years
Interpreting stress tests as ldquopositiverdquo or ldquonegativerdquo is beyond the scope of this document However factors that should be taken into consideration should include the individualrsquos exercise capacity symptoms blood pressure response heart rate response EKG changes and the presence of arrhythmias (Gibbon et al 2002)
Risk factors for CAD include hypercholesterolemia (total cholesterol greater than 240 mgdL) hypertension (systolic greater than 140 andor diastolic greater than 90) smoking diabetes mellitus or family history of premature CAD (heart attack or sudden cardiac death in a first degree relative less than 60 years of age)
There are other non-invasive tests to screen for coronary artery disease One of the most promising appears to be coronary artery calcium (CAD) scoring by computed tomography In 2007 an expert committee published an update to their original guidance document The committeersquos consensus was that ldquoit may be reasonable to consider use of CAC measurement in such patients [between 10 and 20 10-year risk of estimated coronary event]helliprdquo The committee did not recommend CAC measurement in low risk patients [lt10 10-year risk of estimated coronary event] or in high risk patients [gt20 10-year risk of estimate coronary event] (Greenland et al 2007]
43
D22 Cardiology
Chobanian AV Bakris GL Black HR Cushman WC Green LA Izzo JL Jr Jones DW Materson BJ Oparil S Wright JT Jr Roccella EJ the National High Blood Pressure Education Program Coordinating Committee [2003] The seventh report of the Joint National Committee [JNC-7] on Prevention Detection Evaluation and Treatment of High Blood Pressure JAMA 2892560ndash2571
Gibbons RJ Balady GJ Bricker JT Chaitman BR Fletcher GF Froelicher VF Mark DB McCallister BD Mooss AN OrsquoReilly MG Winters WL Jr [2002] ACCAHA 2002 guideline update for exercise testing summary article a report of the ACCAHA Task Force on Practice Guidelines (Committee to Update the 1997 Exercise Testing guidelines) J Am Coll Cardiol 401531ndash 1540
Greenland et al [2007] ACCFAHA 2007 Clinical Expert Consensus Document on Coronary Artery Calcium Scoring By Computed Tomography in Global Cardiovascular Risk Assessment and in Evaluation of Patients With Chest Pain A Report of the American College of Cardiology Foundation Clinical Expert Consensus Task Force (ACCFAHA Writing Committee to Update the 2000 Expert Consensus Document on Electron Beam Computed Tomography) J Am Coll Cardiol 49378-402
Kales SN Tsismenakis AJ Zhang C Soteriades ES [2009] Blood pressure in fire fighters police officers and other emergency responders Am J Hypertens 2211-20
Schlant RC Adolph RJ DiMarco JP Dreifus LS Dunn MI Fisch C Garson A Jr Haywood LJ Levine HJ Murray JA Noble RJ Ronan JA Jr [1992] Guidelines for electrocardiography A report of the American College of CardiologyAmerican Heart Association Task Force on Assessment of Diagnostic and Therapeutic Cardiovascular Procedures (Committee on Electrocardiography) Circulation 85(3)1221-1228
Soteriades ES Kales SN Liarokapis D Christiani DC [2003] Prospective surveillance of hypertension in firefighters J Clin Hypertens 5315-320
Formatted Font Italic
Formatted Line spacing single
Formatted Font Italic
Formatted Font Italic
44
NFPA 1582‐ Draft Revisions for CVDHTN
EKG and stress tests
Reason for Revision
1) Change requirement for annual resting EKG to periodically to be more consistent with ACCAHA
recommendation (Schlant et al 1992)
2) Add language to clarify what constitutes a positive ST
3) Make criteria for conducting diagnostic ST in asymptomatic patients consistent with the
ACCAHA
Language in 2007 Edition with draft revisions in Red (Track changes)
776 Electrocardiograms (EKG) and Stress Tests 7761 A resting EKG shall be performed as part of the baseline medical evaluation and shall be obtained periodically (every 1 to 5 years) thereafter
A7761 A baseline resting EKGs shall be conducted Follow-up resting EKGs should be conducted as clinically indicated but at a minimum of every 1 to 5 years The frequency of these follow-up resting EKGs should increase as a members age increases or with increasing number andor severity of coronary heart disease risk factors Members above the age of 40 should have annual resting EKGs (Schlant et al 1992)
7762 The fire department physician or other qualified medical evaluator shall compare baseline and subsequent EKGs
7763 Stress testing with or without echocardiography or radionuclide scanning shall be performed as clinically indicated by history or symptoms
A7763 No firm guidelines for stress testing in asymptomatic individuals have been developed Stress testing as a screening tool is used as part of an evaluation of aerobic capacity during the annual occupational fitness evaluation Submaximal stress testing testing to 85 percent is commonly used as part of this screening
Submaximal stress testing should not be used for diagnostic purposes Cardiology evaluation with maximal stress testing together with imaging techniques (eg echocardiography technetium Tc99m sestamibi study) is necessary for diagnosticprognostic purposes for the following
(1) Fire fighters with positive or questionably positive changes on screening submaximal stress tests
(2) Fire fighters with new onset chest pain or other symptoms suggestive of coronary artery disease (CAD)
45
(3) Fire fighters with diabetes mellitus who
(a) are gt35 years old or
(b) have type I diabetes for more than 15 years or
(c) have type II diabetes for more than 10 years or
(d) have any other CHD risk factor (see below) or
(e) have the presence of microvascular disease (proliferative retinopathy)
(4) Fire fighters over the age of 45 (for men) and 55 (for women) with one or more risk factors for CAD Risk factors for CAD include hypercholesterolemia (total cholesterol greater than 240 mgdL) hypertension (systolic gt140 mmHg or diastolic gt90 mmHg) smoking or family history of premature CAD (heart attack or sudden cardiac death in a first degree relative less than 60 years of age)
(5) Fire fighters with a Framingham Risk Score gt10 Risk calculator is available at [httphp2010nhlbihinnetatpiiicalculatorasp]
(6) Fire fighters identified in 9431
Negative stress tests should be repeated as clinically indicated or at least every 2 to 5 years
Interpreting stress tests as ldquopositiverdquo or ldquonegativerdquo is beyond the scope of this document However factors that should be taken into consideration should include the individualrsquos exercise capacity symptoms blood pressure response heart rate response EKG changes and the presence of arrhythmias (Gibbon et al 2002)
There are other non-invasive tests to screen for coronary artery disease One of the most promising appears to be coronary artery calcium (CAD) scoring by computed tomography In 2007 an expert committee published an update to their original guidance document The committeersquos consensus was that ldquoit may be reasonable to consider use of CAC measurement in such patients [between 10 and 20 10-year risk of estimated coronary event]helliprdquo The committee did not recommend CAC measurement in low risk patients [lt10 10-year risk of estimated coronary event] or in high risk patients [gt20 10-year risk of estimate coronary event] (Greenland et al 2007]
D22 Cardiology
Resting EKG and Stress Tests
46
Chobanian AV Bakris GL Black HR Cushman WC Green LA Izzo JL Jr Jones DW Materson BJ Oparil S Wright JT Jr Roccella EJ the National High Blood Pressure Education Program Coordinating Committee [2003] The seventh report of the Joint National Committee [JNC-7] on Prevention Detection Evaluation and Treatment of High Blood Pressure JAMA 2892560ndash2571
Gibbons RJ Balady GJ Bricker JT Chaitman BR Fletcher GF Froelicher VF Mark DB McCallister BD Mooss AN OrsquoReilly MG Winters WL Jr [2002] ACCAHA 2002 guideline update for exercise testing summary article a report of the ACCAHA Task Force on Practice Guidelines (Committee to Update the 1997 Exercise Testing guidelines) J Am Coll Cardiol 401531ndash 1540
Greenland et al [2007] ACCFAHA 2007 Clinical Expert Consensus Document on Coronary Artery Calcium Scoring By Computed Tomography in Global Cardiovascular Risk Assessment and in Evaluation of Patients With Chest Pain A Report of the American College of Cardiology Foundation Clinical Expert Consensus Task Force (ACCFAHA Writing Committee to Update the 2000 Expert Consensus Document on Electron Beam Computed Tomography) J Am Coll Cardiol 49378-402
Kales SN Tsismenakis AJ Zhang C Soteriades ES [2009] Blood pressure in fire fighters police officers and other emergency responders Am J Hypertens 2211-20
Schlant RC Adolph RJ DiMarco JP Dreifus LS Dunn MI Fisch C Garson A Jr Haywood LJ Levine HJ Murray JA Noble RJ Ronan JA Jr [1992] Guidelines for electrocardiography A report of the American College of CardiologyAmerican Heart Association Task Force on Assessment of Diagnostic and Therapeutic Cardiovascular Procedures (Committee on Electrocardiography) Circulation 85(3)1221-1228
Soteriades ES Kales SN Liarokapis D Christiani DC [2003] Prospective surveillance of hypertension in firefighters J Clin Hypertens 5315-320
47
ATTACHMENT F
48
1
Current 1582 (2007) language in reference to pregnancy 43 (4) Report to the fire department physician any medical condition that could interfere with the ability of the individual to safely perform essential job tasks such as illness or injury use of prescription or nonprescription drugs and pregnancy 6112 Category B medical conditions shall include the following (1) Pregnancy for its duration A7792 (e) If HIV prophylaxis is to be given the following tests should be done i CBC ii Glucose renal and hepatic chemical function iii Pregnancy test for females B121 Pregnancy and Reproduction Federal regulations as well as many court decisions including the US Supreme Courtrsquos decision in International Union et al v Johnson Controls Inc [499 US 187 111 S Ct 1196 (1991)] have interpreted the requirements of Title VII with respect to pregnancy and reproduction The AHJ should seek the advice of counsel in resolving specific questions concerning these requirements as well as other requirements that can be imposed by state or local laws C211 (4) Review health status with the individual being evaluated Contraindications for evaluations shall be reviewed addressing any changes in the individualrsquos health status since their last medical evaluation that would warrant deferring the evaluation including (g) Pregnancy Recommendations to language enhancement
A female employee who is assigned to regular fire line duty shall report a pregnancy immediately to their respective Supervisor and the fire department physician The employee will then be given the option of a non-hazardous alternative duty position for the duration of her pregnancy (can we say this or is it even appropriate) Any pregnant employee wishing to remain on regular line duty shall be informed of the possible risks and consequences to herself and her fetus that are associated with continued line fire fighting duty Among those risk factors are exposure to teratogens known to have negative effects on the developing fetus such as smoke diesel fumes hazardous chemicals and extreme heat
49
Page 2
appendix It is recommended that the pregnant employee complete a release of liability form signed by herself and her health care provider utilizing NFPArsquos 13 critical tasks as a reference This will inform the health care provider of specific job-related tasks that will need to be performed in order to continue regular line duty These tasks are basic physical standards that any entry level firefighter would have to be able to complete competently The employeersquos health condition will be kept confidential by the department in accordance with HIPAA standards Employees are allowed to remain on active regular duty until they are no longer able to perform their duties in a reasonable manner andor their protective gear no longer fits correctly It is the responsibility of the health care provider to evaluate the pregnant employee If at any time the health care provider feels the pregnant employee can no longer perform the job related tasks this should be reported to the employer by the employee immediately
50
ATTACHMENT G
51
From GLENN BENARICKTo Sawyer SteveSubject RE RE 7743Date Monday August 30 2010 21633 PM
Yes thats my understanding
Glenn P Benarick 211 Winged Elm CircleAiken SC 29803803-644-7093gbenarprodigynet
--- On Mon 83010 Sawyer Steve ltssawyerNFPAorggt wrote
From Sawyer Steve ltssawyerNFPAorggtSubject RE RE 7743To GLENN BENARICK ltgbenarprodigynetgtDate Monday August 30 2010 212 PM
So it should be ldquoorrdquo instead of ldquoandrdquo for now
Steven F Sawyer
Senior Fire Service Specialist
Executive Secretary IFMAFire Service Section
NFPA
1 Batterymarch Park
Quincy MA 02169
6179847423
Fax 6179847056
ssawyernfpaorg
From GLENN BENARICK [mailtogbenarprodigynet] Sent Monday August 30 2010 1202 PMTo Sawyer SteveSubject Fw RE 7743
52
Steve a couple of our docs agree with April Boyer
Glenn P Benarick 211 Winged Elm Circle
Aiken SC 29803
803-644-7093
gbenarprodigynet
--- On Mon 83010 David Prezant ltprezandfdnynycgovgt wrote
From David Prezant ltprezandfdnynycgovgtSubject RE 7743To Thomas R (CDCNIOSHDSHEFS) Hales lttrh1cdcgovgt GLENNBENARICK ltgbenarprodigynetgtCc Sandy Bogucki ltsandyboguckiyaleedugtDate Monday August 30 2010 1004 AM
agree
we should change this to NHANES III rather than Knudson we should alsomodify this to allow not only for predicted cutoffs but all for use of thelower limit of normal cutoff This is important to prevent false-classificationof spirometry as abnormal in older groups and in taller grps The latter ofparticular import to firefighter occupational health surveillance
thanks
David Prezant MDChief Medical Officer Office of Medical AffairsCo-Director WTC Medical Monitoring amp Treatment ProgramsNew York City Fire Department9 Metrotech Center - Rm 4W-1Brooklyn NY 11201Phone 718-999-2696Fax 718-999-0665
Life is full of twists and turns
53
This email may contain confidential information If you are the unintendedrecipient of this email please send it back and delete from your directory
gtgtgt Hales Thomas R (CDCNIOSHDSHEFS) lttrh1cdcgovgt 8302010955 AM gtgtgt
Glen
This seems like a very reasonable comment and illustrates the importance of having clinicians providefeedback on the std Im not familiar with the software program of the various spirometers (NHANES IIIvs KnudsonATS vs both) Given the large role both Dave Prezant and Sandy Bogucki had for thepulmonary section let me forward to them for clarification
Tom
From GLENN BENARICK [mailtogbenarprodigynet] Sent Sunday August 29 2010 456 PMTo Hales Thomas R (CDCNIOSHDSHEFS)Subject FW 7743
Tom is April Boyer correct
Glenn P Benarick 211 Winged Elm Circle
Aiken SC 29803
803-644-7093
gbenarprodigynet
--- On Thu 82610 Sawyer Steve ltssawyerNFPAorggt wrote
From Sawyer Steve ltssawyerNFPAorggtSubject FW 7743To GLENN BENARICK ltgbenarprodigynetgtDate Thursday August 26 2010 925 PM
FYI Do you have any answer She is write
Steven
54
Steven F Sawyer
Senior Fire Service Specialist
Executive Secretary IFMAFire Service Section
NFPA
1 Batterymarch Park
Quincy MA 02169
6179847423
Fax 6179847056
ssawyernfpaorg
From April Boyer [mailtoaboyerbicclinicorg] Sent Thursday August 26 2010 232 PMTo Sawyer SteveCc RobinMWebbmilstateorusSubject 7743
Steven
The spirometry tests cannot be corrected according to both references as the NFPA states because thereferences are contradictory The first part of 7743 states to follow the ATS guidelines and use theKnudsen (we at Basin Immediate Care use the Nhanes III) The second part states to follow the ACOEMguidelines and use the Nhanes III in the occupational setting if available with your unit (which is availableon ours) 7743 does not use the word OR regarding both requirements it uses the word AND whenreferring to the first and second parts thence making 7743 contradictory I realize the NFPA 1582 hasnot been updated since 2007 unless I have just not received an updated version
Our question to you is which part of 7743 do you want us to follow the first or the second part Anyfacility that has an updated computerized spirometry system (as we do) will not be able to follow bothrequired parts for obvious reasons We can either follow the first part of 7743 and use an oldercorrected version of the Knudson by going into our system and changing out of the Nhanes III conversionOR we can follow the second part of 7743 and use the newer corrected version of Nhanes III which ourunit offers too
If you have any questions you may contact me at anytime and I also have many references in regards toboth parts of 7743 if you would like to see them
55
Thank you~
April
Confidentiality NoticeThis message may contain information that isconfidential or privileged
If you are not the intended recipientPlease advise the sender immediately and delete this message
56
ATTACHMENT H
57
NFPA 1582 771(7) Proposed revisions
Why
Preliminary results of two prospective randomized trials on the PSA test were published in 2009 These studies resulted in medical organizations that previously providing guidance to modify their recommendations
Current language
771 Blood Tests Blood tests shall be performed annually and shall include the following
(7) Prostate specific antigen (PSA) after age 40 for positive family history if African American or if otherwise clinically indicated after age 50 for all other male member
Suggested Revision
771 Blood Tests Blood tests shall be performed annually and shall include the following
(7) Prostate specific antigen (PSA) after age 40 for positive family history if African American or if otherwise clinically indicated after age 50 for all other male member
772 Prostate-Specific Antigen (PSA) test At age 50 fire fighters shall have an opportunity to make an informed decision with either the Fire Department physician or their health care provider concerning the PSA test For fire fighters at increased risk of prostate cancer (African-Americans or those with a first degree relative diagnosed with prostate cancer before age 65) shall have the opportunity for this informed decision at age 40
A772 The PSA as a screening test for prostate cancer in asymptomatic men is controversial controversial for two reasons First there is no consensus that PSA screening actually saves lives For example the PSA test may detect small cancers that would never become life threatening Second it is unclear that the benefits of PSA screening outweigh the risks of follow-up diagnostic tests and cancer treatments For example the prostate biopsy used to diagnose prostate cancer may cause bleeding and infection And prostate cancer treatments such as surgery and radiation therapy may cause incontinence (inability to control urine flow) erectile dysfunction (erections inadequate for intercourse) and other complications For these reasons it is important that the benefits and risks of prostate diagnostic procedures and treatment be taken into account when considering the PSA screening test These considerations can be taken account during discussions with the fire department physician or onersquos health care provider
D211 Cancer Screening
Smith R A C J Mettlin K J Davis and H Eyre 2000 ldquoAmerican Cancer Society guidelines for the early detection of cancerrdquo CA J Clin 50(1)34ndash49
Added references
58
Carroll P Albertsen PC Greene K et al [2010] Prostate-specific antigen best practice statement 2009 update Am Urological Assoc Available at httpwwwauanetorgcontentguidelines-and-quality-careclinical-guidelinesmain-reportspsa09pdf Date accessed September 2010
Ferrini R Woolf SH [2009] Screening for prostate cancer in American men American College of Preventive Medicine Practice Policy Statement Available at httpwwwacpmorgprostatehtm Date accessed September 2010
National Cancer Institute [2009] Prostate-specific antigen test National Cancer Institute Fact Sheet Available at httpwwwcancergovcancertopicsfactsheetDetectionPSA Date accessed September 2010
Wolf AMD Wender RC Etzioni RB et al [2010] American Cancer Society guideline for the early detection of prostate cancer Update 2010 Available at httpcaonlineamcancersocorgcgicontentfullcaac20066v1 Date accessed September 2010
59
Address List 9172010
Fire Service Occupational Safety and Health FIX-AAAKenneth Willette
Mario D Rueda
FIX-AAAPrincipalLos Angeles City Fire Department
200 North Main Street Suite 1860
Los Angeles CA 90012
Alternate Craig A FryPhoneCell 213-978-3880
Fax 213-978-3819
Email marioruedalacityorg
U 4152004 Daniel G Samo
FIX-AAAPrincipalNorthwestern Memorial Hospital
Corporate Health
676 North St Clair Suite 900
Chicago IL 60611
PhoneCell 312-926-8282
Fax 312-926-2179
Email dandadaolcom
SE 4171998
Denise L Smith
FIX-AAAPrincipalSkidmore College
University of Illinois Fire Service Institute
815 North Broadway
Saratoga Springs NY 12866
PhoneCell 518-580-5389
Fax 518-580-8356
Email dsmithskidmoreedu
SE 822010 Donald F Stewart
FIX-AAAPrincipalMedocracy IncFairfax County Fire amp Rescue
Fairfax County Occupational Health Center
4080 Chain Bridge Road
Fairfax VA 22030
PhoneCell 703-246-4959
Fax 703-352-0217
Email dstewart97yahoocom
E 4172002
Philip C Stittleburg
FIX-AAAPrincipalLa Farge Fire Department
Chief
114 South State Street
La Farge WI 54639-0009
National Volunteer Fire CouncilAlternate Michael W Smith
PhoneCell 608-625-2185
Fax 608-625-2225
Email lfchiefmwtnet
U 111988 Phillip C Vorlander
FIX-AAAPrincipal1414 Spahn Drive
Waunakee WI 53597
National Incident Management System ConsortiumAlternate Robert D Neamy
PhoneCell 608-850-3892 608-358-8911
FaxEmail pvorlandergmailcom
M 1102008
Teresa Wann
FIX-AAAPrincipalSanta Ana College
Fire Technology Division
1530 West 17th Street
Santa Ana CA 92706-3398
PhoneCell 714-564-6861
Fax 714-564-6850
Email wann_terrisacedu
SE 7241997 Kim D Zagaris
FIX-AAAPrincipalState of California
Governorrsquos Office of Emergency Services
Fire and Rescue Branch
3650 Schriever Avenue
Mather CA 95655-4203
PhoneCell 916-845-8711
Fax 916-845-8396
Email kimzagariscalemacagov
E 7142004
46
Address List 9172010
Fire Service Occupational Safety and Health FIX-AAAKenneth Willette
Brett R Bowman
FIX-AAAAlternatePrince William County Department of Fire amp Rescue
1 County Complex Court
Prince William VA 22192
International Association of Fire ChiefsPrincipal Scott D Kerwood
PhoneCell 703-792-6388
Fax 703-792-7691
Email bbowmanpwcgovorg
E 822010 Leroy B Coffman III
FIX-AAAAlternateTempest Technology Inc
4645 North Bendel Avenue
Fresno CA 93722
Fire Apparatus Manufacturers AssociationPrincipal Dominic J Colletti
PhoneCell 559-277-7577
Fax 559-277-7579
Email leroy3tempest-edgecom
M 7262007
Steven D Corrado
FIX-AAAAlternateUnderwriters Laboratories Inc
12 Laboratory Drive
PO Box 13995
Research Triangle Park NC 27709-3995
Principal Thomas HillenbrandPhoneCell 919-549-1433 919-949-5617
Fax 919-547-6388
Email stevendcorradousulcom
RT 10272009 Craig A Fry
FIX-AAAAlternateLos Angeles City Fire Department
200 North Main Street Room 1770
Los Angeles CA 90012
Principal Mario D RuedaPhoneCell 213-978-3575
Fax 323-957-6411
Email craigfrylacityorg
U 4282000
Robert L McLeod III
FIX-AAAAlternateCity of Chandler Fire Department
PO Box 4008 MS 801
Chandler AZ 85244-4008
Fire Department Safety Officers AssociationPrincipal David Ross
PhoneCell 480-782-2140
Fax 480-782-2125
Email robmcleodchandlerazgov
E 7282006 Robert D Neamy
FIX-AAAAlternate550 Highway 88
Gardnerville NV 89460
National Incident Management System ConsortiumPrincipal Phillip C Vorlander
PhoneCell 775-265-0655
Fax 775-265-0588
Email Buckaroo2bobmsncom
M 111986
Stephen Raynis
FIX-AAAAlternateFire Department City of New York
9 Metrotech 7th Floor
Brooklyn NY 11201
Principal George L Maier IIIPhoneCell 718-999-2245
Fax 718-999-1271
Email raynissfdnynycgov
U 322010 Andrew G Schwartz
FIX-AAAAlternateLion Apparel Inc
6450 Poe Avenue Suite 300
Dayton OH 45414
Principal Donald AldridgePhoneCell 937-415-2913
Fax 937-913-5666
Email andrewslionapparelcom
M 7262007
57
Address List 9172010
Fire Service Occupational Safety and Health FIX-AAAKenneth Willette
Michael W Smith
FIX-AAAAlternateNational Volunteer Fire Council
855 Eastlake Boulevard
Carson City NV 89704
National Volunteer Fire CouncilPrincipal Philip C Stittleburg
FIX-AAANonvoting MemberNational Institute for Occupational Safety amp Health
4676 Columbia Parkway R-9
Cincinnati OH 45226
Alternate Jay L TarleyPhoneCell 513-841-4583
Fax 513-844-4488
Email thalescdcgov
RT 452001
William R Hamilton
FIX-AAANonvoting MemberUS Department of Labor
Occupational Safety amp Health Administration
200 Constitution Ave NW Room N3609
Washington DC 20210
Alternate Andrew LevinsonPhoneCell 202-693-2077
Fax 202-693-1663
Email hamiltonbilldolgov
E 342009 Andrew Levinson
FIX-AAAAlt to Nonvoting MemberUS Department of Labor
Occupational Safety amp Health Administration
200 Constitution Ave NW Room N3718
Washington DC 20210
Occupational Safety amp Health AdministrationPrincipal William R Hamilton
PhoneCell 202-693-2048
Fax 202-693-1678
Email levinsonandrewdolgov
E 7282006
Jay L Tarley
FIX-AAAAlt to Nonvoting MemberUS Department of Health amp Human Services
National Institute for Occupational Safety amp Health
1095 Willowdale Road MS 1808
Morgantown WV 26505
Principal Thomas R HalesPhoneCell 304-285-5858
Fax 304-285-5774
Email jst9cdcgov
RT 3152007 Kenneth Willette
FIX-AAAStaff LiaisonNational Fire Protection Association
1 Batterymarch Park
Quincy MA
PhoneCell 617-984-7299
Fax 617-984-7056
Email kwillettenfpaorg
792010
68
ATTACHMENT B
9
Technical Committee on Fire Service Occupational Safety and Health
Meeting Minutes May 13 ndash 14 2010
Holiday Inn Inner Harbor MD
Attendees Glenn Benarick Chairman Ken Holland Staff Liaison Michael Finkelman Craig Fry Joe Rivera Stephen Raynis Steve Kreis Dennis Childress Don Stewart Phil Stittleburg David Ross Michael Laton Kim Zagaris Tom Hillenbrand Dominic Colletti Andy Schwartz Brett Bowman Guest David Bernzweig Thursday May 13 NFPA 1500 task groups (Vehicle amp Safety OPS SCBA amp Air Mgt PPEProximity) met to discuss the work they have completed since the last meeting The task groups will present their report to the entire TC on May 14th Not enough 1582 task group members were able to make the meeting so there were no reports or work from those task groups Friday May 14 TC meeting called to order at approximately 0800 by Glenn Benarick TC Chair Ken Holland (NFPA Public Fire Protection Staff) in attendance filling in for Frank Florence Ken made two presentations one on the Codes and Standards Development Process and the other on the general procedures for this Pre-ROP meeting The Staff Liaison remains fluid as Frank is not expected back any time soon
10
One guest in attendance Dave Bernzweig (Columbus OH Fire) Dave is assisting TC with SCBAAir Mgt issues The document revision cycles remain as requested NFPA 1500 amp 1582 Annual 2012 NFPA 1521 amp 1561 Fall 2013 NFPA 1581 1583 1584 Annual 2014 The October 7-9 2010 dates are the primary request for our next meeting Location is San Diego Notice will be sent out as soon as approval is received Discussion on the next revision of 1561 will be held at the October meeting regarding changing the document title to ldquoCommand Safety for Fire Department Operationsrdquo This is a suggestion of the TC Chair Ken Holland conducted a briefing for the TC on how to access and use the committee web page Staff will be posting as much information as possible up on the e-committee page for the entire committee More use will be made of this tool Discussion on monocular vision Dennis Childress presented the current issue in Ventura County CA Further discussionwork may be necessary Don Stewart agreed to take the lead Brief discussion held on pregnancy and the need for fire departments to ensure policies match current law The rep from the Diabetes Association declined the invitation to participate at this meeting due to no discussion of the issue planned She has indicated a desire to attend the October meeting There were no reports from these and all other 1582 task groups It is very important for the 1582 TG Chairs to be ready to report in October The following task group reports will be posted on the ecommittee page PPEProximity New definition of proximity fire fighting
VehicleHighway OPS Discussion on use of vehicle data recorders Collapse Zones Submission from Jay Tarley SCBAAir Mgt New exit strategy for SCBA Discussion on having the low air alarm activate when the bottle volume reaches 600 liters Further discussion to take place on ldquobuddy breathingrdquo
On Day 2 Casey Grant (NFPA Fire Protection Research Foundation) made a presentation on Research Planning for FSOSH Dr Ellen Sogolow (DHSFEMA) also present during this presentation She discussed the role of the AFGRampD activities See ecommittee page for his presentation Chair
11
will be in contact with Mr Grant for future work between the TC and the Foundation Also on Day 2 Ken Willette (Division Manager ndash NFPA Public Fire Protection Division) delivered a presentation on the initiative developed by Kelvin Cochran (US Fire Administrator) to reduce fire fighter injuries and deaths NFPA 1500 is an integral part of this initiative See ecommittee page for presentation The Chair will be coordinating a committee conference call in the coming weeks The purpose will be to review the work which needs to be completed for the October meeting The primary focus of the call will be on 1582 issues NOTE Subsequent to the meeting I have had some discussions with a fire chief in Kentucky on the use of hearing aids The TC especially the doctors need to review the current language in 1582 and decide if revisions are needed Also most of you know that Kelvin Cochran has left the USFA unexpectedly to return to Atlanta as their fire chief I have been in contact with the Acting Administrator Glenn Gaines to inform him that our committee remains focused on the work to reduce fire fighter injuries and deaths I told him that I would keep him informed of our work He indicated that one of his primary goals is to bring fire service organizations together in order to create a safe working environment Of particular interest to him is reducing heart related injuries and deaths Submitted by Glenn Benarick
12
Technical Committee on Fire Service Occupational Safety and Health
Conference Call Meeting Minutes August 30th 2010
Members participating
Glenn Benarick TC Chair
Murrey Loflin Secretary Dr Sandy Bogucki
Thomas Cuff Stephen Foley
Scott Kerwood Tammy Lopes
David Love Dr David Prezant
Joe Rivera David Ross
Mario Rueda Phil Stittleburg
Phil Vorlander Dominic Colletti
Thomas Hillenbrand
Denise Smith Brett Bowman Alternate
Andrew Schwartz Alternate Mike Young Alternate
Dr Thomas Hales Non-Voting Member Ken Holland NFPA Staff Liaison
Casey Grant NFPAResearch Foundation Staff Katie Hathway Guest from ADA
Dr Jim Fleming Guest from Phoenix Fire Dept
The chair welcomed everyone to the conference call in which he hoped
would last only an hour The purpose was to discuss any task groups that had reports for proposed changes to NFPA 1582 for the
committee This is in hopes to ensure the committee is ready for their
pre-ROP meeting in October The following topics were discussed and are in no specific order
Comments from ADA Katie Hathaway and the group went into deep
discussion regarding ones medical history and diagnosis of diabetes
13
and some proposed changesremoval of text based on research
findings The specific proposed changes will be available for the committee at their next meeting Some members on the call felt that
this issue was covered in another law enforcement document which might better serve this issue
Research topics for FSOSH projects Casey Grant offered his time to
answer any questions regarding his presentation from the May meeting in Baltimore There was also discussion about further
involvement of the Research Foundation with this committee and some of the medical requirements within the documents Glenn and Casey
are going to be in contact offline to discuss this further
Prosthetics amp Amputees report Nothing new to report
Heart amp Hypertension report There was discussion about the need for
periodic EKGrsquos that were done both in resting and non-resting states as well as discussion about stress test requirements and frequency of
such tests The hopes were to develop text that would point to annual versus periodic evaluations of EKGrsquos and stress tests
Epilepsy report Nothing new to report
Pregnancy report The initial textlanguage has been provided to the
group through email and e-committee page posting
Coagulation amp Meds report Nothing new to report
Hearing Aid discussion Nothing new to report
The committee also discussed the evaluation and documentation of
PSA results and test requirements for the purposes of consistency The proposed text and changes have been posted on the e-committee
page as well
All of the proposed text changes from the May meeting in Baltimore have been emailed out and posted on the e-committee page If there
are any questions or concerns that something was missed please contact Glenn Steven Sawyer or Ken Holland to ensure they are
resolved
The conference call lasted approximately an hour and was adjourned at 1400 hours
14
ATTACHMENT C
15
2012 ANNUAL REVISION CYCLE
PROCESS STAGE PROCESS STEP DATES
FOR TC DATES
FOR TCC 1 PRELIMINARY 10 Notification of intent to enter cycle 7910 7910
2 REPORT ON
PROPOSALS (ROP)
21 Proposal closing date 112310 112310 22 Final date for ROP meeting 22511 2411 23 Final date for mailing TC ballots 31811 21811 24 Receipt of (TC) ballots by staff liaison 42211 31111 25 Receipt of TC recirculation ballots 5611 31811 26 Final date for TCC meeting 41511 27 Final date for mailing TCC ballots 42211 28 Receipt of TCC ballots 51311 29 Receipt of TCC recirculation ballots 52011 210 Final copy (w ballot statements) to Secretary Standards Council 51311 52711 211 Completion of Reports 52011 6311 212 ROP Published and Posted 62411 62411
3 REPORT ON
COMMENTS
(ROC)
31 Comment closing date 83011 83011 32 Final date for ROC meeting 11411 10711 33 Final date for mailing TC ballots 111811 102111 34 Receipt of (TC) ballots by staff liaison 12211 111111 35 Receipt of TC recirculation ballots 12911 111811 36 Final date for TCC meeting 121611 37 Final date for mailing TCC ballots 122311 38 Receipt of TCC ballots 11312 39 Receipt of TCC recirculation ballots 12012 310 Final copy (w ballot statements) to Secretary Standards Council 122311 12712 311 Completion of Reports 11312 2312 312 ROC Published and Posted 22412 22412
4 TECH SESSION
PREPARATION amp
ISSUANCE OF
CONSENT
DOCUMENTS
41 Notice of Intent to Make a Motion (NITMAM) Closing Date 4612 4612 42 Posting of Filed NITMAM 5412 5412
43 Council Issuance Date for Consent Documents 52912 52912
44 Appeal Closing Date for Consent Documents 61312 61312
5 TECHNICAL
SESSION 50 Association Meeting for Documents with Certified Amending Motions
64-712 64-712
6
APPEALS amp
ISSUANCE OF
DOCUMENTS
WCAMS
61 Appeal closing date for Documents with Certified Amending Motions
62712 62712
62 Council issuance for Documents with Certified Amending Motions 8912 8912
Proposal Closing Dates may vary according to documents and schedules for Revision Cycles may change Please check the NFPA website (wwwnfpaorg) for the most up-to-date information on proposal closing dates and schedules
16
ATTACHMENT D
17
This weekrsquos conference call mentioned the Diabetes chapter written for the ACOEM document Guidance for the Medical Evaluation of the Law Enforcement Officer The task group working on this chapter (led Richard Miller of the Secret Service and our very own Dan Samo) worked with the ADA or over 2-3 years to come up with a consensus document
Please find the Chapter attached ltltDiabetes Guidance Sept 2010pdfgtgt
Regarding Dan Loeberrsquos points
1) Physical Evaluation Form - We could modify the LEO form (see end of the attached Chapter)
2) Duration required for stable regiment
1582 for IDDM Type 1 1 yr
Type 2 6 m
Oral Agents None specifically
ACOEM Police for IDDM Type 1 6m
Type 2 3m
Oral Agents 1m
The police document is much clearer about the decision regarding medical fitness for duty is the responsibility of the police physician with the treating diabetes-expert physician providing the data to the police physician to make an informed decision In this regard the police officer must provide the police physician with downloaded self monitoring glucose data for the 1 3 and 6 month time periods (see section 433)
3) HA1C ndash NFPA lt 8 over 3 month period
ACOEM Police ndash (Section 4333) Specifies the frequency on measurement and if gt8 requires further evaluation
Some other discrepancies End organ complications
NFPA ndash end organ complications (eye kidney heart neuro) ndash restriction
ACOEM Police ndash end organ complication -- requires further evaluation
18
Hypoglycemia (incapacitating ndash defined differently between the two documents (434)
NFPA ndash 0 episodes in past year le1 in past 5 yrs
ACOEM Police ndash 0 episodes in past year le2 in past 3 yrs
Given Dan Samorsquos and Richard Millerrsquos work with the ADALoeber it would be helpful to get their opinions on whether any of the changes requested by Loeber are appropriate for FF with DM
Tom
Thomas Hales MD MPH
Senior Medical Epidemiologist
NIOSH CDC
4676 Columbia Pkwy R-9
Cincinnati OH 45241
(513) 841-4583
trh1cdcgov
19
43 ndash DIABETES MELLITUS
431 ndash INTRODUCTION
The educated and motivated law enforcement officer (LEO) with well-managed diabetes mellitus can be capable of
safe and effective job performance1 However diabetes mellitus may place LEOs at risk for sudden incapacitation
thus jeopardizing their ability to perform critical job functions (These job functions include those listed in Sections
32 333 351 352 36 and 37 and discussed in Appendix A)
Therefore an individualized assessment of the LEOrsquos diabetes should be performed using the following evaluative
criteria to determine whether the individuals condition permits safe and effective job performance Such evaluation
must include the following key elements which are discussed in detail below
history of blood glucose control
knowledge of diabetes and its management
current stability of blood glucose
risk for significant hypoglycemia or hyperglycemia and
presence of diabetic complications
432 ndash OVERVIEW OF MEDICAL EVALUATION
The treating endocrinologist or other physician knowledgeable regarding diabetes management should provide
a narrative report certifying whether the LEO has or has not met the criteria set out in Sections 4321 through
4354 below In addition the physician should include supporting data (see Appendix B for the Physician Evalu-
ation Form)
4321 The LEO is under the care of an endocrinologist or other physician knowledgeable regarding diabetes
management Outpatient and in-patient medical record(s) for the last 3 years or since date of diagnosis
(whichever is shorter) should be reviewed by the treating physician and provided to the police physician
4322 If the LEO has type 1 diabetes the individual has been on a basalbolus regimena or an insulin pump
using analogue insulins for the 6 months prior to evaluation2
4323 If the LEO has type 2 diabetes on insulin the individual has been on a stable medication regimenb
for the 3 months prior to evaluation3 If on oral agents alone the LEO has been on a stable medication regimen
for the month prior to evaluationc
ACOEM Guidance for the Medical Evaluation of Law Enforcement Officers 1
43 ndash DIABETES MELLITUS
aA basalbolus insulin regimen consists of the use of a basal insulin (Glargine NPH) in a once or twice daily regimen to provide between-
meal insulin combined with the use of a short acting insulin (Regular Lispro Aspart or Glulisine) at mealtimes Insulin pumps are small
(beeper sized) battery powered devices that deliver small amounts of short-acting insulin in a constant infusion to meet basal insulin
requirements The wearer selects an additional mealtime bolus to be infused at the time of meals For more information on pumps visit
the manufacturerrsquos web sites ndash wwwMinimedcom wwwcozmorecom wwwanimascorpcom wwwdisetroniccom
bA stable insulin regimen is defined as maintaining the same types of insulin (long acting intermediate acting short or rapid acting)
Changes in insulin dose are part of the appropriate self-management of diabetes and do not disqualify an applicant or incumbent under
this section
cChanges in dose within the evaluation period will be allowed but addition of a new class of medications or insulin should result in a new
period of observation
one month for addition of a sulfonylurea or metformin
two months for the addition of a thiazolidinedione to insulin or a sulfonylurea or
three months for the addition of insulin
20
4324 If the LEO uses an insulin pump documentation is needed as follows
proper understanding and education in the use of the insulin pump
start date for the use of the pump
history of insulin site infectionsd
history of pump cessation and pump malfunction
backup plan for pump malfunction including use of injectable insulin and
frequency of infusion set changes
4325 The LEO has been educated in diabetes and its management and thoroughly informed of and under-
stands the procedures that must be followed to monitor and manage hisher diabetes and what procedures
should be followed if complications arise3
433 ndash QUANTITATIVE GLUCOSE MONITORING
4331 The LEO has documentation of ongoing self-monitoring of blood glucose
4332 This must be done with a glucose meter that stores every reading records date and time of reading
and from which data can be downloaded (Most meters now have this capability)
4333 Monitoring logs must be available covering the time period (1 3 or 6 months) as described in
Sections 4322 and 4323 The frequency of glucose monitoring must follow a schedule acceptable to the
police physician in consultation with the treating physician
Testing schedules are individual What follows is a common pattern but individual patterns may differ
2 ACOEM Guidance for the Medical Evaluation of Law Enforcement Officers
43 ndash DIABETES MELLITUS
dIndividual has not had more than one pump-site infection that caused him or her to miss work or usual daily activities in the preceding 6
months
THERAPEUTIC REGIMEN GLUCOSE TESTING SCHEDULE
Diet alone Once or twice a week
Metformin Thiazolidinediones or Alpha
Glucosidase inhibitors alone or in
combination
Once or twice a week
Sulfonylureas meglitanides nateglinide ndash
alone or in combination with the above group
Twice a day ndash AM and at supper with any
suspected hypoglycemic episodes
Insulin ndash one shot in combination with orals Twice a day ndash AM and at supper with any
suspected hypoglycemic episodes
2 to 3 times AM once a week
Insulin ndash two or more shots Insulin pump 3 to 4 times a day ndash at meals and bedtime
2 to 3 times AM once a week with any
suspected hypoglycemic episodes
21
4334 The LEO has had hemoglobin A1C measured at least 4 times a year (intervals of 2 to 3 months) over
the last 12 months prior to evaluation if diagnosis has been present for more than a year4 If hemoglobin A1C is
gt8 this may signal a problem with the LEOrsquos diabetes management that warrants further assessment5
434 ndash INCAPACITATING EVENTS
4341 The LEO has not had any incapacitating episodes within the past 1 year and no more than 2 episodes
in the past 3 years or since diagnosis of diabetes (whichever is shorter) of
43411 Severe hypoglycemia (loss of consciousness seizures or coma requiring assistance of others or
needing urgent treatment [glucagon injectionIV glucose]) or
43412 Blood sugar lt60 mgdl with unawareness demonstrated in current glucose logs6
435 ndash CHRONIC COMPLICATION SCREENING
4351 Chronic complications of diabetes are associated with increased risk for severe hypoglycemic
episodes and warrant further assessmente
4352 The components of screening for chronic complications are
43521 A complete eye exam by a qualified ophthalmologist or optometrist including a dilated retinal
exam demonstrating no more than mild background diabetic retinopathyf7
43522 Normal vibratory testing with a 128 Hz tuning forkg normal testing with 10 gram Semmes-
Weinstein monofilamentg and normal orthostatic blood pressureh and pulse testing89
ACOEM Guidance for the Medical Evaluation of Law Enforcement Officers 3
43 ndash DIABETES MELLITUS
ePresence of chronic complications of diabetes in and of themselves may not require the implementation of work restrictions
fNo more than one dot blot or flame-shaped hemorrhages or microaneurysm in all four fundus quadrants
gThe Michigan Diabetes Research and Training Center of the University of Michigan Health System recommends the following guidance
(see wwwmedumichedumdrtcprofsdocumentssviMNSI_howtopdf) for conducting vibratory and monofilament testing8
Vibration Sensation Vibration sensation should be performed with the great toe unsupported Vibration sensation will be tested bi-
laterally using a 128 Hz tuning fork placed over the dorsum of the great toe on the boney prominence of the DIP joint Patients whose
eyes are closed will be asked to indicate when they can no longer sense the vibration from the vibrating tuning fork In general the
examiner should be able to feel vibration from the hand-held tuning fork for 5 seconds longer on his distal forefinger than a normal subject
can at the great toe (eg examiners DIP joint of the first finger versus patients toe) If the examiner feels vibration for 10 or more seconds
on his or her finger then vibration is considered decreased A trial should be given when the tuning fork is not vibrating to be certain that
the patient is responding to vibration and not pressure or some other clue Vibration is scored as 1) present if the examiner senses the
vibration on his or her finger for lt10 seconds 2) reduced if sensed for 10 seconds or 3) absent (no vibration detection)
Monofilament Testing For this examination it is important that the patients foot be supported (ie allow the sole of the foot to rest on
a flat warm surface) The filament should initially be pre-stressed (4-6 perpendicular applications to the dorsum of the examiner s first
finger) The filament is then applied to the dorsum of the great toe midway between the nail fold and the DIP joint Do not hold the toe
directly The filament is applied perpendicularly and briefly (lt1 second) with an even pressure When the filament bends the force of
10 grams has been applied The patient whose eyes are closed is asked to respond yes if heshe feels the filament Eight correct responses
out of 10 applications is considered normal 1 to 7 correct responses indicates reduced sensation and no correct answers translates into
absent sensation
hOrthostatic hypotension is a physical finding defined by the American Autonomic Society and the American Academy of Neurology as a
systolic blood pressure decrease of at least 20 mm Hg or a diastolic blood pressure decrease of at least 10 mm Hg within 3 minutes of
standing
22
43523 Normal cardiac physical exam Cardiac stress testing to at least 12 METS is recommended and
should begin based on either the criteria of the American Heart AssociationAmerican College of
Cardiologyi10 or those of the American Diabetes Associationj11
Diabetics who have a normal cardiac stress test will be retested every one to three years based on
individual clinical assessment This assessment should consider
the age of the individual
the number and persistence of coronary artery disease (CAD) risk factors
the severity of CAD risk factors
43524 Microalbumincreatinine ratio 301 measured or calculatedk creatinine clearance
gt60 mlmin12
436 ndash ONGOING EVALUATION AND REQUIREMENTS
4361 Should have medical records and glucose meter logs reviewed periodically Because of the nature of
diabetes it is important that regular medical follow up be provided to the LEO The frequency and content of
the evaluation should be determined on an individual basis by the police physician in consultation with the
treating physicianl
4362 Must advise police physician of any change in type of medication
4363 Must advise police physician of any episodes of significant hypoglycemia or hyperglycemia
Urine microalbumincreatinine ratio _________________
III Treating Physician Statement
The above named individual meets all of the criteria provided on this form
Yes No ndash not recommended for position
No but IS recommended for position (letter of explanation attached)
It is my opinion that the above named individual is well-educated and well-motivated in diabetes self-management and has
achieved a level of diabetes management to be capable of safe and effective job performance as a law enforcement officer
I have reached this opinion after careful review of the above criteria
___________________________________________________________ ___________________________Signature of Physician Date
______________________________________________________________ ___________________________Printed or Typed Name of Physician Telephone Number
10 ACOEM Guidance for the Medical Evaluation of Law Enforcement Officers
43 ndash DIABETES MELLITUS
29
439 ndash REFERENCES
1 American Diabetes Association Diagnosis and classification of diabetes mellitus Diabetes Care 200427 Suppl
1S5-S10 See httpcarediabetesjournalsorgcgicontentfull27suppl_1s5
2 American Diabetes Association Continuous subcutaneous insulin infusion Diabetes Care 200427 Suppl 1S110
See httpcarediabetesjournalsorgcgicontentfull27suppl_1s110
3 Mensing C Boucher J Cypress M et al National standards for diabetes self-management education Diabetes
Care 200528 Suppl 1S72-9 See httpcarediabetesjournalsorgcgicontentfull28suppl_1s72
4 Goldstein DE Little RR Lorenz RA Malone JI Nathan DM Peterson CM American Diabetes Association Tests
of glycemia in diabetes Diabetes Care 200427 Suppl 1S91-3
See httpcarediabetesjournalsorgcgicontentfull27suppl_1s91
5 The Diabetes Control and Complications Trial Research Group Hypoglycemia in the Diabetes Control and
Complications Trial Diabetes 199746(2)271-86 See wwwncbinlmnihgovpubmed9000705 for abstract
6 American Diabetes Association Hypoglycemia and employmentlicensure Diabetes Care 200528 Suppl 1S61
See httpcarediabetesjournalsorgcgicontentfull28suppl_1s61
7 Viswanath K McGavin DD Diabetic Retinopathy Clinical Findings and Management J Comm Eye Health
200316(46)21-4 See wwwcehjournalorg0953-683316jceh_16_46_021html
8 Michigan Diabetes Research and Training Center University of Michigan Health System How to use the Michigan
Neuropathy Screening Instrument See wwwmedumichedumdrtcprofsdocumentssviMNSI_howtopdf
9 Bradley JG Davis KA Orthostatic hypotension Am Fam Physician 200368(12)2393-8
See wwwaafporgafp200312152393html
10 Gibbons RJ Balady GJ Bricker JT et al ACCAHA 2002 guideline update for exercise testing a report of the
American College of CardiologyAmerican Heart Association Task Force on Practice Guidelines (Committee on
Exercise Testing) J Am Coll Cardiol 200240(8)1531-40
See wwwaccorgqualityandscienceclinicalguidelinesexerciseexercise_cleanpdf
11 American Diabetes Association Standards of medical care in diabetes Diabetes Care 200528 Suppl 1S4-S36
Erratum in Diabetes Care 200528(4)990 See httpcarediabetesjournalsorgcgicontentfull28suppl_1s4
12 Molitch ME DeFronzo RA Franz MJ et al American Diabetes Association Nephropathy in diabetes Diabetes
Care 200427 Suppl 1S79-83 See httpcarediabetesjournalsorgcgicontentfull27suppl_1s79
13 Kitabchi AE Umpierrez GE Murphy MB et al American Diabetes Association Hyperglycemic crises in diabetes
Diabetes Care 200427 Suppl 1S94-102 See httpcarediabetesjournalsorgcgicontentfull27suppl_1s94
14 US Centers for Disease Control and Prevention National Diabetes Fact Sheet 2007
See wwwcdcgovdiabetespubspdfndfs_2007pdf
ACOEM Guidance for the Medical Evaluation of Law Enforcement Officers 11
43 ndash DIABETES MELLITUS
30
ATTACHMENT E
31
Typos A6921(2) 7th line down test should be plural 94201 Paragraph 2 target organ damage is used though end organ damage was defined earlier and in the appendix for that paragraph
A94201 Para A (1) d Id suggest deleting the phrases in brackets Im not sure either are predictably true or politically wise
a) tests for left ventricular hypertrophy Unfortunately use of the EKG to detect left ventricular hypertrophy is very insensitive (eg 5 sensitivity) The echocardiogram is the best test for diagnosing left ventricular hypertrophy but [it is relatively expensive and not readily available in small rural communities ] conducting echocardiograms on asymptomatic fire fighters with Stage 1 hypertension should be reserved only for those with long-standing hypertension
In addition
7761 A resting EKG shall be performed as part of the baseline medical evaluation and shall be obtained periodically thereafter
Changing from annually to periodically is noted has the language in the wellness-fitness initiative been changed as well Our previous decision was that we would support the W-F language since there was no compelling evidence to either support or refute it
Thanks
Sandy
32
NFPA 1582‐ HTN Draft 1
Reason for Revision
1) New classification of BP by the Joint National Commission [Chobanian et al 2002]
2) A high prevalence of FF have either HTN (~20) and Pre‐HTN (~20) [Soteriades et al 2003]
3) Among FF studies have shown a strong association between HTN and a number of adverse
cardiovascular events [Kales et al 2009]
4) A large percentage of on‐duty FF fatalities were found to have left ventricular hypertrophy a
complication of HTN at autopsy
Language in 2007 Edition with draft revisions in Red (Track changes)
611 The medical evaluation of a candidate shall include a medical history examination and any laboratory tests required to detect physical or medical condition(s) that could adversely affect hisher ability to safely perform the essential job tasks outlined in 511 A611 The medical history should include the candidates known health problems such as major illnesses surgeries medication use and allergies Symptom review is also important for detecting early signs of illness A medical history should also include a personal health history a family health history a health habit history an immunization history and a reproductive history
An occupational history should also be obtained to collect information about the persons past occupational and environmental exposures
(a) BP should be measured according to the Joint National Commission (JNC) -7 recommendations BP should be measured with a properly calibrated and validated instrument Patients should be seated quietly for at least 5 minutes in a chair with feet on the floor and arm supported at heart level An appropriate-sized cuff (cuff bladder encircling at least 80 of the arm) should be used to ensure accuracy At least 2 measurements should be made Systolic BP is the point at which the first of 2 or more sounds is heard (phase 1) and diastolic BP is the point before the disappearance of sounds (phase 5) [Chobanian et al 2003]
(2) Head eyes ears nose and throat (HEENT)
Formatted Font (Default) Times New RomanFont color Black
33
692 Vascular System 6921 Category A medical conditions shall include the following
(1) Uncontrolled or poorly controlled hypertension
(2) Hypertension with evidence of end organ damage
or not controlled by approved medications
A6921(1) Uncontrolled or poorly controlled hHypertension increases the risk of a sudden cardiac event This sudden cardiac event would cause sudden incapacitation which that is uncontrolled poorly controlled or requires medication likely to interferes with the safe performance of essential job tasks Uncontrolled or poorly controlled hypertension can be defined as the presence of end organ damage (see below) or stage 2 hypertension (BP systolic gt160 mmHg or BP diastolic gt100 mmHg) is an illness that can lead to functional impairment and potential for sudden incapacitation Individuals with pre- stage 1 or stage 2 hypertension should be referred to their primary care physician for evaluation lifestyle modification and treatment [QUESTION FOR GROUP _- WHAT ABOUT HAVING CANDIDATE RETURN IN ONE MONTH UNDER TREATMENT WITH NORMAL BP]
A6921(2)
Chronic hypertension can damage the eye (retinopathy) the kidneys (nephropathy) the vascular system (stroke transient ischemic attack or peripheral artery disease) or the heart (left ventricular hypertrophy and heart failure) These hypertension complications are known as end organ damage The cardiac and vascular complications are associated with an increased risk of sudden incapacitation and sudden cardiac death (Koren et al 1991) Unfortunately the cardiac complications are frequently asymptomatic and valid screening tests are not fast and are not inexpensive Therefore determining who to screen for cardiac complications (such as echocardiogram for LVH or a measurement of left ventricular ejection fraction for heart failure) should be based on the severity and the duration of HTN
76 Physical Examination The annual physical examination shall include each of the following components
(a) BP shall be measured according to the Joint National Commission (JNC)-7 recommendations
A76(1)(a) BP should be measured with a properly calibrated and validated instrument Patients should be seated quietly for at least 5 minutes in a chair with feet on the floor and arm supported at heart level An appropriate-sized cuff (cuff bladder encircling at least 80 of the arm) should be used to ensure accuracy At least 2 measurements should be made Systolic BP is the point at which the first of 2 or more sounds is heard (phase 1) and diastolic BP is the point before the disappearance of sounds (phase 5) [Chobanian et al 2003]
(2) Head eyes ears nose and throat (HEENT)
34
9420 Uncontrolled Hypertension 94201 Physician Evaluation Severe uncontrolled hypertension [defined as systolic pressure greater than 180 mm Hg diastolic pressure greater than 100 mm Hg or mean systolic blood
pressure ( systolic + diastolic) greater than 120 mm Hg] or malignant hypertension (defined as hypertension with the presence of target organ damage) compromises the members ability to safely perform essential job tasks 1 5 7 9 and 13 and the physician shall report the applicable job limitations to the fire department
Members with Pre-hypertention (systolic 120-139 mmHg or diastolic 80-89 mmHg) Stage 1 hypertension (systolic 140-159 mmHg or diastolic 90-99 mmHg) or Stage 2 hypertension (systolic ge160 mmHg or diastolic ge100 mmHg) should be referred to their primary care physician for evaluation lifestyle modification and treatment
(1) Members with Stage I hypertension should be followed-up not only by their primary care physician but also by the FD physician every 3 to 6 months to ensure their blood pressure is under control and to determine whether screening tests for asymptomatic end organ damage are appropriate
(2) Members with Stage 2 hypertension or with end organ damage (retinopathy nephropathy vascular or cardiac complications) compromises the members ability to safely perform essential job tasks 1 5 7 9 and 130 and the physician shall report the applicable job limitations to the fire department
A94201 Severe uncontrolled hypertension is a significant risk factor for the development of coronary artery disease congestive heart failure and stroke Blood pressure increases as a normal response to exercise This response is further exaggerated by the emotional and physical stress of performing these critical tasks while operating in personal protective clothing at extremes of temperature This normal elevation of blood pressure under these response conditions can lead to life-threatening hypertensive emergencies if a members daily blood pressure is already elevated to high levels In addition hypertension is a progressive illness that when uncontrolled ultimately and inevitably leads to target organ damage Target organs that are sensitive to the effects of elevated blood pressure are the central nervous system vision heart major blood vessels and kidneys
Chronic hypertension can damage the eye (retinopathy) the kidneys (nephropathy) the vascular system (stroke transient ischemic attack or peripheral artery disease) or the heart (left ventricular hypertrophy and heart failure) These hypertension complications are known as end organ damage The cardiac and vascular complications are associated with an increased risk of sudden incapacitation and sudden cardiac death (Koren et al 1991) Fortunately with proper evaluation life style modification and treatment these complications can be avoided Life style modification includes weight reduction DASH eating plan reduction in dietary sodium an increase in aerobic physical activity and moderation in alcohol consumption [Chobanian 2003]
Formatted Font (Default) Times New Roman12 pt Font color Black
Formatted Font (Default) Times New Roman12 pt Font color Black
35
A94201 (1) Members with Stage I hypertension whose BP returns to either pre-hypertenion or normal with lifestyle modification andor treatment can return to an annual medical evaluation For members with long-standing Stage I hypertension whose BP has not been reduced additional evaluation for possible end organ damage should be considered This evaluation could include any or all of the following
a) a compete patient history for symptoms of heart failure (eg shortness of breath upon exertion) or transient ischemic attacks (TIAs)
b) dilated eye examination for retinopathy
c) blood creatinine measurement for nephropathy
d) tests for left ventricular hypertrophy Unfortunately use of the resting EKG to detect left ventricular hypertrophy is very insensitive (eg 5 sensitivity) The echocardiogram is the best test for diagnosing left ventricular hypertrophy
A 94201 (2) Due to the high risk of a sudden cardiovascular event members with Stage 2 hypertension should be restricted until their BP can be brought under control Once the BP is brought under control they should be followed in the same manner as a member with Stage I hypertension
Formatted Font (Default) Times New Roman12 pt
36
D22 Cardiology Gibbons R J GJ Balady J W Beasley et al 1997 ACCAHA guidelines for exercise testing a report of American College of CardiologyAmerican Heart Association Task Force on Practice Guidelines (Committee on Exercise Testing) J Am Coll Cardiol 30260ndash311
Gibbons RJ Balady GJ Bricker JT Chaitman BR Fletcher GF Froelicher VF Mark DB McCallister BD Mooss AN OrsquoReilly MG Winters WL Jr [2002] ACCAHA 2002 guideline update for exercise testing summary article a report of the ACCAHA Task Force on Practice Guidelines (Committee to Update the 1997 Exercise Testing guidelines) J Am Coll Cardiol 401531ndash 40
Chobanian AV Bakris GL Black HR Cushman WC Green LA Izzo JL Jr Jones DW Materson BJ Oparil S Wright JT Jr Roccella EJ the National High Blood Pressure Education Program Coordinating Committee [2003] The seventh report of the Joint National Committee [JNC-7] on Prevention Detection Evaluation and Treatment of High Blood Pressure JAMA 2892560ndash2571
Soteriades ES Kales SN Liarokapis D Christiani DC [2003] Prospective surveillance of hypertension in firefighters J Clin Hypertens 5315-320
Kales SN Tsismenakis AJ Zhang C Soteriades ES [2009] Blood pressure in fire fighters police officers and other emergency responders Am J Hypertens 2211-20
37
NFPA 1582‐ HTN Draft 1
Reason for Revision
1) New classification of BP by the Joint National Commission [Chobanian et al 2002]
2) A high prevalence of FF have either HTN (~20) and Pre‐HTN (~20) [Soteriades et al 2003]
3) Among FF studies have shown a strong association between HTN and a number of adverse
cardiovascular events [Kales et al 2009]
4) A large percentage of on‐duty FF fatalities were found to have left ventricular hypertrophy a
complication of HTN at autopsy
Language in 2007 Edition with draft revisions in Red (Track changes)
611 The medical evaluation of a candidate shall include a medical history examination and any laboratory tests required to detect physical or medical condition(s) that could adversely affect hisher ability to safely perform the essential job tasks outlined in 511 A611 The medical history should include the candidates known health problems such as major illnesses surgeries medication use and allergies Symptom review is also important for detecting early signs of illness A medical history should also include a personal health history a family health history a health habit history an immunization history and a reproductive history
An occupational history should also be obtained to collect information about the persons past occupational and environmental exposures
(a) BP should be measured according to the Joint National Commission (JNC) -7 recommendations BP should be measured with a properly calibrated and validated instrument Patients should be seated quietly for at least 5 minutes in a chair with feet on the floor and arm supported at heart level An appropriate-sized cuff (cuff bladder encircling at least 80 of the arm) should be used to ensure accuracy At least 2 measurements should be made Systolic BP is the point at which the first of 2 or more sounds is heard (phase 1) and diastolic BP is the point before the disappearance of sounds (phase 5) [Chobanian et al 2003]
(2) Head eyes ears nose and throat
38
692 Vascular System 6921 Category A medical conditions shall include the following
(1) Uncontrolled or poorly controlled hypertension
(2) Hypertension with evidence of end organ damage
A6921(1) Uncontrolled or poorly controlled hypertension increases the risk of a sudden cardiac event This sudden cardiac event would cause sudden incapacitation which interferes with the safe performance of essential job tasks Uncontrolled or poorly controlled hypertension can be defined as the presence of end organ damage (see below) or stage 2 hypertension (BP systolic gt160 mmHg or BP diastolic gt100 mmHg) Individuals with pre- stage 1 or stage 2 hypertension should be referred to their primary care physician for evaluation lifestyle modification and treatment [QUESTION FOR GROUP _- WHAT ABOUT HAVING CANDIDATE RETURN IN ONE MONTH UNDER TREATMENT WITH NORMAL BP]
A6921(2)Chronic hypertension can damage the eye (retinopathy) the kidneys (nephropathy) the vascular system (stroke transient ischemic attack or peripheral artery disease) or the heart (left ventricular hypertrophy and heart failure) These hypertension complications are known as end organ damage The cardiac and vascular complications are associated with an increased risk of sudden incapacitation and sudden cardiac death (Koren et al 1991) Unfortunately the cardiac complications are frequently asymptomatic and valid screening tests are not fast and are not inexpensive Therefore determining who to screen for cardiac complications (such as echocardiogram for LVH or a measurement of left ventricular ejection fraction for heart failure) should be based on the severity and the duration of HTN
76 Physical Examination The annual physical examination shall include each of the following components
(a) BP shall be measured according to the Joint National Commission (JNC)-7 recommendations
A76(1)(a) BP should be measured with a properly calibrated and validated instrument Patients should be seated quietly for at least 5 minutes in a chair with feet on the floor and arm supported at heart level An appropriate-sized cuff (cuff bladder encircling at least 80 of the arm) should be used to ensure accuracy At least 2 measurements should be made Systolic BP is the point at which the first of 2 or more sounds is heard (phase 1) and diastolic BP is the point before the disappearance of sounds (phase 5) [Chobanian et al 2003]
(2) Head eyes ears nose and throat9420 Hypertension 94201 Physician Evaluation Members with Pre-hypertention (systolic 120-139 mmHg or diastolic 80-89 mmHg) Stage 1 hypertension (systolic 140-159 mmHg or diastolic 90-99 mmHg) or Stage 2 hypertension (systolic ge160 mmHg or diastolic ge100 mmHg) should be referred to their primary care physician for evaluation lifestyle modification and treatment
39
(1) Members with Stage I hypertension should be followed-up not only by their primary care physician but also by the FD physician every 3 to 6 months to ensure their blood pressure is under control and to determine whether screening tests for asymptomatic end organ damage are appropriate
(2) Members with Stage 2 hypertension or with end organ damage (retinopathy nephropathy vascular or cardiac complications) compromises the members ability to safely perform essential job tasks 1 5 7 9 and 130 and the physician shall report the applicable job limitations to the fire department
A94201 Chronic hypertension can damage the eye (retinopathy) the kidneys (nephropathy) the vascular system (stroke transient ischemic attack or peripheral artery disease) or the heart (left ventricular hypertrophy and heart failure) These hypertension complications are known as end organ damage The cardiac and vascular complications are associated with an increased risk of sudden incapacitation and sudden cardiac death (Koren et al 1991) Fortunately with proper evaluation life style modification and treatment these complications can be avoided Life style modification includes weight reduction DASH eating plan reduction in dietary sodium an increase in aerobic physical activity and moderation in alcohol consumption [Chobanian 2003]
A94201 (1) Members with Stage I hypertension whose BP returns to either pre-hypertenion or normal with lifestyle modification andor treatment can return to an annual medical evaluation For members with long-standing Stage I hypertension whose BP has not been reduced additional evaluation for possible end organ damage should be considered This evaluation could include any or all of the following
a) a compete patient history for symptoms of heart failure (eg shortness of breath upon exertion) or transient ischemic attacks (TIAs)
b) dilated eye examination for retinopathy
c) blood creatinine measurement for nephropathy
d) tests for left ventricular hypertrophy Unfortunately use of the resting EKG to detect left ventricular hypertrophy is very insensitive (eg 5 sensitivity) The echocardiogram is the best test for diagnosing left ventricular hypertrophy
A 94201 (2) Due to the high risk of a sudden cardiovascular event members with Stage 2 hypertension should be restricted until their BP can be brought under control Once the BP is brought under control they should be followed in the same manner as a member with Stage I hypertension
D22 Cardiology
40
Hypertension
Gibbons RJ Balady GJ Bricker JT Chaitman BR Fletcher GF Froelicher VF Mark DB McCallister BD Mooss AN OrsquoReilly MG Winters WL Jr [2002] ACCAHA 2002 guideline update for exercise testing summary article a report of the ACCAHA Task Force on Practice Guidelines (Committee to Update the 1997 Exercise Testing guidelines) J Am Coll Cardiol 401531ndash 40
Chobanian AV Bakris GL Black HR Cushman WC Green LA Izzo JL Jr Jones DW Materson BJ Oparil S Wright JT Jr Roccella EJ the National High Blood Pressure Education Program Coordinating Committee [2003] The seventh report of the Joint National Committee [JNC-7] on Prevention Detection Evaluation and Treatment of High Blood Pressure JAMA 2892560ndash2571
Soteriades ES Kales SN Liarokapis D Christiani DC [2003] Prospective surveillance of hypertension in firefighters J Clin Hypertens 5315-320
Kales SN Tsismenakis AJ Zhang C Soteriades ES [2009] Blood pressure in fire fighters police officers and other emergency responders Am J Hypertens 2211-20
41
NFPA 1582‐ Draft Revisions for CVDHTN
EKG and stress tests
Reason for Revision
1) Change requirement for annual resting EKG to periodically to be more consistent with ACCAHA
recommendation (Schlant et al 1992)
2) Add language to clarify what constitutes a positive ST
3) Make criteria for conducting diagnostic ST in asymptomatic patients consistent with the
ACCAHA
Language in 2007 Edition with draft revisions in Red (Track changes)
776 Electrocardiograms (EKG)) and Stress Tests 7761 A resting EKG shall be performed as part of the baseline medical evaluation and shall be obtained periodically (every 1 to 5 years) annually thereafter
A7761 A baseline resting EKGs shall be conducted Follow-up resting EKGs should be conducted as clinically indicated but at a minimum of every 1 to 5 years The frequency of these follow-up resting EKGs should increase as a members age increases or with increasing number andor severity of coronary heart disease risk factors Members above the age of 40 should have annual resting EKGs (Schlant et al 1992)
7762 The fire department physician or other qualified medical evaluator shall compare EKGs obtained during yearly evaluations with baseline and subsequent EKGs
7763 Stress testing EKG with or without echocardiography or radionuclide scanning shall be performed as clinically indicated by history or symptoms
A7761 Baseline electrocardiography should be conducted (Periodic resting electrocardiograms have not been shown to be useful but can be reasonable as a members agefactors increase)
A7763 No firm guidelines for stress testingelectrocardiography in asymptomatic individuals have been developed Stress testingelectrocardiography as a screening tool is used as part of an evaluation of aerobic capacity during the annual occupational fitness evaluation Submaximal stress testingelectrocardiography testing to 85 percent is commonly used as part of this screening
Submaximal stress electrocardiography testing should not be used for diagnostic purposes Cardiology evaluation with maximal stress testingelectrocardiography together with imaging techniques (eg echocardiography technetium Tc99m sestamibi study andor coronary angiography) is necessary for diagnosticprognostic purposes for the following
42
(1) Fire fighters with positive or questionably positive changes on screening submaximal stress tests
(2) Fire fighters with new onset chest pain or other symptoms suggestive of coronary artery disease (CAD)
(3) Fire fighters with diabetes mellitus who
(a) are gt35 years old or
(b) have type I diabetes for more than 15 years or
(c) have type II diabetes for more than 10 years or
(d) have any other CHD risk factor (see below) or
(e) have the presence of microvascular disease (proliferative retinopathy)
(4) Fire fighters over the age of 45 (for men) and 55 (for women) with onetwo or more risk factors for CAD Risk factors for CAD include hypercholesterolemia (total cholesterol greater than 240 mgdL) hypertension (systolic gt140 mmHg or diastolic gt90 mmHg) smoking or family history of premature CAD (heart attack or sudden cardiac death in a first degree relative less than 60 years of age)
as defined below if stress electrocardiography with imaging is negative then repeat as clinically indicated or at least every 5 years
(5) Fire fighters with a Framingham Risk Score gt10 Risk calculator is available at [httphp2010nhlbihinnetatpiiicalculatorasp]
(6) Fire fighters identified in 9431
Negative stress tests should be repeated as clinically indicated or at least every 2 to 5 years
Interpreting stress tests as ldquopositiverdquo or ldquonegativerdquo is beyond the scope of this document However factors that should be taken into consideration should include the individualrsquos exercise capacity symptoms blood pressure response heart rate response EKG changes and the presence of arrhythmias (Gibbon et al 2002)
Risk factors for CAD include hypercholesterolemia (total cholesterol greater than 240 mgdL) hypertension (systolic greater than 140 andor diastolic greater than 90) smoking diabetes mellitus or family history of premature CAD (heart attack or sudden cardiac death in a first degree relative less than 60 years of age)
There are other non-invasive tests to screen for coronary artery disease One of the most promising appears to be coronary artery calcium (CAD) scoring by computed tomography In 2007 an expert committee published an update to their original guidance document The committeersquos consensus was that ldquoit may be reasonable to consider use of CAC measurement in such patients [between 10 and 20 10-year risk of estimated coronary event]helliprdquo The committee did not recommend CAC measurement in low risk patients [lt10 10-year risk of estimated coronary event] or in high risk patients [gt20 10-year risk of estimate coronary event] (Greenland et al 2007]
43
D22 Cardiology
Chobanian AV Bakris GL Black HR Cushman WC Green LA Izzo JL Jr Jones DW Materson BJ Oparil S Wright JT Jr Roccella EJ the National High Blood Pressure Education Program Coordinating Committee [2003] The seventh report of the Joint National Committee [JNC-7] on Prevention Detection Evaluation and Treatment of High Blood Pressure JAMA 2892560ndash2571
Gibbons RJ Balady GJ Bricker JT Chaitman BR Fletcher GF Froelicher VF Mark DB McCallister BD Mooss AN OrsquoReilly MG Winters WL Jr [2002] ACCAHA 2002 guideline update for exercise testing summary article a report of the ACCAHA Task Force on Practice Guidelines (Committee to Update the 1997 Exercise Testing guidelines) J Am Coll Cardiol 401531ndash 1540
Greenland et al [2007] ACCFAHA 2007 Clinical Expert Consensus Document on Coronary Artery Calcium Scoring By Computed Tomography in Global Cardiovascular Risk Assessment and in Evaluation of Patients With Chest Pain A Report of the American College of Cardiology Foundation Clinical Expert Consensus Task Force (ACCFAHA Writing Committee to Update the 2000 Expert Consensus Document on Electron Beam Computed Tomography) J Am Coll Cardiol 49378-402
Kales SN Tsismenakis AJ Zhang C Soteriades ES [2009] Blood pressure in fire fighters police officers and other emergency responders Am J Hypertens 2211-20
Schlant RC Adolph RJ DiMarco JP Dreifus LS Dunn MI Fisch C Garson A Jr Haywood LJ Levine HJ Murray JA Noble RJ Ronan JA Jr [1992] Guidelines for electrocardiography A report of the American College of CardiologyAmerican Heart Association Task Force on Assessment of Diagnostic and Therapeutic Cardiovascular Procedures (Committee on Electrocardiography) Circulation 85(3)1221-1228
Soteriades ES Kales SN Liarokapis D Christiani DC [2003] Prospective surveillance of hypertension in firefighters J Clin Hypertens 5315-320
Formatted Font Italic
Formatted Line spacing single
Formatted Font Italic
Formatted Font Italic
44
NFPA 1582‐ Draft Revisions for CVDHTN
EKG and stress tests
Reason for Revision
1) Change requirement for annual resting EKG to periodically to be more consistent with ACCAHA
recommendation (Schlant et al 1992)
2) Add language to clarify what constitutes a positive ST
3) Make criteria for conducting diagnostic ST in asymptomatic patients consistent with the
ACCAHA
Language in 2007 Edition with draft revisions in Red (Track changes)
776 Electrocardiograms (EKG) and Stress Tests 7761 A resting EKG shall be performed as part of the baseline medical evaluation and shall be obtained periodically (every 1 to 5 years) thereafter
A7761 A baseline resting EKGs shall be conducted Follow-up resting EKGs should be conducted as clinically indicated but at a minimum of every 1 to 5 years The frequency of these follow-up resting EKGs should increase as a members age increases or with increasing number andor severity of coronary heart disease risk factors Members above the age of 40 should have annual resting EKGs (Schlant et al 1992)
7762 The fire department physician or other qualified medical evaluator shall compare baseline and subsequent EKGs
7763 Stress testing with or without echocardiography or radionuclide scanning shall be performed as clinically indicated by history or symptoms
A7763 No firm guidelines for stress testing in asymptomatic individuals have been developed Stress testing as a screening tool is used as part of an evaluation of aerobic capacity during the annual occupational fitness evaluation Submaximal stress testing testing to 85 percent is commonly used as part of this screening
Submaximal stress testing should not be used for diagnostic purposes Cardiology evaluation with maximal stress testing together with imaging techniques (eg echocardiography technetium Tc99m sestamibi study) is necessary for diagnosticprognostic purposes for the following
(1) Fire fighters with positive or questionably positive changes on screening submaximal stress tests
(2) Fire fighters with new onset chest pain or other symptoms suggestive of coronary artery disease (CAD)
45
(3) Fire fighters with diabetes mellitus who
(a) are gt35 years old or
(b) have type I diabetes for more than 15 years or
(c) have type II diabetes for more than 10 years or
(d) have any other CHD risk factor (see below) or
(e) have the presence of microvascular disease (proliferative retinopathy)
(4) Fire fighters over the age of 45 (for men) and 55 (for women) with one or more risk factors for CAD Risk factors for CAD include hypercholesterolemia (total cholesterol greater than 240 mgdL) hypertension (systolic gt140 mmHg or diastolic gt90 mmHg) smoking or family history of premature CAD (heart attack or sudden cardiac death in a first degree relative less than 60 years of age)
(5) Fire fighters with a Framingham Risk Score gt10 Risk calculator is available at [httphp2010nhlbihinnetatpiiicalculatorasp]
(6) Fire fighters identified in 9431
Negative stress tests should be repeated as clinically indicated or at least every 2 to 5 years
Interpreting stress tests as ldquopositiverdquo or ldquonegativerdquo is beyond the scope of this document However factors that should be taken into consideration should include the individualrsquos exercise capacity symptoms blood pressure response heart rate response EKG changes and the presence of arrhythmias (Gibbon et al 2002)
There are other non-invasive tests to screen for coronary artery disease One of the most promising appears to be coronary artery calcium (CAD) scoring by computed tomography In 2007 an expert committee published an update to their original guidance document The committeersquos consensus was that ldquoit may be reasonable to consider use of CAC measurement in such patients [between 10 and 20 10-year risk of estimated coronary event]helliprdquo The committee did not recommend CAC measurement in low risk patients [lt10 10-year risk of estimated coronary event] or in high risk patients [gt20 10-year risk of estimate coronary event] (Greenland et al 2007]
D22 Cardiology
Resting EKG and Stress Tests
46
Chobanian AV Bakris GL Black HR Cushman WC Green LA Izzo JL Jr Jones DW Materson BJ Oparil S Wright JT Jr Roccella EJ the National High Blood Pressure Education Program Coordinating Committee [2003] The seventh report of the Joint National Committee [JNC-7] on Prevention Detection Evaluation and Treatment of High Blood Pressure JAMA 2892560ndash2571
Gibbons RJ Balady GJ Bricker JT Chaitman BR Fletcher GF Froelicher VF Mark DB McCallister BD Mooss AN OrsquoReilly MG Winters WL Jr [2002] ACCAHA 2002 guideline update for exercise testing summary article a report of the ACCAHA Task Force on Practice Guidelines (Committee to Update the 1997 Exercise Testing guidelines) J Am Coll Cardiol 401531ndash 1540
Greenland et al [2007] ACCFAHA 2007 Clinical Expert Consensus Document on Coronary Artery Calcium Scoring By Computed Tomography in Global Cardiovascular Risk Assessment and in Evaluation of Patients With Chest Pain A Report of the American College of Cardiology Foundation Clinical Expert Consensus Task Force (ACCFAHA Writing Committee to Update the 2000 Expert Consensus Document on Electron Beam Computed Tomography) J Am Coll Cardiol 49378-402
Kales SN Tsismenakis AJ Zhang C Soteriades ES [2009] Blood pressure in fire fighters police officers and other emergency responders Am J Hypertens 2211-20
Schlant RC Adolph RJ DiMarco JP Dreifus LS Dunn MI Fisch C Garson A Jr Haywood LJ Levine HJ Murray JA Noble RJ Ronan JA Jr [1992] Guidelines for electrocardiography A report of the American College of CardiologyAmerican Heart Association Task Force on Assessment of Diagnostic and Therapeutic Cardiovascular Procedures (Committee on Electrocardiography) Circulation 85(3)1221-1228
Soteriades ES Kales SN Liarokapis D Christiani DC [2003] Prospective surveillance of hypertension in firefighters J Clin Hypertens 5315-320
47
ATTACHMENT F
48
1
Current 1582 (2007) language in reference to pregnancy 43 (4) Report to the fire department physician any medical condition that could interfere with the ability of the individual to safely perform essential job tasks such as illness or injury use of prescription or nonprescription drugs and pregnancy 6112 Category B medical conditions shall include the following (1) Pregnancy for its duration A7792 (e) If HIV prophylaxis is to be given the following tests should be done i CBC ii Glucose renal and hepatic chemical function iii Pregnancy test for females B121 Pregnancy and Reproduction Federal regulations as well as many court decisions including the US Supreme Courtrsquos decision in International Union et al v Johnson Controls Inc [499 US 187 111 S Ct 1196 (1991)] have interpreted the requirements of Title VII with respect to pregnancy and reproduction The AHJ should seek the advice of counsel in resolving specific questions concerning these requirements as well as other requirements that can be imposed by state or local laws C211 (4) Review health status with the individual being evaluated Contraindications for evaluations shall be reviewed addressing any changes in the individualrsquos health status since their last medical evaluation that would warrant deferring the evaluation including (g) Pregnancy Recommendations to language enhancement
A female employee who is assigned to regular fire line duty shall report a pregnancy immediately to their respective Supervisor and the fire department physician The employee will then be given the option of a non-hazardous alternative duty position for the duration of her pregnancy (can we say this or is it even appropriate) Any pregnant employee wishing to remain on regular line duty shall be informed of the possible risks and consequences to herself and her fetus that are associated with continued line fire fighting duty Among those risk factors are exposure to teratogens known to have negative effects on the developing fetus such as smoke diesel fumes hazardous chemicals and extreme heat
49
Page 2
appendix It is recommended that the pregnant employee complete a release of liability form signed by herself and her health care provider utilizing NFPArsquos 13 critical tasks as a reference This will inform the health care provider of specific job-related tasks that will need to be performed in order to continue regular line duty These tasks are basic physical standards that any entry level firefighter would have to be able to complete competently The employeersquos health condition will be kept confidential by the department in accordance with HIPAA standards Employees are allowed to remain on active regular duty until they are no longer able to perform their duties in a reasonable manner andor their protective gear no longer fits correctly It is the responsibility of the health care provider to evaluate the pregnant employee If at any time the health care provider feels the pregnant employee can no longer perform the job related tasks this should be reported to the employer by the employee immediately
50
ATTACHMENT G
51
From GLENN BENARICKTo Sawyer SteveSubject RE RE 7743Date Monday August 30 2010 21633 PM
Yes thats my understanding
Glenn P Benarick 211 Winged Elm CircleAiken SC 29803803-644-7093gbenarprodigynet
--- On Mon 83010 Sawyer Steve ltssawyerNFPAorggt wrote
From Sawyer Steve ltssawyerNFPAorggtSubject RE RE 7743To GLENN BENARICK ltgbenarprodigynetgtDate Monday August 30 2010 212 PM
So it should be ldquoorrdquo instead of ldquoandrdquo for now
Steven F Sawyer
Senior Fire Service Specialist
Executive Secretary IFMAFire Service Section
NFPA
1 Batterymarch Park
Quincy MA 02169
6179847423
Fax 6179847056
ssawyernfpaorg
From GLENN BENARICK [mailtogbenarprodigynet] Sent Monday August 30 2010 1202 PMTo Sawyer SteveSubject Fw RE 7743
52
Steve a couple of our docs agree with April Boyer
Glenn P Benarick 211 Winged Elm Circle
Aiken SC 29803
803-644-7093
gbenarprodigynet
--- On Mon 83010 David Prezant ltprezandfdnynycgovgt wrote
From David Prezant ltprezandfdnynycgovgtSubject RE 7743To Thomas R (CDCNIOSHDSHEFS) Hales lttrh1cdcgovgt GLENNBENARICK ltgbenarprodigynetgtCc Sandy Bogucki ltsandyboguckiyaleedugtDate Monday August 30 2010 1004 AM
agree
we should change this to NHANES III rather than Knudson we should alsomodify this to allow not only for predicted cutoffs but all for use of thelower limit of normal cutoff This is important to prevent false-classificationof spirometry as abnormal in older groups and in taller grps The latter ofparticular import to firefighter occupational health surveillance
thanks
David Prezant MDChief Medical Officer Office of Medical AffairsCo-Director WTC Medical Monitoring amp Treatment ProgramsNew York City Fire Department9 Metrotech Center - Rm 4W-1Brooklyn NY 11201Phone 718-999-2696Fax 718-999-0665
Life is full of twists and turns
53
This email may contain confidential information If you are the unintendedrecipient of this email please send it back and delete from your directory
gtgtgt Hales Thomas R (CDCNIOSHDSHEFS) lttrh1cdcgovgt 8302010955 AM gtgtgt
Glen
This seems like a very reasonable comment and illustrates the importance of having clinicians providefeedback on the std Im not familiar with the software program of the various spirometers (NHANES IIIvs KnudsonATS vs both) Given the large role both Dave Prezant and Sandy Bogucki had for thepulmonary section let me forward to them for clarification
Tom
From GLENN BENARICK [mailtogbenarprodigynet] Sent Sunday August 29 2010 456 PMTo Hales Thomas R (CDCNIOSHDSHEFS)Subject FW 7743
Tom is April Boyer correct
Glenn P Benarick 211 Winged Elm Circle
Aiken SC 29803
803-644-7093
gbenarprodigynet
--- On Thu 82610 Sawyer Steve ltssawyerNFPAorggt wrote
From Sawyer Steve ltssawyerNFPAorggtSubject FW 7743To GLENN BENARICK ltgbenarprodigynetgtDate Thursday August 26 2010 925 PM
FYI Do you have any answer She is write
Steven
54
Steven F Sawyer
Senior Fire Service Specialist
Executive Secretary IFMAFire Service Section
NFPA
1 Batterymarch Park
Quincy MA 02169
6179847423
Fax 6179847056
ssawyernfpaorg
From April Boyer [mailtoaboyerbicclinicorg] Sent Thursday August 26 2010 232 PMTo Sawyer SteveCc RobinMWebbmilstateorusSubject 7743
Steven
The spirometry tests cannot be corrected according to both references as the NFPA states because thereferences are contradictory The first part of 7743 states to follow the ATS guidelines and use theKnudsen (we at Basin Immediate Care use the Nhanes III) The second part states to follow the ACOEMguidelines and use the Nhanes III in the occupational setting if available with your unit (which is availableon ours) 7743 does not use the word OR regarding both requirements it uses the word AND whenreferring to the first and second parts thence making 7743 contradictory I realize the NFPA 1582 hasnot been updated since 2007 unless I have just not received an updated version
Our question to you is which part of 7743 do you want us to follow the first or the second part Anyfacility that has an updated computerized spirometry system (as we do) will not be able to follow bothrequired parts for obvious reasons We can either follow the first part of 7743 and use an oldercorrected version of the Knudson by going into our system and changing out of the Nhanes III conversionOR we can follow the second part of 7743 and use the newer corrected version of Nhanes III which ourunit offers too
If you have any questions you may contact me at anytime and I also have many references in regards toboth parts of 7743 if you would like to see them
55
Thank you~
April
Confidentiality NoticeThis message may contain information that isconfidential or privileged
If you are not the intended recipientPlease advise the sender immediately and delete this message
56
ATTACHMENT H
57
NFPA 1582 771(7) Proposed revisions
Why
Preliminary results of two prospective randomized trials on the PSA test were published in 2009 These studies resulted in medical organizations that previously providing guidance to modify their recommendations
Current language
771 Blood Tests Blood tests shall be performed annually and shall include the following
(7) Prostate specific antigen (PSA) after age 40 for positive family history if African American or if otherwise clinically indicated after age 50 for all other male member
Suggested Revision
771 Blood Tests Blood tests shall be performed annually and shall include the following
(7) Prostate specific antigen (PSA) after age 40 for positive family history if African American or if otherwise clinically indicated after age 50 for all other male member
772 Prostate-Specific Antigen (PSA) test At age 50 fire fighters shall have an opportunity to make an informed decision with either the Fire Department physician or their health care provider concerning the PSA test For fire fighters at increased risk of prostate cancer (African-Americans or those with a first degree relative diagnosed with prostate cancer before age 65) shall have the opportunity for this informed decision at age 40
A772 The PSA as a screening test for prostate cancer in asymptomatic men is controversial controversial for two reasons First there is no consensus that PSA screening actually saves lives For example the PSA test may detect small cancers that would never become life threatening Second it is unclear that the benefits of PSA screening outweigh the risks of follow-up diagnostic tests and cancer treatments For example the prostate biopsy used to diagnose prostate cancer may cause bleeding and infection And prostate cancer treatments such as surgery and radiation therapy may cause incontinence (inability to control urine flow) erectile dysfunction (erections inadequate for intercourse) and other complications For these reasons it is important that the benefits and risks of prostate diagnostic procedures and treatment be taken into account when considering the PSA screening test These considerations can be taken account during discussions with the fire department physician or onersquos health care provider
D211 Cancer Screening
Smith R A C J Mettlin K J Davis and H Eyre 2000 ldquoAmerican Cancer Society guidelines for the early detection of cancerrdquo CA J Clin 50(1)34ndash49
Added references
58
Carroll P Albertsen PC Greene K et al [2010] Prostate-specific antigen best practice statement 2009 update Am Urological Assoc Available at httpwwwauanetorgcontentguidelines-and-quality-careclinical-guidelinesmain-reportspsa09pdf Date accessed September 2010
Ferrini R Woolf SH [2009] Screening for prostate cancer in American men American College of Preventive Medicine Practice Policy Statement Available at httpwwwacpmorgprostatehtm Date accessed September 2010
National Cancer Institute [2009] Prostate-specific antigen test National Cancer Institute Fact Sheet Available at httpwwwcancergovcancertopicsfactsheetDetectionPSA Date accessed September 2010
Wolf AMD Wender RC Etzioni RB et al [2010] American Cancer Society guideline for the early detection of prostate cancer Update 2010 Available at httpcaonlineamcancersocorgcgicontentfullcaac20066v1 Date accessed September 2010
59
Address List 9172010
Fire Service Occupational Safety and Health FIX-AAAKenneth Willette
Brett R Bowman
FIX-AAAAlternatePrince William County Department of Fire amp Rescue
1 County Complex Court
Prince William VA 22192
International Association of Fire ChiefsPrincipal Scott D Kerwood
PhoneCell 703-792-6388
Fax 703-792-7691
Email bbowmanpwcgovorg
E 822010 Leroy B Coffman III
FIX-AAAAlternateTempest Technology Inc
4645 North Bendel Avenue
Fresno CA 93722
Fire Apparatus Manufacturers AssociationPrincipal Dominic J Colletti
PhoneCell 559-277-7577
Fax 559-277-7579
Email leroy3tempest-edgecom
M 7262007
Steven D Corrado
FIX-AAAAlternateUnderwriters Laboratories Inc
12 Laboratory Drive
PO Box 13995
Research Triangle Park NC 27709-3995
Principal Thomas HillenbrandPhoneCell 919-549-1433 919-949-5617
Fax 919-547-6388
Email stevendcorradousulcom
RT 10272009 Craig A Fry
FIX-AAAAlternateLos Angeles City Fire Department
200 North Main Street Room 1770
Los Angeles CA 90012
Principal Mario D RuedaPhoneCell 213-978-3575
Fax 323-957-6411
Email craigfrylacityorg
U 4282000
Robert L McLeod III
FIX-AAAAlternateCity of Chandler Fire Department
PO Box 4008 MS 801
Chandler AZ 85244-4008
Fire Department Safety Officers AssociationPrincipal David Ross
PhoneCell 480-782-2140
Fax 480-782-2125
Email robmcleodchandlerazgov
E 7282006 Robert D Neamy
FIX-AAAAlternate550 Highway 88
Gardnerville NV 89460
National Incident Management System ConsortiumPrincipal Phillip C Vorlander
PhoneCell 775-265-0655
Fax 775-265-0588
Email Buckaroo2bobmsncom
M 111986
Stephen Raynis
FIX-AAAAlternateFire Department City of New York
9 Metrotech 7th Floor
Brooklyn NY 11201
Principal George L Maier IIIPhoneCell 718-999-2245
Fax 718-999-1271
Email raynissfdnynycgov
U 322010 Andrew G Schwartz
FIX-AAAAlternateLion Apparel Inc
6450 Poe Avenue Suite 300
Dayton OH 45414
Principal Donald AldridgePhoneCell 937-415-2913
Fax 937-913-5666
Email andrewslionapparelcom
M 7262007
57
Address List 9172010
Fire Service Occupational Safety and Health FIX-AAAKenneth Willette
Michael W Smith
FIX-AAAAlternateNational Volunteer Fire Council
855 Eastlake Boulevard
Carson City NV 89704
National Volunteer Fire CouncilPrincipal Philip C Stittleburg
FIX-AAANonvoting MemberNational Institute for Occupational Safety amp Health
4676 Columbia Parkway R-9
Cincinnati OH 45226
Alternate Jay L TarleyPhoneCell 513-841-4583
Fax 513-844-4488
Email thalescdcgov
RT 452001
William R Hamilton
FIX-AAANonvoting MemberUS Department of Labor
Occupational Safety amp Health Administration
200 Constitution Ave NW Room N3609
Washington DC 20210
Alternate Andrew LevinsonPhoneCell 202-693-2077
Fax 202-693-1663
Email hamiltonbilldolgov
E 342009 Andrew Levinson
FIX-AAAAlt to Nonvoting MemberUS Department of Labor
Occupational Safety amp Health Administration
200 Constitution Ave NW Room N3718
Washington DC 20210
Occupational Safety amp Health AdministrationPrincipal William R Hamilton
PhoneCell 202-693-2048
Fax 202-693-1678
Email levinsonandrewdolgov
E 7282006
Jay L Tarley
FIX-AAAAlt to Nonvoting MemberUS Department of Health amp Human Services
National Institute for Occupational Safety amp Health
1095 Willowdale Road MS 1808
Morgantown WV 26505
Principal Thomas R HalesPhoneCell 304-285-5858
Fax 304-285-5774
Email jst9cdcgov
RT 3152007 Kenneth Willette
FIX-AAAStaff LiaisonNational Fire Protection Association
1 Batterymarch Park
Quincy MA
PhoneCell 617-984-7299
Fax 617-984-7056
Email kwillettenfpaorg
792010
68
ATTACHMENT B
9
Technical Committee on Fire Service Occupational Safety and Health
Meeting Minutes May 13 ndash 14 2010
Holiday Inn Inner Harbor MD
Attendees Glenn Benarick Chairman Ken Holland Staff Liaison Michael Finkelman Craig Fry Joe Rivera Stephen Raynis Steve Kreis Dennis Childress Don Stewart Phil Stittleburg David Ross Michael Laton Kim Zagaris Tom Hillenbrand Dominic Colletti Andy Schwartz Brett Bowman Guest David Bernzweig Thursday May 13 NFPA 1500 task groups (Vehicle amp Safety OPS SCBA amp Air Mgt PPEProximity) met to discuss the work they have completed since the last meeting The task groups will present their report to the entire TC on May 14th Not enough 1582 task group members were able to make the meeting so there were no reports or work from those task groups Friday May 14 TC meeting called to order at approximately 0800 by Glenn Benarick TC Chair Ken Holland (NFPA Public Fire Protection Staff) in attendance filling in for Frank Florence Ken made two presentations one on the Codes and Standards Development Process and the other on the general procedures for this Pre-ROP meeting The Staff Liaison remains fluid as Frank is not expected back any time soon
10
One guest in attendance Dave Bernzweig (Columbus OH Fire) Dave is assisting TC with SCBAAir Mgt issues The document revision cycles remain as requested NFPA 1500 amp 1582 Annual 2012 NFPA 1521 amp 1561 Fall 2013 NFPA 1581 1583 1584 Annual 2014 The October 7-9 2010 dates are the primary request for our next meeting Location is San Diego Notice will be sent out as soon as approval is received Discussion on the next revision of 1561 will be held at the October meeting regarding changing the document title to ldquoCommand Safety for Fire Department Operationsrdquo This is a suggestion of the TC Chair Ken Holland conducted a briefing for the TC on how to access and use the committee web page Staff will be posting as much information as possible up on the e-committee page for the entire committee More use will be made of this tool Discussion on monocular vision Dennis Childress presented the current issue in Ventura County CA Further discussionwork may be necessary Don Stewart agreed to take the lead Brief discussion held on pregnancy and the need for fire departments to ensure policies match current law The rep from the Diabetes Association declined the invitation to participate at this meeting due to no discussion of the issue planned She has indicated a desire to attend the October meeting There were no reports from these and all other 1582 task groups It is very important for the 1582 TG Chairs to be ready to report in October The following task group reports will be posted on the ecommittee page PPEProximity New definition of proximity fire fighting
VehicleHighway OPS Discussion on use of vehicle data recorders Collapse Zones Submission from Jay Tarley SCBAAir Mgt New exit strategy for SCBA Discussion on having the low air alarm activate when the bottle volume reaches 600 liters Further discussion to take place on ldquobuddy breathingrdquo
On Day 2 Casey Grant (NFPA Fire Protection Research Foundation) made a presentation on Research Planning for FSOSH Dr Ellen Sogolow (DHSFEMA) also present during this presentation She discussed the role of the AFGRampD activities See ecommittee page for his presentation Chair
11
will be in contact with Mr Grant for future work between the TC and the Foundation Also on Day 2 Ken Willette (Division Manager ndash NFPA Public Fire Protection Division) delivered a presentation on the initiative developed by Kelvin Cochran (US Fire Administrator) to reduce fire fighter injuries and deaths NFPA 1500 is an integral part of this initiative See ecommittee page for presentation The Chair will be coordinating a committee conference call in the coming weeks The purpose will be to review the work which needs to be completed for the October meeting The primary focus of the call will be on 1582 issues NOTE Subsequent to the meeting I have had some discussions with a fire chief in Kentucky on the use of hearing aids The TC especially the doctors need to review the current language in 1582 and decide if revisions are needed Also most of you know that Kelvin Cochran has left the USFA unexpectedly to return to Atlanta as their fire chief I have been in contact with the Acting Administrator Glenn Gaines to inform him that our committee remains focused on the work to reduce fire fighter injuries and deaths I told him that I would keep him informed of our work He indicated that one of his primary goals is to bring fire service organizations together in order to create a safe working environment Of particular interest to him is reducing heart related injuries and deaths Submitted by Glenn Benarick
12
Technical Committee on Fire Service Occupational Safety and Health
Conference Call Meeting Minutes August 30th 2010
Members participating
Glenn Benarick TC Chair
Murrey Loflin Secretary Dr Sandy Bogucki
Thomas Cuff Stephen Foley
Scott Kerwood Tammy Lopes
David Love Dr David Prezant
Joe Rivera David Ross
Mario Rueda Phil Stittleburg
Phil Vorlander Dominic Colletti
Thomas Hillenbrand
Denise Smith Brett Bowman Alternate
Andrew Schwartz Alternate Mike Young Alternate
Dr Thomas Hales Non-Voting Member Ken Holland NFPA Staff Liaison
Casey Grant NFPAResearch Foundation Staff Katie Hathway Guest from ADA
Dr Jim Fleming Guest from Phoenix Fire Dept
The chair welcomed everyone to the conference call in which he hoped
would last only an hour The purpose was to discuss any task groups that had reports for proposed changes to NFPA 1582 for the
committee This is in hopes to ensure the committee is ready for their
pre-ROP meeting in October The following topics were discussed and are in no specific order
Comments from ADA Katie Hathaway and the group went into deep
discussion regarding ones medical history and diagnosis of diabetes
13
and some proposed changesremoval of text based on research
findings The specific proposed changes will be available for the committee at their next meeting Some members on the call felt that
this issue was covered in another law enforcement document which might better serve this issue
Research topics for FSOSH projects Casey Grant offered his time to
answer any questions regarding his presentation from the May meeting in Baltimore There was also discussion about further
involvement of the Research Foundation with this committee and some of the medical requirements within the documents Glenn and Casey
are going to be in contact offline to discuss this further
Prosthetics amp Amputees report Nothing new to report
Heart amp Hypertension report There was discussion about the need for
periodic EKGrsquos that were done both in resting and non-resting states as well as discussion about stress test requirements and frequency of
such tests The hopes were to develop text that would point to annual versus periodic evaluations of EKGrsquos and stress tests
Epilepsy report Nothing new to report
Pregnancy report The initial textlanguage has been provided to the
group through email and e-committee page posting
Coagulation amp Meds report Nothing new to report
Hearing Aid discussion Nothing new to report
The committee also discussed the evaluation and documentation of
PSA results and test requirements for the purposes of consistency The proposed text and changes have been posted on the e-committee
page as well
All of the proposed text changes from the May meeting in Baltimore have been emailed out and posted on the e-committee page If there
are any questions or concerns that something was missed please contact Glenn Steven Sawyer or Ken Holland to ensure they are
resolved
The conference call lasted approximately an hour and was adjourned at 1400 hours
14
ATTACHMENT C
15
2012 ANNUAL REVISION CYCLE
PROCESS STAGE PROCESS STEP DATES
FOR TC DATES
FOR TCC 1 PRELIMINARY 10 Notification of intent to enter cycle 7910 7910
2 REPORT ON
PROPOSALS (ROP)
21 Proposal closing date 112310 112310 22 Final date for ROP meeting 22511 2411 23 Final date for mailing TC ballots 31811 21811 24 Receipt of (TC) ballots by staff liaison 42211 31111 25 Receipt of TC recirculation ballots 5611 31811 26 Final date for TCC meeting 41511 27 Final date for mailing TCC ballots 42211 28 Receipt of TCC ballots 51311 29 Receipt of TCC recirculation ballots 52011 210 Final copy (w ballot statements) to Secretary Standards Council 51311 52711 211 Completion of Reports 52011 6311 212 ROP Published and Posted 62411 62411
3 REPORT ON
COMMENTS
(ROC)
31 Comment closing date 83011 83011 32 Final date for ROC meeting 11411 10711 33 Final date for mailing TC ballots 111811 102111 34 Receipt of (TC) ballots by staff liaison 12211 111111 35 Receipt of TC recirculation ballots 12911 111811 36 Final date for TCC meeting 121611 37 Final date for mailing TCC ballots 122311 38 Receipt of TCC ballots 11312 39 Receipt of TCC recirculation ballots 12012 310 Final copy (w ballot statements) to Secretary Standards Council 122311 12712 311 Completion of Reports 11312 2312 312 ROC Published and Posted 22412 22412
4 TECH SESSION
PREPARATION amp
ISSUANCE OF
CONSENT
DOCUMENTS
41 Notice of Intent to Make a Motion (NITMAM) Closing Date 4612 4612 42 Posting of Filed NITMAM 5412 5412
43 Council Issuance Date for Consent Documents 52912 52912
44 Appeal Closing Date for Consent Documents 61312 61312
5 TECHNICAL
SESSION 50 Association Meeting for Documents with Certified Amending Motions
64-712 64-712
6
APPEALS amp
ISSUANCE OF
DOCUMENTS
WCAMS
61 Appeal closing date for Documents with Certified Amending Motions
62712 62712
62 Council issuance for Documents with Certified Amending Motions 8912 8912
Proposal Closing Dates may vary according to documents and schedules for Revision Cycles may change Please check the NFPA website (wwwnfpaorg) for the most up-to-date information on proposal closing dates and schedules
16
ATTACHMENT D
17
This weekrsquos conference call mentioned the Diabetes chapter written for the ACOEM document Guidance for the Medical Evaluation of the Law Enforcement Officer The task group working on this chapter (led Richard Miller of the Secret Service and our very own Dan Samo) worked with the ADA or over 2-3 years to come up with a consensus document
Please find the Chapter attached ltltDiabetes Guidance Sept 2010pdfgtgt
Regarding Dan Loeberrsquos points
1) Physical Evaluation Form - We could modify the LEO form (see end of the attached Chapter)
2) Duration required for stable regiment
1582 for IDDM Type 1 1 yr
Type 2 6 m
Oral Agents None specifically
ACOEM Police for IDDM Type 1 6m
Type 2 3m
Oral Agents 1m
The police document is much clearer about the decision regarding medical fitness for duty is the responsibility of the police physician with the treating diabetes-expert physician providing the data to the police physician to make an informed decision In this regard the police officer must provide the police physician with downloaded self monitoring glucose data for the 1 3 and 6 month time periods (see section 433)
3) HA1C ndash NFPA lt 8 over 3 month period
ACOEM Police ndash (Section 4333) Specifies the frequency on measurement and if gt8 requires further evaluation
Some other discrepancies End organ complications
NFPA ndash end organ complications (eye kidney heart neuro) ndash restriction
ACOEM Police ndash end organ complication -- requires further evaluation
18
Hypoglycemia (incapacitating ndash defined differently between the two documents (434)
NFPA ndash 0 episodes in past year le1 in past 5 yrs
ACOEM Police ndash 0 episodes in past year le2 in past 3 yrs
Given Dan Samorsquos and Richard Millerrsquos work with the ADALoeber it would be helpful to get their opinions on whether any of the changes requested by Loeber are appropriate for FF with DM
Tom
Thomas Hales MD MPH
Senior Medical Epidemiologist
NIOSH CDC
4676 Columbia Pkwy R-9
Cincinnati OH 45241
(513) 841-4583
trh1cdcgov
19
43 ndash DIABETES MELLITUS
431 ndash INTRODUCTION
The educated and motivated law enforcement officer (LEO) with well-managed diabetes mellitus can be capable of
safe and effective job performance1 However diabetes mellitus may place LEOs at risk for sudden incapacitation
thus jeopardizing their ability to perform critical job functions (These job functions include those listed in Sections
32 333 351 352 36 and 37 and discussed in Appendix A)
Therefore an individualized assessment of the LEOrsquos diabetes should be performed using the following evaluative
criteria to determine whether the individuals condition permits safe and effective job performance Such evaluation
must include the following key elements which are discussed in detail below
history of blood glucose control
knowledge of diabetes and its management
current stability of blood glucose
risk for significant hypoglycemia or hyperglycemia and
presence of diabetic complications
432 ndash OVERVIEW OF MEDICAL EVALUATION
The treating endocrinologist or other physician knowledgeable regarding diabetes management should provide
a narrative report certifying whether the LEO has or has not met the criteria set out in Sections 4321 through
4354 below In addition the physician should include supporting data (see Appendix B for the Physician Evalu-
ation Form)
4321 The LEO is under the care of an endocrinologist or other physician knowledgeable regarding diabetes
management Outpatient and in-patient medical record(s) for the last 3 years or since date of diagnosis
(whichever is shorter) should be reviewed by the treating physician and provided to the police physician
4322 If the LEO has type 1 diabetes the individual has been on a basalbolus regimena or an insulin pump
using analogue insulins for the 6 months prior to evaluation2
4323 If the LEO has type 2 diabetes on insulin the individual has been on a stable medication regimenb
for the 3 months prior to evaluation3 If on oral agents alone the LEO has been on a stable medication regimen
for the month prior to evaluationc
ACOEM Guidance for the Medical Evaluation of Law Enforcement Officers 1
43 ndash DIABETES MELLITUS
aA basalbolus insulin regimen consists of the use of a basal insulin (Glargine NPH) in a once or twice daily regimen to provide between-
meal insulin combined with the use of a short acting insulin (Regular Lispro Aspart or Glulisine) at mealtimes Insulin pumps are small
(beeper sized) battery powered devices that deliver small amounts of short-acting insulin in a constant infusion to meet basal insulin
requirements The wearer selects an additional mealtime bolus to be infused at the time of meals For more information on pumps visit
the manufacturerrsquos web sites ndash wwwMinimedcom wwwcozmorecom wwwanimascorpcom wwwdisetroniccom
bA stable insulin regimen is defined as maintaining the same types of insulin (long acting intermediate acting short or rapid acting)
Changes in insulin dose are part of the appropriate self-management of diabetes and do not disqualify an applicant or incumbent under
this section
cChanges in dose within the evaluation period will be allowed but addition of a new class of medications or insulin should result in a new
period of observation
one month for addition of a sulfonylurea or metformin
two months for the addition of a thiazolidinedione to insulin or a sulfonylurea or
three months for the addition of insulin
20
4324 If the LEO uses an insulin pump documentation is needed as follows
proper understanding and education in the use of the insulin pump
start date for the use of the pump
history of insulin site infectionsd
history of pump cessation and pump malfunction
backup plan for pump malfunction including use of injectable insulin and
frequency of infusion set changes
4325 The LEO has been educated in diabetes and its management and thoroughly informed of and under-
stands the procedures that must be followed to monitor and manage hisher diabetes and what procedures
should be followed if complications arise3
433 ndash QUANTITATIVE GLUCOSE MONITORING
4331 The LEO has documentation of ongoing self-monitoring of blood glucose
4332 This must be done with a glucose meter that stores every reading records date and time of reading
and from which data can be downloaded (Most meters now have this capability)
4333 Monitoring logs must be available covering the time period (1 3 or 6 months) as described in
Sections 4322 and 4323 The frequency of glucose monitoring must follow a schedule acceptable to the
police physician in consultation with the treating physician
Testing schedules are individual What follows is a common pattern but individual patterns may differ
2 ACOEM Guidance for the Medical Evaluation of Law Enforcement Officers
43 ndash DIABETES MELLITUS
dIndividual has not had more than one pump-site infection that caused him or her to miss work or usual daily activities in the preceding 6
months
THERAPEUTIC REGIMEN GLUCOSE TESTING SCHEDULE
Diet alone Once or twice a week
Metformin Thiazolidinediones or Alpha
Glucosidase inhibitors alone or in
combination
Once or twice a week
Sulfonylureas meglitanides nateglinide ndash
alone or in combination with the above group
Twice a day ndash AM and at supper with any
suspected hypoglycemic episodes
Insulin ndash one shot in combination with orals Twice a day ndash AM and at supper with any
suspected hypoglycemic episodes
2 to 3 times AM once a week
Insulin ndash two or more shots Insulin pump 3 to 4 times a day ndash at meals and bedtime
2 to 3 times AM once a week with any
suspected hypoglycemic episodes
21
4334 The LEO has had hemoglobin A1C measured at least 4 times a year (intervals of 2 to 3 months) over
the last 12 months prior to evaluation if diagnosis has been present for more than a year4 If hemoglobin A1C is
gt8 this may signal a problem with the LEOrsquos diabetes management that warrants further assessment5
434 ndash INCAPACITATING EVENTS
4341 The LEO has not had any incapacitating episodes within the past 1 year and no more than 2 episodes
in the past 3 years or since diagnosis of diabetes (whichever is shorter) of
43411 Severe hypoglycemia (loss of consciousness seizures or coma requiring assistance of others or
needing urgent treatment [glucagon injectionIV glucose]) or
43412 Blood sugar lt60 mgdl with unawareness demonstrated in current glucose logs6
435 ndash CHRONIC COMPLICATION SCREENING
4351 Chronic complications of diabetes are associated with increased risk for severe hypoglycemic
episodes and warrant further assessmente
4352 The components of screening for chronic complications are
43521 A complete eye exam by a qualified ophthalmologist or optometrist including a dilated retinal
exam demonstrating no more than mild background diabetic retinopathyf7
43522 Normal vibratory testing with a 128 Hz tuning forkg normal testing with 10 gram Semmes-
Weinstein monofilamentg and normal orthostatic blood pressureh and pulse testing89
ACOEM Guidance for the Medical Evaluation of Law Enforcement Officers 3
43 ndash DIABETES MELLITUS
ePresence of chronic complications of diabetes in and of themselves may not require the implementation of work restrictions
fNo more than one dot blot or flame-shaped hemorrhages or microaneurysm in all four fundus quadrants
gThe Michigan Diabetes Research and Training Center of the University of Michigan Health System recommends the following guidance
(see wwwmedumichedumdrtcprofsdocumentssviMNSI_howtopdf) for conducting vibratory and monofilament testing8
Vibration Sensation Vibration sensation should be performed with the great toe unsupported Vibration sensation will be tested bi-
laterally using a 128 Hz tuning fork placed over the dorsum of the great toe on the boney prominence of the DIP joint Patients whose
eyes are closed will be asked to indicate when they can no longer sense the vibration from the vibrating tuning fork In general the
examiner should be able to feel vibration from the hand-held tuning fork for 5 seconds longer on his distal forefinger than a normal subject
can at the great toe (eg examiners DIP joint of the first finger versus patients toe) If the examiner feels vibration for 10 or more seconds
on his or her finger then vibration is considered decreased A trial should be given when the tuning fork is not vibrating to be certain that
the patient is responding to vibration and not pressure or some other clue Vibration is scored as 1) present if the examiner senses the
vibration on his or her finger for lt10 seconds 2) reduced if sensed for 10 seconds or 3) absent (no vibration detection)
Monofilament Testing For this examination it is important that the patients foot be supported (ie allow the sole of the foot to rest on
a flat warm surface) The filament should initially be pre-stressed (4-6 perpendicular applications to the dorsum of the examiner s first
finger) The filament is then applied to the dorsum of the great toe midway between the nail fold and the DIP joint Do not hold the toe
directly The filament is applied perpendicularly and briefly (lt1 second) with an even pressure When the filament bends the force of
10 grams has been applied The patient whose eyes are closed is asked to respond yes if heshe feels the filament Eight correct responses
out of 10 applications is considered normal 1 to 7 correct responses indicates reduced sensation and no correct answers translates into
absent sensation
hOrthostatic hypotension is a physical finding defined by the American Autonomic Society and the American Academy of Neurology as a
systolic blood pressure decrease of at least 20 mm Hg or a diastolic blood pressure decrease of at least 10 mm Hg within 3 minutes of
standing
22
43523 Normal cardiac physical exam Cardiac stress testing to at least 12 METS is recommended and
should begin based on either the criteria of the American Heart AssociationAmerican College of
Cardiologyi10 or those of the American Diabetes Associationj11
Diabetics who have a normal cardiac stress test will be retested every one to three years based on
individual clinical assessment This assessment should consider
the age of the individual
the number and persistence of coronary artery disease (CAD) risk factors
the severity of CAD risk factors
43524 Microalbumincreatinine ratio 301 measured or calculatedk creatinine clearance
gt60 mlmin12
436 ndash ONGOING EVALUATION AND REQUIREMENTS
4361 Should have medical records and glucose meter logs reviewed periodically Because of the nature of
diabetes it is important that regular medical follow up be provided to the LEO The frequency and content of
the evaluation should be determined on an individual basis by the police physician in consultation with the
treating physicianl
4362 Must advise police physician of any change in type of medication
4363 Must advise police physician of any episodes of significant hypoglycemia or hyperglycemia
Urine microalbumincreatinine ratio _________________
III Treating Physician Statement
The above named individual meets all of the criteria provided on this form
Yes No ndash not recommended for position
No but IS recommended for position (letter of explanation attached)
It is my opinion that the above named individual is well-educated and well-motivated in diabetes self-management and has
achieved a level of diabetes management to be capable of safe and effective job performance as a law enforcement officer
I have reached this opinion after careful review of the above criteria
___________________________________________________________ ___________________________Signature of Physician Date
______________________________________________________________ ___________________________Printed or Typed Name of Physician Telephone Number
10 ACOEM Guidance for the Medical Evaluation of Law Enforcement Officers
43 ndash DIABETES MELLITUS
29
439 ndash REFERENCES
1 American Diabetes Association Diagnosis and classification of diabetes mellitus Diabetes Care 200427 Suppl
1S5-S10 See httpcarediabetesjournalsorgcgicontentfull27suppl_1s5
2 American Diabetes Association Continuous subcutaneous insulin infusion Diabetes Care 200427 Suppl 1S110
See httpcarediabetesjournalsorgcgicontentfull27suppl_1s110
3 Mensing C Boucher J Cypress M et al National standards for diabetes self-management education Diabetes
Care 200528 Suppl 1S72-9 See httpcarediabetesjournalsorgcgicontentfull28suppl_1s72
4 Goldstein DE Little RR Lorenz RA Malone JI Nathan DM Peterson CM American Diabetes Association Tests
of glycemia in diabetes Diabetes Care 200427 Suppl 1S91-3
See httpcarediabetesjournalsorgcgicontentfull27suppl_1s91
5 The Diabetes Control and Complications Trial Research Group Hypoglycemia in the Diabetes Control and
Complications Trial Diabetes 199746(2)271-86 See wwwncbinlmnihgovpubmed9000705 for abstract
6 American Diabetes Association Hypoglycemia and employmentlicensure Diabetes Care 200528 Suppl 1S61
See httpcarediabetesjournalsorgcgicontentfull28suppl_1s61
7 Viswanath K McGavin DD Diabetic Retinopathy Clinical Findings and Management J Comm Eye Health
200316(46)21-4 See wwwcehjournalorg0953-683316jceh_16_46_021html
8 Michigan Diabetes Research and Training Center University of Michigan Health System How to use the Michigan
Neuropathy Screening Instrument See wwwmedumichedumdrtcprofsdocumentssviMNSI_howtopdf
9 Bradley JG Davis KA Orthostatic hypotension Am Fam Physician 200368(12)2393-8
See wwwaafporgafp200312152393html
10 Gibbons RJ Balady GJ Bricker JT et al ACCAHA 2002 guideline update for exercise testing a report of the
American College of CardiologyAmerican Heart Association Task Force on Practice Guidelines (Committee on
Exercise Testing) J Am Coll Cardiol 200240(8)1531-40
See wwwaccorgqualityandscienceclinicalguidelinesexerciseexercise_cleanpdf
11 American Diabetes Association Standards of medical care in diabetes Diabetes Care 200528 Suppl 1S4-S36
Erratum in Diabetes Care 200528(4)990 See httpcarediabetesjournalsorgcgicontentfull28suppl_1s4
12 Molitch ME DeFronzo RA Franz MJ et al American Diabetes Association Nephropathy in diabetes Diabetes
Care 200427 Suppl 1S79-83 See httpcarediabetesjournalsorgcgicontentfull27suppl_1s79
13 Kitabchi AE Umpierrez GE Murphy MB et al American Diabetes Association Hyperglycemic crises in diabetes
Diabetes Care 200427 Suppl 1S94-102 See httpcarediabetesjournalsorgcgicontentfull27suppl_1s94
14 US Centers for Disease Control and Prevention National Diabetes Fact Sheet 2007
See wwwcdcgovdiabetespubspdfndfs_2007pdf
ACOEM Guidance for the Medical Evaluation of Law Enforcement Officers 11
43 ndash DIABETES MELLITUS
30
ATTACHMENT E
31
Typos A6921(2) 7th line down test should be plural 94201 Paragraph 2 target organ damage is used though end organ damage was defined earlier and in the appendix for that paragraph
A94201 Para A (1) d Id suggest deleting the phrases in brackets Im not sure either are predictably true or politically wise
a) tests for left ventricular hypertrophy Unfortunately use of the EKG to detect left ventricular hypertrophy is very insensitive (eg 5 sensitivity) The echocardiogram is the best test for diagnosing left ventricular hypertrophy but [it is relatively expensive and not readily available in small rural communities ] conducting echocardiograms on asymptomatic fire fighters with Stage 1 hypertension should be reserved only for those with long-standing hypertension
In addition
7761 A resting EKG shall be performed as part of the baseline medical evaluation and shall be obtained periodically thereafter
Changing from annually to periodically is noted has the language in the wellness-fitness initiative been changed as well Our previous decision was that we would support the W-F language since there was no compelling evidence to either support or refute it
Thanks
Sandy
32
NFPA 1582‐ HTN Draft 1
Reason for Revision
1) New classification of BP by the Joint National Commission [Chobanian et al 2002]
2) A high prevalence of FF have either HTN (~20) and Pre‐HTN (~20) [Soteriades et al 2003]
3) Among FF studies have shown a strong association between HTN and a number of adverse
cardiovascular events [Kales et al 2009]
4) A large percentage of on‐duty FF fatalities were found to have left ventricular hypertrophy a
complication of HTN at autopsy
Language in 2007 Edition with draft revisions in Red (Track changes)
611 The medical evaluation of a candidate shall include a medical history examination and any laboratory tests required to detect physical or medical condition(s) that could adversely affect hisher ability to safely perform the essential job tasks outlined in 511 A611 The medical history should include the candidates known health problems such as major illnesses surgeries medication use and allergies Symptom review is also important for detecting early signs of illness A medical history should also include a personal health history a family health history a health habit history an immunization history and a reproductive history
An occupational history should also be obtained to collect information about the persons past occupational and environmental exposures
(a) BP should be measured according to the Joint National Commission (JNC) -7 recommendations BP should be measured with a properly calibrated and validated instrument Patients should be seated quietly for at least 5 minutes in a chair with feet on the floor and arm supported at heart level An appropriate-sized cuff (cuff bladder encircling at least 80 of the arm) should be used to ensure accuracy At least 2 measurements should be made Systolic BP is the point at which the first of 2 or more sounds is heard (phase 1) and diastolic BP is the point before the disappearance of sounds (phase 5) [Chobanian et al 2003]
(2) Head eyes ears nose and throat (HEENT)
Formatted Font (Default) Times New RomanFont color Black
33
692 Vascular System 6921 Category A medical conditions shall include the following
(1) Uncontrolled or poorly controlled hypertension
(2) Hypertension with evidence of end organ damage
or not controlled by approved medications
A6921(1) Uncontrolled or poorly controlled hHypertension increases the risk of a sudden cardiac event This sudden cardiac event would cause sudden incapacitation which that is uncontrolled poorly controlled or requires medication likely to interferes with the safe performance of essential job tasks Uncontrolled or poorly controlled hypertension can be defined as the presence of end organ damage (see below) or stage 2 hypertension (BP systolic gt160 mmHg or BP diastolic gt100 mmHg) is an illness that can lead to functional impairment and potential for sudden incapacitation Individuals with pre- stage 1 or stage 2 hypertension should be referred to their primary care physician for evaluation lifestyle modification and treatment [QUESTION FOR GROUP _- WHAT ABOUT HAVING CANDIDATE RETURN IN ONE MONTH UNDER TREATMENT WITH NORMAL BP]
A6921(2)
Chronic hypertension can damage the eye (retinopathy) the kidneys (nephropathy) the vascular system (stroke transient ischemic attack or peripheral artery disease) or the heart (left ventricular hypertrophy and heart failure) These hypertension complications are known as end organ damage The cardiac and vascular complications are associated with an increased risk of sudden incapacitation and sudden cardiac death (Koren et al 1991) Unfortunately the cardiac complications are frequently asymptomatic and valid screening tests are not fast and are not inexpensive Therefore determining who to screen for cardiac complications (such as echocardiogram for LVH or a measurement of left ventricular ejection fraction for heart failure) should be based on the severity and the duration of HTN
76 Physical Examination The annual physical examination shall include each of the following components
(a) BP shall be measured according to the Joint National Commission (JNC)-7 recommendations
A76(1)(a) BP should be measured with a properly calibrated and validated instrument Patients should be seated quietly for at least 5 minutes in a chair with feet on the floor and arm supported at heart level An appropriate-sized cuff (cuff bladder encircling at least 80 of the arm) should be used to ensure accuracy At least 2 measurements should be made Systolic BP is the point at which the first of 2 or more sounds is heard (phase 1) and diastolic BP is the point before the disappearance of sounds (phase 5) [Chobanian et al 2003]
(2) Head eyes ears nose and throat (HEENT)
34
9420 Uncontrolled Hypertension 94201 Physician Evaluation Severe uncontrolled hypertension [defined as systolic pressure greater than 180 mm Hg diastolic pressure greater than 100 mm Hg or mean systolic blood
pressure ( systolic + diastolic) greater than 120 mm Hg] or malignant hypertension (defined as hypertension with the presence of target organ damage) compromises the members ability to safely perform essential job tasks 1 5 7 9 and 13 and the physician shall report the applicable job limitations to the fire department
Members with Pre-hypertention (systolic 120-139 mmHg or diastolic 80-89 mmHg) Stage 1 hypertension (systolic 140-159 mmHg or diastolic 90-99 mmHg) or Stage 2 hypertension (systolic ge160 mmHg or diastolic ge100 mmHg) should be referred to their primary care physician for evaluation lifestyle modification and treatment
(1) Members with Stage I hypertension should be followed-up not only by their primary care physician but also by the FD physician every 3 to 6 months to ensure their blood pressure is under control and to determine whether screening tests for asymptomatic end organ damage are appropriate
(2) Members with Stage 2 hypertension or with end organ damage (retinopathy nephropathy vascular or cardiac complications) compromises the members ability to safely perform essential job tasks 1 5 7 9 and 130 and the physician shall report the applicable job limitations to the fire department
A94201 Severe uncontrolled hypertension is a significant risk factor for the development of coronary artery disease congestive heart failure and stroke Blood pressure increases as a normal response to exercise This response is further exaggerated by the emotional and physical stress of performing these critical tasks while operating in personal protective clothing at extremes of temperature This normal elevation of blood pressure under these response conditions can lead to life-threatening hypertensive emergencies if a members daily blood pressure is already elevated to high levels In addition hypertension is a progressive illness that when uncontrolled ultimately and inevitably leads to target organ damage Target organs that are sensitive to the effects of elevated blood pressure are the central nervous system vision heart major blood vessels and kidneys
Chronic hypertension can damage the eye (retinopathy) the kidneys (nephropathy) the vascular system (stroke transient ischemic attack or peripheral artery disease) or the heart (left ventricular hypertrophy and heart failure) These hypertension complications are known as end organ damage The cardiac and vascular complications are associated with an increased risk of sudden incapacitation and sudden cardiac death (Koren et al 1991) Fortunately with proper evaluation life style modification and treatment these complications can be avoided Life style modification includes weight reduction DASH eating plan reduction in dietary sodium an increase in aerobic physical activity and moderation in alcohol consumption [Chobanian 2003]
Formatted Font (Default) Times New Roman12 pt Font color Black
Formatted Font (Default) Times New Roman12 pt Font color Black
35
A94201 (1) Members with Stage I hypertension whose BP returns to either pre-hypertenion or normal with lifestyle modification andor treatment can return to an annual medical evaluation For members with long-standing Stage I hypertension whose BP has not been reduced additional evaluation for possible end organ damage should be considered This evaluation could include any or all of the following
a) a compete patient history for symptoms of heart failure (eg shortness of breath upon exertion) or transient ischemic attacks (TIAs)
b) dilated eye examination for retinopathy
c) blood creatinine measurement for nephropathy
d) tests for left ventricular hypertrophy Unfortunately use of the resting EKG to detect left ventricular hypertrophy is very insensitive (eg 5 sensitivity) The echocardiogram is the best test for diagnosing left ventricular hypertrophy
A 94201 (2) Due to the high risk of a sudden cardiovascular event members with Stage 2 hypertension should be restricted until their BP can be brought under control Once the BP is brought under control they should be followed in the same manner as a member with Stage I hypertension
Formatted Font (Default) Times New Roman12 pt
36
D22 Cardiology Gibbons R J GJ Balady J W Beasley et al 1997 ACCAHA guidelines for exercise testing a report of American College of CardiologyAmerican Heart Association Task Force on Practice Guidelines (Committee on Exercise Testing) J Am Coll Cardiol 30260ndash311
Gibbons RJ Balady GJ Bricker JT Chaitman BR Fletcher GF Froelicher VF Mark DB McCallister BD Mooss AN OrsquoReilly MG Winters WL Jr [2002] ACCAHA 2002 guideline update for exercise testing summary article a report of the ACCAHA Task Force on Practice Guidelines (Committee to Update the 1997 Exercise Testing guidelines) J Am Coll Cardiol 401531ndash 40
Chobanian AV Bakris GL Black HR Cushman WC Green LA Izzo JL Jr Jones DW Materson BJ Oparil S Wright JT Jr Roccella EJ the National High Blood Pressure Education Program Coordinating Committee [2003] The seventh report of the Joint National Committee [JNC-7] on Prevention Detection Evaluation and Treatment of High Blood Pressure JAMA 2892560ndash2571
Soteriades ES Kales SN Liarokapis D Christiani DC [2003] Prospective surveillance of hypertension in firefighters J Clin Hypertens 5315-320
Kales SN Tsismenakis AJ Zhang C Soteriades ES [2009] Blood pressure in fire fighters police officers and other emergency responders Am J Hypertens 2211-20
37
NFPA 1582‐ HTN Draft 1
Reason for Revision
1) New classification of BP by the Joint National Commission [Chobanian et al 2002]
2) A high prevalence of FF have either HTN (~20) and Pre‐HTN (~20) [Soteriades et al 2003]
3) Among FF studies have shown a strong association between HTN and a number of adverse
cardiovascular events [Kales et al 2009]
4) A large percentage of on‐duty FF fatalities were found to have left ventricular hypertrophy a
complication of HTN at autopsy
Language in 2007 Edition with draft revisions in Red (Track changes)
611 The medical evaluation of a candidate shall include a medical history examination and any laboratory tests required to detect physical or medical condition(s) that could adversely affect hisher ability to safely perform the essential job tasks outlined in 511 A611 The medical history should include the candidates known health problems such as major illnesses surgeries medication use and allergies Symptom review is also important for detecting early signs of illness A medical history should also include a personal health history a family health history a health habit history an immunization history and a reproductive history
An occupational history should also be obtained to collect information about the persons past occupational and environmental exposures
(a) BP should be measured according to the Joint National Commission (JNC) -7 recommendations BP should be measured with a properly calibrated and validated instrument Patients should be seated quietly for at least 5 minutes in a chair with feet on the floor and arm supported at heart level An appropriate-sized cuff (cuff bladder encircling at least 80 of the arm) should be used to ensure accuracy At least 2 measurements should be made Systolic BP is the point at which the first of 2 or more sounds is heard (phase 1) and diastolic BP is the point before the disappearance of sounds (phase 5) [Chobanian et al 2003]
(2) Head eyes ears nose and throat
38
692 Vascular System 6921 Category A medical conditions shall include the following
(1) Uncontrolled or poorly controlled hypertension
(2) Hypertension with evidence of end organ damage
A6921(1) Uncontrolled or poorly controlled hypertension increases the risk of a sudden cardiac event This sudden cardiac event would cause sudden incapacitation which interferes with the safe performance of essential job tasks Uncontrolled or poorly controlled hypertension can be defined as the presence of end organ damage (see below) or stage 2 hypertension (BP systolic gt160 mmHg or BP diastolic gt100 mmHg) Individuals with pre- stage 1 or stage 2 hypertension should be referred to their primary care physician for evaluation lifestyle modification and treatment [QUESTION FOR GROUP _- WHAT ABOUT HAVING CANDIDATE RETURN IN ONE MONTH UNDER TREATMENT WITH NORMAL BP]
A6921(2)Chronic hypertension can damage the eye (retinopathy) the kidneys (nephropathy) the vascular system (stroke transient ischemic attack or peripheral artery disease) or the heart (left ventricular hypertrophy and heart failure) These hypertension complications are known as end organ damage The cardiac and vascular complications are associated with an increased risk of sudden incapacitation and sudden cardiac death (Koren et al 1991) Unfortunately the cardiac complications are frequently asymptomatic and valid screening tests are not fast and are not inexpensive Therefore determining who to screen for cardiac complications (such as echocardiogram for LVH or a measurement of left ventricular ejection fraction for heart failure) should be based on the severity and the duration of HTN
76 Physical Examination The annual physical examination shall include each of the following components
(a) BP shall be measured according to the Joint National Commission (JNC)-7 recommendations
A76(1)(a) BP should be measured with a properly calibrated and validated instrument Patients should be seated quietly for at least 5 minutes in a chair with feet on the floor and arm supported at heart level An appropriate-sized cuff (cuff bladder encircling at least 80 of the arm) should be used to ensure accuracy At least 2 measurements should be made Systolic BP is the point at which the first of 2 or more sounds is heard (phase 1) and diastolic BP is the point before the disappearance of sounds (phase 5) [Chobanian et al 2003]
(2) Head eyes ears nose and throat9420 Hypertension 94201 Physician Evaluation Members with Pre-hypertention (systolic 120-139 mmHg or diastolic 80-89 mmHg) Stage 1 hypertension (systolic 140-159 mmHg or diastolic 90-99 mmHg) or Stage 2 hypertension (systolic ge160 mmHg or diastolic ge100 mmHg) should be referred to their primary care physician for evaluation lifestyle modification and treatment
39
(1) Members with Stage I hypertension should be followed-up not only by their primary care physician but also by the FD physician every 3 to 6 months to ensure their blood pressure is under control and to determine whether screening tests for asymptomatic end organ damage are appropriate
(2) Members with Stage 2 hypertension or with end organ damage (retinopathy nephropathy vascular or cardiac complications) compromises the members ability to safely perform essential job tasks 1 5 7 9 and 130 and the physician shall report the applicable job limitations to the fire department
A94201 Chronic hypertension can damage the eye (retinopathy) the kidneys (nephropathy) the vascular system (stroke transient ischemic attack or peripheral artery disease) or the heart (left ventricular hypertrophy and heart failure) These hypertension complications are known as end organ damage The cardiac and vascular complications are associated with an increased risk of sudden incapacitation and sudden cardiac death (Koren et al 1991) Fortunately with proper evaluation life style modification and treatment these complications can be avoided Life style modification includes weight reduction DASH eating plan reduction in dietary sodium an increase in aerobic physical activity and moderation in alcohol consumption [Chobanian 2003]
A94201 (1) Members with Stage I hypertension whose BP returns to either pre-hypertenion or normal with lifestyle modification andor treatment can return to an annual medical evaluation For members with long-standing Stage I hypertension whose BP has not been reduced additional evaluation for possible end organ damage should be considered This evaluation could include any or all of the following
a) a compete patient history for symptoms of heart failure (eg shortness of breath upon exertion) or transient ischemic attacks (TIAs)
b) dilated eye examination for retinopathy
c) blood creatinine measurement for nephropathy
d) tests for left ventricular hypertrophy Unfortunately use of the resting EKG to detect left ventricular hypertrophy is very insensitive (eg 5 sensitivity) The echocardiogram is the best test for diagnosing left ventricular hypertrophy
A 94201 (2) Due to the high risk of a sudden cardiovascular event members with Stage 2 hypertension should be restricted until their BP can be brought under control Once the BP is brought under control they should be followed in the same manner as a member with Stage I hypertension
D22 Cardiology
40
Hypertension
Gibbons RJ Balady GJ Bricker JT Chaitman BR Fletcher GF Froelicher VF Mark DB McCallister BD Mooss AN OrsquoReilly MG Winters WL Jr [2002] ACCAHA 2002 guideline update for exercise testing summary article a report of the ACCAHA Task Force on Practice Guidelines (Committee to Update the 1997 Exercise Testing guidelines) J Am Coll Cardiol 401531ndash 40
Chobanian AV Bakris GL Black HR Cushman WC Green LA Izzo JL Jr Jones DW Materson BJ Oparil S Wright JT Jr Roccella EJ the National High Blood Pressure Education Program Coordinating Committee [2003] The seventh report of the Joint National Committee [JNC-7] on Prevention Detection Evaluation and Treatment of High Blood Pressure JAMA 2892560ndash2571
Soteriades ES Kales SN Liarokapis D Christiani DC [2003] Prospective surveillance of hypertension in firefighters J Clin Hypertens 5315-320
Kales SN Tsismenakis AJ Zhang C Soteriades ES [2009] Blood pressure in fire fighters police officers and other emergency responders Am J Hypertens 2211-20
41
NFPA 1582‐ Draft Revisions for CVDHTN
EKG and stress tests
Reason for Revision
1) Change requirement for annual resting EKG to periodically to be more consistent with ACCAHA
recommendation (Schlant et al 1992)
2) Add language to clarify what constitutes a positive ST
3) Make criteria for conducting diagnostic ST in asymptomatic patients consistent with the
ACCAHA
Language in 2007 Edition with draft revisions in Red (Track changes)
776 Electrocardiograms (EKG)) and Stress Tests 7761 A resting EKG shall be performed as part of the baseline medical evaluation and shall be obtained periodically (every 1 to 5 years) annually thereafter
A7761 A baseline resting EKGs shall be conducted Follow-up resting EKGs should be conducted as clinically indicated but at a minimum of every 1 to 5 years The frequency of these follow-up resting EKGs should increase as a members age increases or with increasing number andor severity of coronary heart disease risk factors Members above the age of 40 should have annual resting EKGs (Schlant et al 1992)
7762 The fire department physician or other qualified medical evaluator shall compare EKGs obtained during yearly evaluations with baseline and subsequent EKGs
7763 Stress testing EKG with or without echocardiography or radionuclide scanning shall be performed as clinically indicated by history or symptoms
A7761 Baseline electrocardiography should be conducted (Periodic resting electrocardiograms have not been shown to be useful but can be reasonable as a members agefactors increase)
A7763 No firm guidelines for stress testingelectrocardiography in asymptomatic individuals have been developed Stress testingelectrocardiography as a screening tool is used as part of an evaluation of aerobic capacity during the annual occupational fitness evaluation Submaximal stress testingelectrocardiography testing to 85 percent is commonly used as part of this screening
Submaximal stress electrocardiography testing should not be used for diagnostic purposes Cardiology evaluation with maximal stress testingelectrocardiography together with imaging techniques (eg echocardiography technetium Tc99m sestamibi study andor coronary angiography) is necessary for diagnosticprognostic purposes for the following
42
(1) Fire fighters with positive or questionably positive changes on screening submaximal stress tests
(2) Fire fighters with new onset chest pain or other symptoms suggestive of coronary artery disease (CAD)
(3) Fire fighters with diabetes mellitus who
(a) are gt35 years old or
(b) have type I diabetes for more than 15 years or
(c) have type II diabetes for more than 10 years or
(d) have any other CHD risk factor (see below) or
(e) have the presence of microvascular disease (proliferative retinopathy)
(4) Fire fighters over the age of 45 (for men) and 55 (for women) with onetwo or more risk factors for CAD Risk factors for CAD include hypercholesterolemia (total cholesterol greater than 240 mgdL) hypertension (systolic gt140 mmHg or diastolic gt90 mmHg) smoking or family history of premature CAD (heart attack or sudden cardiac death in a first degree relative less than 60 years of age)
as defined below if stress electrocardiography with imaging is negative then repeat as clinically indicated or at least every 5 years
(5) Fire fighters with a Framingham Risk Score gt10 Risk calculator is available at [httphp2010nhlbihinnetatpiiicalculatorasp]
(6) Fire fighters identified in 9431
Negative stress tests should be repeated as clinically indicated or at least every 2 to 5 years
Interpreting stress tests as ldquopositiverdquo or ldquonegativerdquo is beyond the scope of this document However factors that should be taken into consideration should include the individualrsquos exercise capacity symptoms blood pressure response heart rate response EKG changes and the presence of arrhythmias (Gibbon et al 2002)
Risk factors for CAD include hypercholesterolemia (total cholesterol greater than 240 mgdL) hypertension (systolic greater than 140 andor diastolic greater than 90) smoking diabetes mellitus or family history of premature CAD (heart attack or sudden cardiac death in a first degree relative less than 60 years of age)
There are other non-invasive tests to screen for coronary artery disease One of the most promising appears to be coronary artery calcium (CAD) scoring by computed tomography In 2007 an expert committee published an update to their original guidance document The committeersquos consensus was that ldquoit may be reasonable to consider use of CAC measurement in such patients [between 10 and 20 10-year risk of estimated coronary event]helliprdquo The committee did not recommend CAC measurement in low risk patients [lt10 10-year risk of estimated coronary event] or in high risk patients [gt20 10-year risk of estimate coronary event] (Greenland et al 2007]
43
D22 Cardiology
Chobanian AV Bakris GL Black HR Cushman WC Green LA Izzo JL Jr Jones DW Materson BJ Oparil S Wright JT Jr Roccella EJ the National High Blood Pressure Education Program Coordinating Committee [2003] The seventh report of the Joint National Committee [JNC-7] on Prevention Detection Evaluation and Treatment of High Blood Pressure JAMA 2892560ndash2571
Gibbons RJ Balady GJ Bricker JT Chaitman BR Fletcher GF Froelicher VF Mark DB McCallister BD Mooss AN OrsquoReilly MG Winters WL Jr [2002] ACCAHA 2002 guideline update for exercise testing summary article a report of the ACCAHA Task Force on Practice Guidelines (Committee to Update the 1997 Exercise Testing guidelines) J Am Coll Cardiol 401531ndash 1540
Greenland et al [2007] ACCFAHA 2007 Clinical Expert Consensus Document on Coronary Artery Calcium Scoring By Computed Tomography in Global Cardiovascular Risk Assessment and in Evaluation of Patients With Chest Pain A Report of the American College of Cardiology Foundation Clinical Expert Consensus Task Force (ACCFAHA Writing Committee to Update the 2000 Expert Consensus Document on Electron Beam Computed Tomography) J Am Coll Cardiol 49378-402
Kales SN Tsismenakis AJ Zhang C Soteriades ES [2009] Blood pressure in fire fighters police officers and other emergency responders Am J Hypertens 2211-20
Schlant RC Adolph RJ DiMarco JP Dreifus LS Dunn MI Fisch C Garson A Jr Haywood LJ Levine HJ Murray JA Noble RJ Ronan JA Jr [1992] Guidelines for electrocardiography A report of the American College of CardiologyAmerican Heart Association Task Force on Assessment of Diagnostic and Therapeutic Cardiovascular Procedures (Committee on Electrocardiography) Circulation 85(3)1221-1228
Soteriades ES Kales SN Liarokapis D Christiani DC [2003] Prospective surveillance of hypertension in firefighters J Clin Hypertens 5315-320
Formatted Font Italic
Formatted Line spacing single
Formatted Font Italic
Formatted Font Italic
44
NFPA 1582‐ Draft Revisions for CVDHTN
EKG and stress tests
Reason for Revision
1) Change requirement for annual resting EKG to periodically to be more consistent with ACCAHA
recommendation (Schlant et al 1992)
2) Add language to clarify what constitutes a positive ST
3) Make criteria for conducting diagnostic ST in asymptomatic patients consistent with the
ACCAHA
Language in 2007 Edition with draft revisions in Red (Track changes)
776 Electrocardiograms (EKG) and Stress Tests 7761 A resting EKG shall be performed as part of the baseline medical evaluation and shall be obtained periodically (every 1 to 5 years) thereafter
A7761 A baseline resting EKGs shall be conducted Follow-up resting EKGs should be conducted as clinically indicated but at a minimum of every 1 to 5 years The frequency of these follow-up resting EKGs should increase as a members age increases or with increasing number andor severity of coronary heart disease risk factors Members above the age of 40 should have annual resting EKGs (Schlant et al 1992)
7762 The fire department physician or other qualified medical evaluator shall compare baseline and subsequent EKGs
7763 Stress testing with or without echocardiography or radionuclide scanning shall be performed as clinically indicated by history or symptoms
A7763 No firm guidelines for stress testing in asymptomatic individuals have been developed Stress testing as a screening tool is used as part of an evaluation of aerobic capacity during the annual occupational fitness evaluation Submaximal stress testing testing to 85 percent is commonly used as part of this screening
Submaximal stress testing should not be used for diagnostic purposes Cardiology evaluation with maximal stress testing together with imaging techniques (eg echocardiography technetium Tc99m sestamibi study) is necessary for diagnosticprognostic purposes for the following
(1) Fire fighters with positive or questionably positive changes on screening submaximal stress tests
(2) Fire fighters with new onset chest pain or other symptoms suggestive of coronary artery disease (CAD)
45
(3) Fire fighters with diabetes mellitus who
(a) are gt35 years old or
(b) have type I diabetes for more than 15 years or
(c) have type II diabetes for more than 10 years or
(d) have any other CHD risk factor (see below) or
(e) have the presence of microvascular disease (proliferative retinopathy)
(4) Fire fighters over the age of 45 (for men) and 55 (for women) with one or more risk factors for CAD Risk factors for CAD include hypercholesterolemia (total cholesterol greater than 240 mgdL) hypertension (systolic gt140 mmHg or diastolic gt90 mmHg) smoking or family history of premature CAD (heart attack or sudden cardiac death in a first degree relative less than 60 years of age)
(5) Fire fighters with a Framingham Risk Score gt10 Risk calculator is available at [httphp2010nhlbihinnetatpiiicalculatorasp]
(6) Fire fighters identified in 9431
Negative stress tests should be repeated as clinically indicated or at least every 2 to 5 years
Interpreting stress tests as ldquopositiverdquo or ldquonegativerdquo is beyond the scope of this document However factors that should be taken into consideration should include the individualrsquos exercise capacity symptoms blood pressure response heart rate response EKG changes and the presence of arrhythmias (Gibbon et al 2002)
There are other non-invasive tests to screen for coronary artery disease One of the most promising appears to be coronary artery calcium (CAD) scoring by computed tomography In 2007 an expert committee published an update to their original guidance document The committeersquos consensus was that ldquoit may be reasonable to consider use of CAC measurement in such patients [between 10 and 20 10-year risk of estimated coronary event]helliprdquo The committee did not recommend CAC measurement in low risk patients [lt10 10-year risk of estimated coronary event] or in high risk patients [gt20 10-year risk of estimate coronary event] (Greenland et al 2007]
D22 Cardiology
Resting EKG and Stress Tests
46
Chobanian AV Bakris GL Black HR Cushman WC Green LA Izzo JL Jr Jones DW Materson BJ Oparil S Wright JT Jr Roccella EJ the National High Blood Pressure Education Program Coordinating Committee [2003] The seventh report of the Joint National Committee [JNC-7] on Prevention Detection Evaluation and Treatment of High Blood Pressure JAMA 2892560ndash2571
Gibbons RJ Balady GJ Bricker JT Chaitman BR Fletcher GF Froelicher VF Mark DB McCallister BD Mooss AN OrsquoReilly MG Winters WL Jr [2002] ACCAHA 2002 guideline update for exercise testing summary article a report of the ACCAHA Task Force on Practice Guidelines (Committee to Update the 1997 Exercise Testing guidelines) J Am Coll Cardiol 401531ndash 1540
Greenland et al [2007] ACCFAHA 2007 Clinical Expert Consensus Document on Coronary Artery Calcium Scoring By Computed Tomography in Global Cardiovascular Risk Assessment and in Evaluation of Patients With Chest Pain A Report of the American College of Cardiology Foundation Clinical Expert Consensus Task Force (ACCFAHA Writing Committee to Update the 2000 Expert Consensus Document on Electron Beam Computed Tomography) J Am Coll Cardiol 49378-402
Kales SN Tsismenakis AJ Zhang C Soteriades ES [2009] Blood pressure in fire fighters police officers and other emergency responders Am J Hypertens 2211-20
Schlant RC Adolph RJ DiMarco JP Dreifus LS Dunn MI Fisch C Garson A Jr Haywood LJ Levine HJ Murray JA Noble RJ Ronan JA Jr [1992] Guidelines for electrocardiography A report of the American College of CardiologyAmerican Heart Association Task Force on Assessment of Diagnostic and Therapeutic Cardiovascular Procedures (Committee on Electrocardiography) Circulation 85(3)1221-1228
Soteriades ES Kales SN Liarokapis D Christiani DC [2003] Prospective surveillance of hypertension in firefighters J Clin Hypertens 5315-320
47
ATTACHMENT F
48
1
Current 1582 (2007) language in reference to pregnancy 43 (4) Report to the fire department physician any medical condition that could interfere with the ability of the individual to safely perform essential job tasks such as illness or injury use of prescription or nonprescription drugs and pregnancy 6112 Category B medical conditions shall include the following (1) Pregnancy for its duration A7792 (e) If HIV prophylaxis is to be given the following tests should be done i CBC ii Glucose renal and hepatic chemical function iii Pregnancy test for females B121 Pregnancy and Reproduction Federal regulations as well as many court decisions including the US Supreme Courtrsquos decision in International Union et al v Johnson Controls Inc [499 US 187 111 S Ct 1196 (1991)] have interpreted the requirements of Title VII with respect to pregnancy and reproduction The AHJ should seek the advice of counsel in resolving specific questions concerning these requirements as well as other requirements that can be imposed by state or local laws C211 (4) Review health status with the individual being evaluated Contraindications for evaluations shall be reviewed addressing any changes in the individualrsquos health status since their last medical evaluation that would warrant deferring the evaluation including (g) Pregnancy Recommendations to language enhancement
A female employee who is assigned to regular fire line duty shall report a pregnancy immediately to their respective Supervisor and the fire department physician The employee will then be given the option of a non-hazardous alternative duty position for the duration of her pregnancy (can we say this or is it even appropriate) Any pregnant employee wishing to remain on regular line duty shall be informed of the possible risks and consequences to herself and her fetus that are associated with continued line fire fighting duty Among those risk factors are exposure to teratogens known to have negative effects on the developing fetus such as smoke diesel fumes hazardous chemicals and extreme heat
49
Page 2
appendix It is recommended that the pregnant employee complete a release of liability form signed by herself and her health care provider utilizing NFPArsquos 13 critical tasks as a reference This will inform the health care provider of specific job-related tasks that will need to be performed in order to continue regular line duty These tasks are basic physical standards that any entry level firefighter would have to be able to complete competently The employeersquos health condition will be kept confidential by the department in accordance with HIPAA standards Employees are allowed to remain on active regular duty until they are no longer able to perform their duties in a reasonable manner andor their protective gear no longer fits correctly It is the responsibility of the health care provider to evaluate the pregnant employee If at any time the health care provider feels the pregnant employee can no longer perform the job related tasks this should be reported to the employer by the employee immediately
50
ATTACHMENT G
51
From GLENN BENARICKTo Sawyer SteveSubject RE RE 7743Date Monday August 30 2010 21633 PM
Yes thats my understanding
Glenn P Benarick 211 Winged Elm CircleAiken SC 29803803-644-7093gbenarprodigynet
--- On Mon 83010 Sawyer Steve ltssawyerNFPAorggt wrote
From Sawyer Steve ltssawyerNFPAorggtSubject RE RE 7743To GLENN BENARICK ltgbenarprodigynetgtDate Monday August 30 2010 212 PM
So it should be ldquoorrdquo instead of ldquoandrdquo for now
Steven F Sawyer
Senior Fire Service Specialist
Executive Secretary IFMAFire Service Section
NFPA
1 Batterymarch Park
Quincy MA 02169
6179847423
Fax 6179847056
ssawyernfpaorg
From GLENN BENARICK [mailtogbenarprodigynet] Sent Monday August 30 2010 1202 PMTo Sawyer SteveSubject Fw RE 7743
52
Steve a couple of our docs agree with April Boyer
Glenn P Benarick 211 Winged Elm Circle
Aiken SC 29803
803-644-7093
gbenarprodigynet
--- On Mon 83010 David Prezant ltprezandfdnynycgovgt wrote
From David Prezant ltprezandfdnynycgovgtSubject RE 7743To Thomas R (CDCNIOSHDSHEFS) Hales lttrh1cdcgovgt GLENNBENARICK ltgbenarprodigynetgtCc Sandy Bogucki ltsandyboguckiyaleedugtDate Monday August 30 2010 1004 AM
agree
we should change this to NHANES III rather than Knudson we should alsomodify this to allow not only for predicted cutoffs but all for use of thelower limit of normal cutoff This is important to prevent false-classificationof spirometry as abnormal in older groups and in taller grps The latter ofparticular import to firefighter occupational health surveillance
thanks
David Prezant MDChief Medical Officer Office of Medical AffairsCo-Director WTC Medical Monitoring amp Treatment ProgramsNew York City Fire Department9 Metrotech Center - Rm 4W-1Brooklyn NY 11201Phone 718-999-2696Fax 718-999-0665
Life is full of twists and turns
53
This email may contain confidential information If you are the unintendedrecipient of this email please send it back and delete from your directory
gtgtgt Hales Thomas R (CDCNIOSHDSHEFS) lttrh1cdcgovgt 8302010955 AM gtgtgt
Glen
This seems like a very reasonable comment and illustrates the importance of having clinicians providefeedback on the std Im not familiar with the software program of the various spirometers (NHANES IIIvs KnudsonATS vs both) Given the large role both Dave Prezant and Sandy Bogucki had for thepulmonary section let me forward to them for clarification
Tom
From GLENN BENARICK [mailtogbenarprodigynet] Sent Sunday August 29 2010 456 PMTo Hales Thomas R (CDCNIOSHDSHEFS)Subject FW 7743
Tom is April Boyer correct
Glenn P Benarick 211 Winged Elm Circle
Aiken SC 29803
803-644-7093
gbenarprodigynet
--- On Thu 82610 Sawyer Steve ltssawyerNFPAorggt wrote
From Sawyer Steve ltssawyerNFPAorggtSubject FW 7743To GLENN BENARICK ltgbenarprodigynetgtDate Thursday August 26 2010 925 PM
FYI Do you have any answer She is write
Steven
54
Steven F Sawyer
Senior Fire Service Specialist
Executive Secretary IFMAFire Service Section
NFPA
1 Batterymarch Park
Quincy MA 02169
6179847423
Fax 6179847056
ssawyernfpaorg
From April Boyer [mailtoaboyerbicclinicorg] Sent Thursday August 26 2010 232 PMTo Sawyer SteveCc RobinMWebbmilstateorusSubject 7743
Steven
The spirometry tests cannot be corrected according to both references as the NFPA states because thereferences are contradictory The first part of 7743 states to follow the ATS guidelines and use theKnudsen (we at Basin Immediate Care use the Nhanes III) The second part states to follow the ACOEMguidelines and use the Nhanes III in the occupational setting if available with your unit (which is availableon ours) 7743 does not use the word OR regarding both requirements it uses the word AND whenreferring to the first and second parts thence making 7743 contradictory I realize the NFPA 1582 hasnot been updated since 2007 unless I have just not received an updated version
Our question to you is which part of 7743 do you want us to follow the first or the second part Anyfacility that has an updated computerized spirometry system (as we do) will not be able to follow bothrequired parts for obvious reasons We can either follow the first part of 7743 and use an oldercorrected version of the Knudson by going into our system and changing out of the Nhanes III conversionOR we can follow the second part of 7743 and use the newer corrected version of Nhanes III which ourunit offers too
If you have any questions you may contact me at anytime and I also have many references in regards toboth parts of 7743 if you would like to see them
55
Thank you~
April
Confidentiality NoticeThis message may contain information that isconfidential or privileged
If you are not the intended recipientPlease advise the sender immediately and delete this message
56
ATTACHMENT H
57
NFPA 1582 771(7) Proposed revisions
Why
Preliminary results of two prospective randomized trials on the PSA test were published in 2009 These studies resulted in medical organizations that previously providing guidance to modify their recommendations
Current language
771 Blood Tests Blood tests shall be performed annually and shall include the following
(7) Prostate specific antigen (PSA) after age 40 for positive family history if African American or if otherwise clinically indicated after age 50 for all other male member
Suggested Revision
771 Blood Tests Blood tests shall be performed annually and shall include the following
(7) Prostate specific antigen (PSA) after age 40 for positive family history if African American or if otherwise clinically indicated after age 50 for all other male member
772 Prostate-Specific Antigen (PSA) test At age 50 fire fighters shall have an opportunity to make an informed decision with either the Fire Department physician or their health care provider concerning the PSA test For fire fighters at increased risk of prostate cancer (African-Americans or those with a first degree relative diagnosed with prostate cancer before age 65) shall have the opportunity for this informed decision at age 40
A772 The PSA as a screening test for prostate cancer in asymptomatic men is controversial controversial for two reasons First there is no consensus that PSA screening actually saves lives For example the PSA test may detect small cancers that would never become life threatening Second it is unclear that the benefits of PSA screening outweigh the risks of follow-up diagnostic tests and cancer treatments For example the prostate biopsy used to diagnose prostate cancer may cause bleeding and infection And prostate cancer treatments such as surgery and radiation therapy may cause incontinence (inability to control urine flow) erectile dysfunction (erections inadequate for intercourse) and other complications For these reasons it is important that the benefits and risks of prostate diagnostic procedures and treatment be taken into account when considering the PSA screening test These considerations can be taken account during discussions with the fire department physician or onersquos health care provider
D211 Cancer Screening
Smith R A C J Mettlin K J Davis and H Eyre 2000 ldquoAmerican Cancer Society guidelines for the early detection of cancerrdquo CA J Clin 50(1)34ndash49
Added references
58
Carroll P Albertsen PC Greene K et al [2010] Prostate-specific antigen best practice statement 2009 update Am Urological Assoc Available at httpwwwauanetorgcontentguidelines-and-quality-careclinical-guidelinesmain-reportspsa09pdf Date accessed September 2010
Ferrini R Woolf SH [2009] Screening for prostate cancer in American men American College of Preventive Medicine Practice Policy Statement Available at httpwwwacpmorgprostatehtm Date accessed September 2010
National Cancer Institute [2009] Prostate-specific antigen test National Cancer Institute Fact Sheet Available at httpwwwcancergovcancertopicsfactsheetDetectionPSA Date accessed September 2010
Wolf AMD Wender RC Etzioni RB et al [2010] American Cancer Society guideline for the early detection of prostate cancer Update 2010 Available at httpcaonlineamcancersocorgcgicontentfullcaac20066v1 Date accessed September 2010
59
Address List 9172010
Fire Service Occupational Safety and Health FIX-AAAKenneth Willette
Michael W Smith
FIX-AAAAlternateNational Volunteer Fire Council
855 Eastlake Boulevard
Carson City NV 89704
National Volunteer Fire CouncilPrincipal Philip C Stittleburg
FIX-AAANonvoting MemberNational Institute for Occupational Safety amp Health
4676 Columbia Parkway R-9
Cincinnati OH 45226
Alternate Jay L TarleyPhoneCell 513-841-4583
Fax 513-844-4488
Email thalescdcgov
RT 452001
William R Hamilton
FIX-AAANonvoting MemberUS Department of Labor
Occupational Safety amp Health Administration
200 Constitution Ave NW Room N3609
Washington DC 20210
Alternate Andrew LevinsonPhoneCell 202-693-2077
Fax 202-693-1663
Email hamiltonbilldolgov
E 342009 Andrew Levinson
FIX-AAAAlt to Nonvoting MemberUS Department of Labor
Occupational Safety amp Health Administration
200 Constitution Ave NW Room N3718
Washington DC 20210
Occupational Safety amp Health AdministrationPrincipal William R Hamilton
PhoneCell 202-693-2048
Fax 202-693-1678
Email levinsonandrewdolgov
E 7282006
Jay L Tarley
FIX-AAAAlt to Nonvoting MemberUS Department of Health amp Human Services
National Institute for Occupational Safety amp Health
1095 Willowdale Road MS 1808
Morgantown WV 26505
Principal Thomas R HalesPhoneCell 304-285-5858
Fax 304-285-5774
Email jst9cdcgov
RT 3152007 Kenneth Willette
FIX-AAAStaff LiaisonNational Fire Protection Association
1 Batterymarch Park
Quincy MA
PhoneCell 617-984-7299
Fax 617-984-7056
Email kwillettenfpaorg
792010
68
ATTACHMENT B
9
Technical Committee on Fire Service Occupational Safety and Health
Meeting Minutes May 13 ndash 14 2010
Holiday Inn Inner Harbor MD
Attendees Glenn Benarick Chairman Ken Holland Staff Liaison Michael Finkelman Craig Fry Joe Rivera Stephen Raynis Steve Kreis Dennis Childress Don Stewart Phil Stittleburg David Ross Michael Laton Kim Zagaris Tom Hillenbrand Dominic Colletti Andy Schwartz Brett Bowman Guest David Bernzweig Thursday May 13 NFPA 1500 task groups (Vehicle amp Safety OPS SCBA amp Air Mgt PPEProximity) met to discuss the work they have completed since the last meeting The task groups will present their report to the entire TC on May 14th Not enough 1582 task group members were able to make the meeting so there were no reports or work from those task groups Friday May 14 TC meeting called to order at approximately 0800 by Glenn Benarick TC Chair Ken Holland (NFPA Public Fire Protection Staff) in attendance filling in for Frank Florence Ken made two presentations one on the Codes and Standards Development Process and the other on the general procedures for this Pre-ROP meeting The Staff Liaison remains fluid as Frank is not expected back any time soon
10
One guest in attendance Dave Bernzweig (Columbus OH Fire) Dave is assisting TC with SCBAAir Mgt issues The document revision cycles remain as requested NFPA 1500 amp 1582 Annual 2012 NFPA 1521 amp 1561 Fall 2013 NFPA 1581 1583 1584 Annual 2014 The October 7-9 2010 dates are the primary request for our next meeting Location is San Diego Notice will be sent out as soon as approval is received Discussion on the next revision of 1561 will be held at the October meeting regarding changing the document title to ldquoCommand Safety for Fire Department Operationsrdquo This is a suggestion of the TC Chair Ken Holland conducted a briefing for the TC on how to access and use the committee web page Staff will be posting as much information as possible up on the e-committee page for the entire committee More use will be made of this tool Discussion on monocular vision Dennis Childress presented the current issue in Ventura County CA Further discussionwork may be necessary Don Stewart agreed to take the lead Brief discussion held on pregnancy and the need for fire departments to ensure policies match current law The rep from the Diabetes Association declined the invitation to participate at this meeting due to no discussion of the issue planned She has indicated a desire to attend the October meeting There were no reports from these and all other 1582 task groups It is very important for the 1582 TG Chairs to be ready to report in October The following task group reports will be posted on the ecommittee page PPEProximity New definition of proximity fire fighting
VehicleHighway OPS Discussion on use of vehicle data recorders Collapse Zones Submission from Jay Tarley SCBAAir Mgt New exit strategy for SCBA Discussion on having the low air alarm activate when the bottle volume reaches 600 liters Further discussion to take place on ldquobuddy breathingrdquo
On Day 2 Casey Grant (NFPA Fire Protection Research Foundation) made a presentation on Research Planning for FSOSH Dr Ellen Sogolow (DHSFEMA) also present during this presentation She discussed the role of the AFGRampD activities See ecommittee page for his presentation Chair
11
will be in contact with Mr Grant for future work between the TC and the Foundation Also on Day 2 Ken Willette (Division Manager ndash NFPA Public Fire Protection Division) delivered a presentation on the initiative developed by Kelvin Cochran (US Fire Administrator) to reduce fire fighter injuries and deaths NFPA 1500 is an integral part of this initiative See ecommittee page for presentation The Chair will be coordinating a committee conference call in the coming weeks The purpose will be to review the work which needs to be completed for the October meeting The primary focus of the call will be on 1582 issues NOTE Subsequent to the meeting I have had some discussions with a fire chief in Kentucky on the use of hearing aids The TC especially the doctors need to review the current language in 1582 and decide if revisions are needed Also most of you know that Kelvin Cochran has left the USFA unexpectedly to return to Atlanta as their fire chief I have been in contact with the Acting Administrator Glenn Gaines to inform him that our committee remains focused on the work to reduce fire fighter injuries and deaths I told him that I would keep him informed of our work He indicated that one of his primary goals is to bring fire service organizations together in order to create a safe working environment Of particular interest to him is reducing heart related injuries and deaths Submitted by Glenn Benarick
12
Technical Committee on Fire Service Occupational Safety and Health
Conference Call Meeting Minutes August 30th 2010
Members participating
Glenn Benarick TC Chair
Murrey Loflin Secretary Dr Sandy Bogucki
Thomas Cuff Stephen Foley
Scott Kerwood Tammy Lopes
David Love Dr David Prezant
Joe Rivera David Ross
Mario Rueda Phil Stittleburg
Phil Vorlander Dominic Colletti
Thomas Hillenbrand
Denise Smith Brett Bowman Alternate
Andrew Schwartz Alternate Mike Young Alternate
Dr Thomas Hales Non-Voting Member Ken Holland NFPA Staff Liaison
Casey Grant NFPAResearch Foundation Staff Katie Hathway Guest from ADA
Dr Jim Fleming Guest from Phoenix Fire Dept
The chair welcomed everyone to the conference call in which he hoped
would last only an hour The purpose was to discuss any task groups that had reports for proposed changes to NFPA 1582 for the
committee This is in hopes to ensure the committee is ready for their
pre-ROP meeting in October The following topics were discussed and are in no specific order
Comments from ADA Katie Hathaway and the group went into deep
discussion regarding ones medical history and diagnosis of diabetes
13
and some proposed changesremoval of text based on research
findings The specific proposed changes will be available for the committee at their next meeting Some members on the call felt that
this issue was covered in another law enforcement document which might better serve this issue
Research topics for FSOSH projects Casey Grant offered his time to
answer any questions regarding his presentation from the May meeting in Baltimore There was also discussion about further
involvement of the Research Foundation with this committee and some of the medical requirements within the documents Glenn and Casey
are going to be in contact offline to discuss this further
Prosthetics amp Amputees report Nothing new to report
Heart amp Hypertension report There was discussion about the need for
periodic EKGrsquos that were done both in resting and non-resting states as well as discussion about stress test requirements and frequency of
such tests The hopes were to develop text that would point to annual versus periodic evaluations of EKGrsquos and stress tests
Epilepsy report Nothing new to report
Pregnancy report The initial textlanguage has been provided to the
group through email and e-committee page posting
Coagulation amp Meds report Nothing new to report
Hearing Aid discussion Nothing new to report
The committee also discussed the evaluation and documentation of
PSA results and test requirements for the purposes of consistency The proposed text and changes have been posted on the e-committee
page as well
All of the proposed text changes from the May meeting in Baltimore have been emailed out and posted on the e-committee page If there
are any questions or concerns that something was missed please contact Glenn Steven Sawyer or Ken Holland to ensure they are
resolved
The conference call lasted approximately an hour and was adjourned at 1400 hours
14
ATTACHMENT C
15
2012 ANNUAL REVISION CYCLE
PROCESS STAGE PROCESS STEP DATES
FOR TC DATES
FOR TCC 1 PRELIMINARY 10 Notification of intent to enter cycle 7910 7910
2 REPORT ON
PROPOSALS (ROP)
21 Proposal closing date 112310 112310 22 Final date for ROP meeting 22511 2411 23 Final date for mailing TC ballots 31811 21811 24 Receipt of (TC) ballots by staff liaison 42211 31111 25 Receipt of TC recirculation ballots 5611 31811 26 Final date for TCC meeting 41511 27 Final date for mailing TCC ballots 42211 28 Receipt of TCC ballots 51311 29 Receipt of TCC recirculation ballots 52011 210 Final copy (w ballot statements) to Secretary Standards Council 51311 52711 211 Completion of Reports 52011 6311 212 ROP Published and Posted 62411 62411
3 REPORT ON
COMMENTS
(ROC)
31 Comment closing date 83011 83011 32 Final date for ROC meeting 11411 10711 33 Final date for mailing TC ballots 111811 102111 34 Receipt of (TC) ballots by staff liaison 12211 111111 35 Receipt of TC recirculation ballots 12911 111811 36 Final date for TCC meeting 121611 37 Final date for mailing TCC ballots 122311 38 Receipt of TCC ballots 11312 39 Receipt of TCC recirculation ballots 12012 310 Final copy (w ballot statements) to Secretary Standards Council 122311 12712 311 Completion of Reports 11312 2312 312 ROC Published and Posted 22412 22412
4 TECH SESSION
PREPARATION amp
ISSUANCE OF
CONSENT
DOCUMENTS
41 Notice of Intent to Make a Motion (NITMAM) Closing Date 4612 4612 42 Posting of Filed NITMAM 5412 5412
43 Council Issuance Date for Consent Documents 52912 52912
44 Appeal Closing Date for Consent Documents 61312 61312
5 TECHNICAL
SESSION 50 Association Meeting for Documents with Certified Amending Motions
64-712 64-712
6
APPEALS amp
ISSUANCE OF
DOCUMENTS
WCAMS
61 Appeal closing date for Documents with Certified Amending Motions
62712 62712
62 Council issuance for Documents with Certified Amending Motions 8912 8912
Proposal Closing Dates may vary according to documents and schedules for Revision Cycles may change Please check the NFPA website (wwwnfpaorg) for the most up-to-date information on proposal closing dates and schedules
16
ATTACHMENT D
17
This weekrsquos conference call mentioned the Diabetes chapter written for the ACOEM document Guidance for the Medical Evaluation of the Law Enforcement Officer The task group working on this chapter (led Richard Miller of the Secret Service and our very own Dan Samo) worked with the ADA or over 2-3 years to come up with a consensus document
Please find the Chapter attached ltltDiabetes Guidance Sept 2010pdfgtgt
Regarding Dan Loeberrsquos points
1) Physical Evaluation Form - We could modify the LEO form (see end of the attached Chapter)
2) Duration required for stable regiment
1582 for IDDM Type 1 1 yr
Type 2 6 m
Oral Agents None specifically
ACOEM Police for IDDM Type 1 6m
Type 2 3m
Oral Agents 1m
The police document is much clearer about the decision regarding medical fitness for duty is the responsibility of the police physician with the treating diabetes-expert physician providing the data to the police physician to make an informed decision In this regard the police officer must provide the police physician with downloaded self monitoring glucose data for the 1 3 and 6 month time periods (see section 433)
3) HA1C ndash NFPA lt 8 over 3 month period
ACOEM Police ndash (Section 4333) Specifies the frequency on measurement and if gt8 requires further evaluation
Some other discrepancies End organ complications
NFPA ndash end organ complications (eye kidney heart neuro) ndash restriction
ACOEM Police ndash end organ complication -- requires further evaluation
18
Hypoglycemia (incapacitating ndash defined differently between the two documents (434)
NFPA ndash 0 episodes in past year le1 in past 5 yrs
ACOEM Police ndash 0 episodes in past year le2 in past 3 yrs
Given Dan Samorsquos and Richard Millerrsquos work with the ADALoeber it would be helpful to get their opinions on whether any of the changes requested by Loeber are appropriate for FF with DM
Tom
Thomas Hales MD MPH
Senior Medical Epidemiologist
NIOSH CDC
4676 Columbia Pkwy R-9
Cincinnati OH 45241
(513) 841-4583
trh1cdcgov
19
43 ndash DIABETES MELLITUS
431 ndash INTRODUCTION
The educated and motivated law enforcement officer (LEO) with well-managed diabetes mellitus can be capable of
safe and effective job performance1 However diabetes mellitus may place LEOs at risk for sudden incapacitation
thus jeopardizing their ability to perform critical job functions (These job functions include those listed in Sections
32 333 351 352 36 and 37 and discussed in Appendix A)
Therefore an individualized assessment of the LEOrsquos diabetes should be performed using the following evaluative
criteria to determine whether the individuals condition permits safe and effective job performance Such evaluation
must include the following key elements which are discussed in detail below
history of blood glucose control
knowledge of diabetes and its management
current stability of blood glucose
risk for significant hypoglycemia or hyperglycemia and
presence of diabetic complications
432 ndash OVERVIEW OF MEDICAL EVALUATION
The treating endocrinologist or other physician knowledgeable regarding diabetes management should provide
a narrative report certifying whether the LEO has or has not met the criteria set out in Sections 4321 through
4354 below In addition the physician should include supporting data (see Appendix B for the Physician Evalu-
ation Form)
4321 The LEO is under the care of an endocrinologist or other physician knowledgeable regarding diabetes
management Outpatient and in-patient medical record(s) for the last 3 years or since date of diagnosis
(whichever is shorter) should be reviewed by the treating physician and provided to the police physician
4322 If the LEO has type 1 diabetes the individual has been on a basalbolus regimena or an insulin pump
using analogue insulins for the 6 months prior to evaluation2
4323 If the LEO has type 2 diabetes on insulin the individual has been on a stable medication regimenb
for the 3 months prior to evaluation3 If on oral agents alone the LEO has been on a stable medication regimen
for the month prior to evaluationc
ACOEM Guidance for the Medical Evaluation of Law Enforcement Officers 1
43 ndash DIABETES MELLITUS
aA basalbolus insulin regimen consists of the use of a basal insulin (Glargine NPH) in a once or twice daily regimen to provide between-
meal insulin combined with the use of a short acting insulin (Regular Lispro Aspart or Glulisine) at mealtimes Insulin pumps are small
(beeper sized) battery powered devices that deliver small amounts of short-acting insulin in a constant infusion to meet basal insulin
requirements The wearer selects an additional mealtime bolus to be infused at the time of meals For more information on pumps visit
the manufacturerrsquos web sites ndash wwwMinimedcom wwwcozmorecom wwwanimascorpcom wwwdisetroniccom
bA stable insulin regimen is defined as maintaining the same types of insulin (long acting intermediate acting short or rapid acting)
Changes in insulin dose are part of the appropriate self-management of diabetes and do not disqualify an applicant or incumbent under
this section
cChanges in dose within the evaluation period will be allowed but addition of a new class of medications or insulin should result in a new
period of observation
one month for addition of a sulfonylurea or metformin
two months for the addition of a thiazolidinedione to insulin or a sulfonylurea or
three months for the addition of insulin
20
4324 If the LEO uses an insulin pump documentation is needed as follows
proper understanding and education in the use of the insulin pump
start date for the use of the pump
history of insulin site infectionsd
history of pump cessation and pump malfunction
backup plan for pump malfunction including use of injectable insulin and
frequency of infusion set changes
4325 The LEO has been educated in diabetes and its management and thoroughly informed of and under-
stands the procedures that must be followed to monitor and manage hisher diabetes and what procedures
should be followed if complications arise3
433 ndash QUANTITATIVE GLUCOSE MONITORING
4331 The LEO has documentation of ongoing self-monitoring of blood glucose
4332 This must be done with a glucose meter that stores every reading records date and time of reading
and from which data can be downloaded (Most meters now have this capability)
4333 Monitoring logs must be available covering the time period (1 3 or 6 months) as described in
Sections 4322 and 4323 The frequency of glucose monitoring must follow a schedule acceptable to the
police physician in consultation with the treating physician
Testing schedules are individual What follows is a common pattern but individual patterns may differ
2 ACOEM Guidance for the Medical Evaluation of Law Enforcement Officers
43 ndash DIABETES MELLITUS
dIndividual has not had more than one pump-site infection that caused him or her to miss work or usual daily activities in the preceding 6
months
THERAPEUTIC REGIMEN GLUCOSE TESTING SCHEDULE
Diet alone Once or twice a week
Metformin Thiazolidinediones or Alpha
Glucosidase inhibitors alone or in
combination
Once or twice a week
Sulfonylureas meglitanides nateglinide ndash
alone or in combination with the above group
Twice a day ndash AM and at supper with any
suspected hypoglycemic episodes
Insulin ndash one shot in combination with orals Twice a day ndash AM and at supper with any
suspected hypoglycemic episodes
2 to 3 times AM once a week
Insulin ndash two or more shots Insulin pump 3 to 4 times a day ndash at meals and bedtime
2 to 3 times AM once a week with any
suspected hypoglycemic episodes
21
4334 The LEO has had hemoglobin A1C measured at least 4 times a year (intervals of 2 to 3 months) over
the last 12 months prior to evaluation if diagnosis has been present for more than a year4 If hemoglobin A1C is
gt8 this may signal a problem with the LEOrsquos diabetes management that warrants further assessment5
434 ndash INCAPACITATING EVENTS
4341 The LEO has not had any incapacitating episodes within the past 1 year and no more than 2 episodes
in the past 3 years or since diagnosis of diabetes (whichever is shorter) of
43411 Severe hypoglycemia (loss of consciousness seizures or coma requiring assistance of others or
needing urgent treatment [glucagon injectionIV glucose]) or
43412 Blood sugar lt60 mgdl with unawareness demonstrated in current glucose logs6
435 ndash CHRONIC COMPLICATION SCREENING
4351 Chronic complications of diabetes are associated with increased risk for severe hypoglycemic
episodes and warrant further assessmente
4352 The components of screening for chronic complications are
43521 A complete eye exam by a qualified ophthalmologist or optometrist including a dilated retinal
exam demonstrating no more than mild background diabetic retinopathyf7
43522 Normal vibratory testing with a 128 Hz tuning forkg normal testing with 10 gram Semmes-
Weinstein monofilamentg and normal orthostatic blood pressureh and pulse testing89
ACOEM Guidance for the Medical Evaluation of Law Enforcement Officers 3
43 ndash DIABETES MELLITUS
ePresence of chronic complications of diabetes in and of themselves may not require the implementation of work restrictions
fNo more than one dot blot or flame-shaped hemorrhages or microaneurysm in all four fundus quadrants
gThe Michigan Diabetes Research and Training Center of the University of Michigan Health System recommends the following guidance
(see wwwmedumichedumdrtcprofsdocumentssviMNSI_howtopdf) for conducting vibratory and monofilament testing8
Vibration Sensation Vibration sensation should be performed with the great toe unsupported Vibration sensation will be tested bi-
laterally using a 128 Hz tuning fork placed over the dorsum of the great toe on the boney prominence of the DIP joint Patients whose
eyes are closed will be asked to indicate when they can no longer sense the vibration from the vibrating tuning fork In general the
examiner should be able to feel vibration from the hand-held tuning fork for 5 seconds longer on his distal forefinger than a normal subject
can at the great toe (eg examiners DIP joint of the first finger versus patients toe) If the examiner feels vibration for 10 or more seconds
on his or her finger then vibration is considered decreased A trial should be given when the tuning fork is not vibrating to be certain that
the patient is responding to vibration and not pressure or some other clue Vibration is scored as 1) present if the examiner senses the
vibration on his or her finger for lt10 seconds 2) reduced if sensed for 10 seconds or 3) absent (no vibration detection)
Monofilament Testing For this examination it is important that the patients foot be supported (ie allow the sole of the foot to rest on
a flat warm surface) The filament should initially be pre-stressed (4-6 perpendicular applications to the dorsum of the examiner s first
finger) The filament is then applied to the dorsum of the great toe midway between the nail fold and the DIP joint Do not hold the toe
directly The filament is applied perpendicularly and briefly (lt1 second) with an even pressure When the filament bends the force of
10 grams has been applied The patient whose eyes are closed is asked to respond yes if heshe feels the filament Eight correct responses
out of 10 applications is considered normal 1 to 7 correct responses indicates reduced sensation and no correct answers translates into
absent sensation
hOrthostatic hypotension is a physical finding defined by the American Autonomic Society and the American Academy of Neurology as a
systolic blood pressure decrease of at least 20 mm Hg or a diastolic blood pressure decrease of at least 10 mm Hg within 3 minutes of
standing
22
43523 Normal cardiac physical exam Cardiac stress testing to at least 12 METS is recommended and
should begin based on either the criteria of the American Heart AssociationAmerican College of
Cardiologyi10 or those of the American Diabetes Associationj11
Diabetics who have a normal cardiac stress test will be retested every one to three years based on
individual clinical assessment This assessment should consider
the age of the individual
the number and persistence of coronary artery disease (CAD) risk factors
the severity of CAD risk factors
43524 Microalbumincreatinine ratio 301 measured or calculatedk creatinine clearance
gt60 mlmin12
436 ndash ONGOING EVALUATION AND REQUIREMENTS
4361 Should have medical records and glucose meter logs reviewed periodically Because of the nature of
diabetes it is important that regular medical follow up be provided to the LEO The frequency and content of
the evaluation should be determined on an individual basis by the police physician in consultation with the
treating physicianl
4362 Must advise police physician of any change in type of medication
4363 Must advise police physician of any episodes of significant hypoglycemia or hyperglycemia
Urine microalbumincreatinine ratio _________________
III Treating Physician Statement
The above named individual meets all of the criteria provided on this form
Yes No ndash not recommended for position
No but IS recommended for position (letter of explanation attached)
It is my opinion that the above named individual is well-educated and well-motivated in diabetes self-management and has
achieved a level of diabetes management to be capable of safe and effective job performance as a law enforcement officer
I have reached this opinion after careful review of the above criteria
___________________________________________________________ ___________________________Signature of Physician Date
______________________________________________________________ ___________________________Printed or Typed Name of Physician Telephone Number
10 ACOEM Guidance for the Medical Evaluation of Law Enforcement Officers
43 ndash DIABETES MELLITUS
29
439 ndash REFERENCES
1 American Diabetes Association Diagnosis and classification of diabetes mellitus Diabetes Care 200427 Suppl
1S5-S10 See httpcarediabetesjournalsorgcgicontentfull27suppl_1s5
2 American Diabetes Association Continuous subcutaneous insulin infusion Diabetes Care 200427 Suppl 1S110
See httpcarediabetesjournalsorgcgicontentfull27suppl_1s110
3 Mensing C Boucher J Cypress M et al National standards for diabetes self-management education Diabetes
Care 200528 Suppl 1S72-9 See httpcarediabetesjournalsorgcgicontentfull28suppl_1s72
4 Goldstein DE Little RR Lorenz RA Malone JI Nathan DM Peterson CM American Diabetes Association Tests
of glycemia in diabetes Diabetes Care 200427 Suppl 1S91-3
See httpcarediabetesjournalsorgcgicontentfull27suppl_1s91
5 The Diabetes Control and Complications Trial Research Group Hypoglycemia in the Diabetes Control and
Complications Trial Diabetes 199746(2)271-86 See wwwncbinlmnihgovpubmed9000705 for abstract
6 American Diabetes Association Hypoglycemia and employmentlicensure Diabetes Care 200528 Suppl 1S61
See httpcarediabetesjournalsorgcgicontentfull28suppl_1s61
7 Viswanath K McGavin DD Diabetic Retinopathy Clinical Findings and Management J Comm Eye Health
200316(46)21-4 See wwwcehjournalorg0953-683316jceh_16_46_021html
8 Michigan Diabetes Research and Training Center University of Michigan Health System How to use the Michigan
Neuropathy Screening Instrument See wwwmedumichedumdrtcprofsdocumentssviMNSI_howtopdf
9 Bradley JG Davis KA Orthostatic hypotension Am Fam Physician 200368(12)2393-8
See wwwaafporgafp200312152393html
10 Gibbons RJ Balady GJ Bricker JT et al ACCAHA 2002 guideline update for exercise testing a report of the
American College of CardiologyAmerican Heart Association Task Force on Practice Guidelines (Committee on
Exercise Testing) J Am Coll Cardiol 200240(8)1531-40
See wwwaccorgqualityandscienceclinicalguidelinesexerciseexercise_cleanpdf
11 American Diabetes Association Standards of medical care in diabetes Diabetes Care 200528 Suppl 1S4-S36
Erratum in Diabetes Care 200528(4)990 See httpcarediabetesjournalsorgcgicontentfull28suppl_1s4
12 Molitch ME DeFronzo RA Franz MJ et al American Diabetes Association Nephropathy in diabetes Diabetes
Care 200427 Suppl 1S79-83 See httpcarediabetesjournalsorgcgicontentfull27suppl_1s79
13 Kitabchi AE Umpierrez GE Murphy MB et al American Diabetes Association Hyperglycemic crises in diabetes
Diabetes Care 200427 Suppl 1S94-102 See httpcarediabetesjournalsorgcgicontentfull27suppl_1s94
14 US Centers for Disease Control and Prevention National Diabetes Fact Sheet 2007
See wwwcdcgovdiabetespubspdfndfs_2007pdf
ACOEM Guidance for the Medical Evaluation of Law Enforcement Officers 11
43 ndash DIABETES MELLITUS
30
ATTACHMENT E
31
Typos A6921(2) 7th line down test should be plural 94201 Paragraph 2 target organ damage is used though end organ damage was defined earlier and in the appendix for that paragraph
A94201 Para A (1) d Id suggest deleting the phrases in brackets Im not sure either are predictably true or politically wise
a) tests for left ventricular hypertrophy Unfortunately use of the EKG to detect left ventricular hypertrophy is very insensitive (eg 5 sensitivity) The echocardiogram is the best test for diagnosing left ventricular hypertrophy but [it is relatively expensive and not readily available in small rural communities ] conducting echocardiograms on asymptomatic fire fighters with Stage 1 hypertension should be reserved only for those with long-standing hypertension
In addition
7761 A resting EKG shall be performed as part of the baseline medical evaluation and shall be obtained periodically thereafter
Changing from annually to periodically is noted has the language in the wellness-fitness initiative been changed as well Our previous decision was that we would support the W-F language since there was no compelling evidence to either support or refute it
Thanks
Sandy
32
NFPA 1582‐ HTN Draft 1
Reason for Revision
1) New classification of BP by the Joint National Commission [Chobanian et al 2002]
2) A high prevalence of FF have either HTN (~20) and Pre‐HTN (~20) [Soteriades et al 2003]
3) Among FF studies have shown a strong association between HTN and a number of adverse
cardiovascular events [Kales et al 2009]
4) A large percentage of on‐duty FF fatalities were found to have left ventricular hypertrophy a
complication of HTN at autopsy
Language in 2007 Edition with draft revisions in Red (Track changes)
611 The medical evaluation of a candidate shall include a medical history examination and any laboratory tests required to detect physical or medical condition(s) that could adversely affect hisher ability to safely perform the essential job tasks outlined in 511 A611 The medical history should include the candidates known health problems such as major illnesses surgeries medication use and allergies Symptom review is also important for detecting early signs of illness A medical history should also include a personal health history a family health history a health habit history an immunization history and a reproductive history
An occupational history should also be obtained to collect information about the persons past occupational and environmental exposures
(a) BP should be measured according to the Joint National Commission (JNC) -7 recommendations BP should be measured with a properly calibrated and validated instrument Patients should be seated quietly for at least 5 minutes in a chair with feet on the floor and arm supported at heart level An appropriate-sized cuff (cuff bladder encircling at least 80 of the arm) should be used to ensure accuracy At least 2 measurements should be made Systolic BP is the point at which the first of 2 or more sounds is heard (phase 1) and diastolic BP is the point before the disappearance of sounds (phase 5) [Chobanian et al 2003]
(2) Head eyes ears nose and throat (HEENT)
Formatted Font (Default) Times New RomanFont color Black
33
692 Vascular System 6921 Category A medical conditions shall include the following
(1) Uncontrolled or poorly controlled hypertension
(2) Hypertension with evidence of end organ damage
or not controlled by approved medications
A6921(1) Uncontrolled or poorly controlled hHypertension increases the risk of a sudden cardiac event This sudden cardiac event would cause sudden incapacitation which that is uncontrolled poorly controlled or requires medication likely to interferes with the safe performance of essential job tasks Uncontrolled or poorly controlled hypertension can be defined as the presence of end organ damage (see below) or stage 2 hypertension (BP systolic gt160 mmHg or BP diastolic gt100 mmHg) is an illness that can lead to functional impairment and potential for sudden incapacitation Individuals with pre- stage 1 or stage 2 hypertension should be referred to their primary care physician for evaluation lifestyle modification and treatment [QUESTION FOR GROUP _- WHAT ABOUT HAVING CANDIDATE RETURN IN ONE MONTH UNDER TREATMENT WITH NORMAL BP]
A6921(2)
Chronic hypertension can damage the eye (retinopathy) the kidneys (nephropathy) the vascular system (stroke transient ischemic attack or peripheral artery disease) or the heart (left ventricular hypertrophy and heart failure) These hypertension complications are known as end organ damage The cardiac and vascular complications are associated with an increased risk of sudden incapacitation and sudden cardiac death (Koren et al 1991) Unfortunately the cardiac complications are frequently asymptomatic and valid screening tests are not fast and are not inexpensive Therefore determining who to screen for cardiac complications (such as echocardiogram for LVH or a measurement of left ventricular ejection fraction for heart failure) should be based on the severity and the duration of HTN
76 Physical Examination The annual physical examination shall include each of the following components
(a) BP shall be measured according to the Joint National Commission (JNC)-7 recommendations
A76(1)(a) BP should be measured with a properly calibrated and validated instrument Patients should be seated quietly for at least 5 minutes in a chair with feet on the floor and arm supported at heart level An appropriate-sized cuff (cuff bladder encircling at least 80 of the arm) should be used to ensure accuracy At least 2 measurements should be made Systolic BP is the point at which the first of 2 or more sounds is heard (phase 1) and diastolic BP is the point before the disappearance of sounds (phase 5) [Chobanian et al 2003]
(2) Head eyes ears nose and throat (HEENT)
34
9420 Uncontrolled Hypertension 94201 Physician Evaluation Severe uncontrolled hypertension [defined as systolic pressure greater than 180 mm Hg diastolic pressure greater than 100 mm Hg or mean systolic blood
pressure ( systolic + diastolic) greater than 120 mm Hg] or malignant hypertension (defined as hypertension with the presence of target organ damage) compromises the members ability to safely perform essential job tasks 1 5 7 9 and 13 and the physician shall report the applicable job limitations to the fire department
Members with Pre-hypertention (systolic 120-139 mmHg or diastolic 80-89 mmHg) Stage 1 hypertension (systolic 140-159 mmHg or diastolic 90-99 mmHg) or Stage 2 hypertension (systolic ge160 mmHg or diastolic ge100 mmHg) should be referred to their primary care physician for evaluation lifestyle modification and treatment
(1) Members with Stage I hypertension should be followed-up not only by their primary care physician but also by the FD physician every 3 to 6 months to ensure their blood pressure is under control and to determine whether screening tests for asymptomatic end organ damage are appropriate
(2) Members with Stage 2 hypertension or with end organ damage (retinopathy nephropathy vascular or cardiac complications) compromises the members ability to safely perform essential job tasks 1 5 7 9 and 130 and the physician shall report the applicable job limitations to the fire department
A94201 Severe uncontrolled hypertension is a significant risk factor for the development of coronary artery disease congestive heart failure and stroke Blood pressure increases as a normal response to exercise This response is further exaggerated by the emotional and physical stress of performing these critical tasks while operating in personal protective clothing at extremes of temperature This normal elevation of blood pressure under these response conditions can lead to life-threatening hypertensive emergencies if a members daily blood pressure is already elevated to high levels In addition hypertension is a progressive illness that when uncontrolled ultimately and inevitably leads to target organ damage Target organs that are sensitive to the effects of elevated blood pressure are the central nervous system vision heart major blood vessels and kidneys
Chronic hypertension can damage the eye (retinopathy) the kidneys (nephropathy) the vascular system (stroke transient ischemic attack or peripheral artery disease) or the heart (left ventricular hypertrophy and heart failure) These hypertension complications are known as end organ damage The cardiac and vascular complications are associated with an increased risk of sudden incapacitation and sudden cardiac death (Koren et al 1991) Fortunately with proper evaluation life style modification and treatment these complications can be avoided Life style modification includes weight reduction DASH eating plan reduction in dietary sodium an increase in aerobic physical activity and moderation in alcohol consumption [Chobanian 2003]
Formatted Font (Default) Times New Roman12 pt Font color Black
Formatted Font (Default) Times New Roman12 pt Font color Black
35
A94201 (1) Members with Stage I hypertension whose BP returns to either pre-hypertenion or normal with lifestyle modification andor treatment can return to an annual medical evaluation For members with long-standing Stage I hypertension whose BP has not been reduced additional evaluation for possible end organ damage should be considered This evaluation could include any or all of the following
a) a compete patient history for symptoms of heart failure (eg shortness of breath upon exertion) or transient ischemic attacks (TIAs)
b) dilated eye examination for retinopathy
c) blood creatinine measurement for nephropathy
d) tests for left ventricular hypertrophy Unfortunately use of the resting EKG to detect left ventricular hypertrophy is very insensitive (eg 5 sensitivity) The echocardiogram is the best test for diagnosing left ventricular hypertrophy
A 94201 (2) Due to the high risk of a sudden cardiovascular event members with Stage 2 hypertension should be restricted until their BP can be brought under control Once the BP is brought under control they should be followed in the same manner as a member with Stage I hypertension
Formatted Font (Default) Times New Roman12 pt
36
D22 Cardiology Gibbons R J GJ Balady J W Beasley et al 1997 ACCAHA guidelines for exercise testing a report of American College of CardiologyAmerican Heart Association Task Force on Practice Guidelines (Committee on Exercise Testing) J Am Coll Cardiol 30260ndash311
Gibbons RJ Balady GJ Bricker JT Chaitman BR Fletcher GF Froelicher VF Mark DB McCallister BD Mooss AN OrsquoReilly MG Winters WL Jr [2002] ACCAHA 2002 guideline update for exercise testing summary article a report of the ACCAHA Task Force on Practice Guidelines (Committee to Update the 1997 Exercise Testing guidelines) J Am Coll Cardiol 401531ndash 40
Chobanian AV Bakris GL Black HR Cushman WC Green LA Izzo JL Jr Jones DW Materson BJ Oparil S Wright JT Jr Roccella EJ the National High Blood Pressure Education Program Coordinating Committee [2003] The seventh report of the Joint National Committee [JNC-7] on Prevention Detection Evaluation and Treatment of High Blood Pressure JAMA 2892560ndash2571
Soteriades ES Kales SN Liarokapis D Christiani DC [2003] Prospective surveillance of hypertension in firefighters J Clin Hypertens 5315-320
Kales SN Tsismenakis AJ Zhang C Soteriades ES [2009] Blood pressure in fire fighters police officers and other emergency responders Am J Hypertens 2211-20
37
NFPA 1582‐ HTN Draft 1
Reason for Revision
1) New classification of BP by the Joint National Commission [Chobanian et al 2002]
2) A high prevalence of FF have either HTN (~20) and Pre‐HTN (~20) [Soteriades et al 2003]
3) Among FF studies have shown a strong association between HTN and a number of adverse
cardiovascular events [Kales et al 2009]
4) A large percentage of on‐duty FF fatalities were found to have left ventricular hypertrophy a
complication of HTN at autopsy
Language in 2007 Edition with draft revisions in Red (Track changes)
611 The medical evaluation of a candidate shall include a medical history examination and any laboratory tests required to detect physical or medical condition(s) that could adversely affect hisher ability to safely perform the essential job tasks outlined in 511 A611 The medical history should include the candidates known health problems such as major illnesses surgeries medication use and allergies Symptom review is also important for detecting early signs of illness A medical history should also include a personal health history a family health history a health habit history an immunization history and a reproductive history
An occupational history should also be obtained to collect information about the persons past occupational and environmental exposures
(a) BP should be measured according to the Joint National Commission (JNC) -7 recommendations BP should be measured with a properly calibrated and validated instrument Patients should be seated quietly for at least 5 minutes in a chair with feet on the floor and arm supported at heart level An appropriate-sized cuff (cuff bladder encircling at least 80 of the arm) should be used to ensure accuracy At least 2 measurements should be made Systolic BP is the point at which the first of 2 or more sounds is heard (phase 1) and diastolic BP is the point before the disappearance of sounds (phase 5) [Chobanian et al 2003]
(2) Head eyes ears nose and throat
38
692 Vascular System 6921 Category A medical conditions shall include the following
(1) Uncontrolled or poorly controlled hypertension
(2) Hypertension with evidence of end organ damage
A6921(1) Uncontrolled or poorly controlled hypertension increases the risk of a sudden cardiac event This sudden cardiac event would cause sudden incapacitation which interferes with the safe performance of essential job tasks Uncontrolled or poorly controlled hypertension can be defined as the presence of end organ damage (see below) or stage 2 hypertension (BP systolic gt160 mmHg or BP diastolic gt100 mmHg) Individuals with pre- stage 1 or stage 2 hypertension should be referred to their primary care physician for evaluation lifestyle modification and treatment [QUESTION FOR GROUP _- WHAT ABOUT HAVING CANDIDATE RETURN IN ONE MONTH UNDER TREATMENT WITH NORMAL BP]
A6921(2)Chronic hypertension can damage the eye (retinopathy) the kidneys (nephropathy) the vascular system (stroke transient ischemic attack or peripheral artery disease) or the heart (left ventricular hypertrophy and heart failure) These hypertension complications are known as end organ damage The cardiac and vascular complications are associated with an increased risk of sudden incapacitation and sudden cardiac death (Koren et al 1991) Unfortunately the cardiac complications are frequently asymptomatic and valid screening tests are not fast and are not inexpensive Therefore determining who to screen for cardiac complications (such as echocardiogram for LVH or a measurement of left ventricular ejection fraction for heart failure) should be based on the severity and the duration of HTN
76 Physical Examination The annual physical examination shall include each of the following components
(a) BP shall be measured according to the Joint National Commission (JNC)-7 recommendations
A76(1)(a) BP should be measured with a properly calibrated and validated instrument Patients should be seated quietly for at least 5 minutes in a chair with feet on the floor and arm supported at heart level An appropriate-sized cuff (cuff bladder encircling at least 80 of the arm) should be used to ensure accuracy At least 2 measurements should be made Systolic BP is the point at which the first of 2 or more sounds is heard (phase 1) and diastolic BP is the point before the disappearance of sounds (phase 5) [Chobanian et al 2003]
(2) Head eyes ears nose and throat9420 Hypertension 94201 Physician Evaluation Members with Pre-hypertention (systolic 120-139 mmHg or diastolic 80-89 mmHg) Stage 1 hypertension (systolic 140-159 mmHg or diastolic 90-99 mmHg) or Stage 2 hypertension (systolic ge160 mmHg or diastolic ge100 mmHg) should be referred to their primary care physician for evaluation lifestyle modification and treatment
39
(1) Members with Stage I hypertension should be followed-up not only by their primary care physician but also by the FD physician every 3 to 6 months to ensure their blood pressure is under control and to determine whether screening tests for asymptomatic end organ damage are appropriate
(2) Members with Stage 2 hypertension or with end organ damage (retinopathy nephropathy vascular or cardiac complications) compromises the members ability to safely perform essential job tasks 1 5 7 9 and 130 and the physician shall report the applicable job limitations to the fire department
A94201 Chronic hypertension can damage the eye (retinopathy) the kidneys (nephropathy) the vascular system (stroke transient ischemic attack or peripheral artery disease) or the heart (left ventricular hypertrophy and heart failure) These hypertension complications are known as end organ damage The cardiac and vascular complications are associated with an increased risk of sudden incapacitation and sudden cardiac death (Koren et al 1991) Fortunately with proper evaluation life style modification and treatment these complications can be avoided Life style modification includes weight reduction DASH eating plan reduction in dietary sodium an increase in aerobic physical activity and moderation in alcohol consumption [Chobanian 2003]
A94201 (1) Members with Stage I hypertension whose BP returns to either pre-hypertenion or normal with lifestyle modification andor treatment can return to an annual medical evaluation For members with long-standing Stage I hypertension whose BP has not been reduced additional evaluation for possible end organ damage should be considered This evaluation could include any or all of the following
a) a compete patient history for symptoms of heart failure (eg shortness of breath upon exertion) or transient ischemic attacks (TIAs)
b) dilated eye examination for retinopathy
c) blood creatinine measurement for nephropathy
d) tests for left ventricular hypertrophy Unfortunately use of the resting EKG to detect left ventricular hypertrophy is very insensitive (eg 5 sensitivity) The echocardiogram is the best test for diagnosing left ventricular hypertrophy
A 94201 (2) Due to the high risk of a sudden cardiovascular event members with Stage 2 hypertension should be restricted until their BP can be brought under control Once the BP is brought under control they should be followed in the same manner as a member with Stage I hypertension
D22 Cardiology
40
Hypertension
Gibbons RJ Balady GJ Bricker JT Chaitman BR Fletcher GF Froelicher VF Mark DB McCallister BD Mooss AN OrsquoReilly MG Winters WL Jr [2002] ACCAHA 2002 guideline update for exercise testing summary article a report of the ACCAHA Task Force on Practice Guidelines (Committee to Update the 1997 Exercise Testing guidelines) J Am Coll Cardiol 401531ndash 40
Chobanian AV Bakris GL Black HR Cushman WC Green LA Izzo JL Jr Jones DW Materson BJ Oparil S Wright JT Jr Roccella EJ the National High Blood Pressure Education Program Coordinating Committee [2003] The seventh report of the Joint National Committee [JNC-7] on Prevention Detection Evaluation and Treatment of High Blood Pressure JAMA 2892560ndash2571
Soteriades ES Kales SN Liarokapis D Christiani DC [2003] Prospective surveillance of hypertension in firefighters J Clin Hypertens 5315-320
Kales SN Tsismenakis AJ Zhang C Soteriades ES [2009] Blood pressure in fire fighters police officers and other emergency responders Am J Hypertens 2211-20
41
NFPA 1582‐ Draft Revisions for CVDHTN
EKG and stress tests
Reason for Revision
1) Change requirement for annual resting EKG to periodically to be more consistent with ACCAHA
recommendation (Schlant et al 1992)
2) Add language to clarify what constitutes a positive ST
3) Make criteria for conducting diagnostic ST in asymptomatic patients consistent with the
ACCAHA
Language in 2007 Edition with draft revisions in Red (Track changes)
776 Electrocardiograms (EKG)) and Stress Tests 7761 A resting EKG shall be performed as part of the baseline medical evaluation and shall be obtained periodically (every 1 to 5 years) annually thereafter
A7761 A baseline resting EKGs shall be conducted Follow-up resting EKGs should be conducted as clinically indicated but at a minimum of every 1 to 5 years The frequency of these follow-up resting EKGs should increase as a members age increases or with increasing number andor severity of coronary heart disease risk factors Members above the age of 40 should have annual resting EKGs (Schlant et al 1992)
7762 The fire department physician or other qualified medical evaluator shall compare EKGs obtained during yearly evaluations with baseline and subsequent EKGs
7763 Stress testing EKG with or without echocardiography or radionuclide scanning shall be performed as clinically indicated by history or symptoms
A7761 Baseline electrocardiography should be conducted (Periodic resting electrocardiograms have not been shown to be useful but can be reasonable as a members agefactors increase)
A7763 No firm guidelines for stress testingelectrocardiography in asymptomatic individuals have been developed Stress testingelectrocardiography as a screening tool is used as part of an evaluation of aerobic capacity during the annual occupational fitness evaluation Submaximal stress testingelectrocardiography testing to 85 percent is commonly used as part of this screening
Submaximal stress electrocardiography testing should not be used for diagnostic purposes Cardiology evaluation with maximal stress testingelectrocardiography together with imaging techniques (eg echocardiography technetium Tc99m sestamibi study andor coronary angiography) is necessary for diagnosticprognostic purposes for the following
42
(1) Fire fighters with positive or questionably positive changes on screening submaximal stress tests
(2) Fire fighters with new onset chest pain or other symptoms suggestive of coronary artery disease (CAD)
(3) Fire fighters with diabetes mellitus who
(a) are gt35 years old or
(b) have type I diabetes for more than 15 years or
(c) have type II diabetes for more than 10 years or
(d) have any other CHD risk factor (see below) or
(e) have the presence of microvascular disease (proliferative retinopathy)
(4) Fire fighters over the age of 45 (for men) and 55 (for women) with onetwo or more risk factors for CAD Risk factors for CAD include hypercholesterolemia (total cholesterol greater than 240 mgdL) hypertension (systolic gt140 mmHg or diastolic gt90 mmHg) smoking or family history of premature CAD (heart attack or sudden cardiac death in a first degree relative less than 60 years of age)
as defined below if stress electrocardiography with imaging is negative then repeat as clinically indicated or at least every 5 years
(5) Fire fighters with a Framingham Risk Score gt10 Risk calculator is available at [httphp2010nhlbihinnetatpiiicalculatorasp]
(6) Fire fighters identified in 9431
Negative stress tests should be repeated as clinically indicated or at least every 2 to 5 years
Interpreting stress tests as ldquopositiverdquo or ldquonegativerdquo is beyond the scope of this document However factors that should be taken into consideration should include the individualrsquos exercise capacity symptoms blood pressure response heart rate response EKG changes and the presence of arrhythmias (Gibbon et al 2002)
Risk factors for CAD include hypercholesterolemia (total cholesterol greater than 240 mgdL) hypertension (systolic greater than 140 andor diastolic greater than 90) smoking diabetes mellitus or family history of premature CAD (heart attack or sudden cardiac death in a first degree relative less than 60 years of age)
There are other non-invasive tests to screen for coronary artery disease One of the most promising appears to be coronary artery calcium (CAD) scoring by computed tomography In 2007 an expert committee published an update to their original guidance document The committeersquos consensus was that ldquoit may be reasonable to consider use of CAC measurement in such patients [between 10 and 20 10-year risk of estimated coronary event]helliprdquo The committee did not recommend CAC measurement in low risk patients [lt10 10-year risk of estimated coronary event] or in high risk patients [gt20 10-year risk of estimate coronary event] (Greenland et al 2007]
43
D22 Cardiology
Chobanian AV Bakris GL Black HR Cushman WC Green LA Izzo JL Jr Jones DW Materson BJ Oparil S Wright JT Jr Roccella EJ the National High Blood Pressure Education Program Coordinating Committee [2003] The seventh report of the Joint National Committee [JNC-7] on Prevention Detection Evaluation and Treatment of High Blood Pressure JAMA 2892560ndash2571
Gibbons RJ Balady GJ Bricker JT Chaitman BR Fletcher GF Froelicher VF Mark DB McCallister BD Mooss AN OrsquoReilly MG Winters WL Jr [2002] ACCAHA 2002 guideline update for exercise testing summary article a report of the ACCAHA Task Force on Practice Guidelines (Committee to Update the 1997 Exercise Testing guidelines) J Am Coll Cardiol 401531ndash 1540
Greenland et al [2007] ACCFAHA 2007 Clinical Expert Consensus Document on Coronary Artery Calcium Scoring By Computed Tomography in Global Cardiovascular Risk Assessment and in Evaluation of Patients With Chest Pain A Report of the American College of Cardiology Foundation Clinical Expert Consensus Task Force (ACCFAHA Writing Committee to Update the 2000 Expert Consensus Document on Electron Beam Computed Tomography) J Am Coll Cardiol 49378-402
Kales SN Tsismenakis AJ Zhang C Soteriades ES [2009] Blood pressure in fire fighters police officers and other emergency responders Am J Hypertens 2211-20
Schlant RC Adolph RJ DiMarco JP Dreifus LS Dunn MI Fisch C Garson A Jr Haywood LJ Levine HJ Murray JA Noble RJ Ronan JA Jr [1992] Guidelines for electrocardiography A report of the American College of CardiologyAmerican Heart Association Task Force on Assessment of Diagnostic and Therapeutic Cardiovascular Procedures (Committee on Electrocardiography) Circulation 85(3)1221-1228
Soteriades ES Kales SN Liarokapis D Christiani DC [2003] Prospective surveillance of hypertension in firefighters J Clin Hypertens 5315-320
Formatted Font Italic
Formatted Line spacing single
Formatted Font Italic
Formatted Font Italic
44
NFPA 1582‐ Draft Revisions for CVDHTN
EKG and stress tests
Reason for Revision
1) Change requirement for annual resting EKG to periodically to be more consistent with ACCAHA
recommendation (Schlant et al 1992)
2) Add language to clarify what constitutes a positive ST
3) Make criteria for conducting diagnostic ST in asymptomatic patients consistent with the
ACCAHA
Language in 2007 Edition with draft revisions in Red (Track changes)
776 Electrocardiograms (EKG) and Stress Tests 7761 A resting EKG shall be performed as part of the baseline medical evaluation and shall be obtained periodically (every 1 to 5 years) thereafter
A7761 A baseline resting EKGs shall be conducted Follow-up resting EKGs should be conducted as clinically indicated but at a minimum of every 1 to 5 years The frequency of these follow-up resting EKGs should increase as a members age increases or with increasing number andor severity of coronary heart disease risk factors Members above the age of 40 should have annual resting EKGs (Schlant et al 1992)
7762 The fire department physician or other qualified medical evaluator shall compare baseline and subsequent EKGs
7763 Stress testing with or without echocardiography or radionuclide scanning shall be performed as clinically indicated by history or symptoms
A7763 No firm guidelines for stress testing in asymptomatic individuals have been developed Stress testing as a screening tool is used as part of an evaluation of aerobic capacity during the annual occupational fitness evaluation Submaximal stress testing testing to 85 percent is commonly used as part of this screening
Submaximal stress testing should not be used for diagnostic purposes Cardiology evaluation with maximal stress testing together with imaging techniques (eg echocardiography technetium Tc99m sestamibi study) is necessary for diagnosticprognostic purposes for the following
(1) Fire fighters with positive or questionably positive changes on screening submaximal stress tests
(2) Fire fighters with new onset chest pain or other symptoms suggestive of coronary artery disease (CAD)
45
(3) Fire fighters with diabetes mellitus who
(a) are gt35 years old or
(b) have type I diabetes for more than 15 years or
(c) have type II diabetes for more than 10 years or
(d) have any other CHD risk factor (see below) or
(e) have the presence of microvascular disease (proliferative retinopathy)
(4) Fire fighters over the age of 45 (for men) and 55 (for women) with one or more risk factors for CAD Risk factors for CAD include hypercholesterolemia (total cholesterol greater than 240 mgdL) hypertension (systolic gt140 mmHg or diastolic gt90 mmHg) smoking or family history of premature CAD (heart attack or sudden cardiac death in a first degree relative less than 60 years of age)
(5) Fire fighters with a Framingham Risk Score gt10 Risk calculator is available at [httphp2010nhlbihinnetatpiiicalculatorasp]
(6) Fire fighters identified in 9431
Negative stress tests should be repeated as clinically indicated or at least every 2 to 5 years
Interpreting stress tests as ldquopositiverdquo or ldquonegativerdquo is beyond the scope of this document However factors that should be taken into consideration should include the individualrsquos exercise capacity symptoms blood pressure response heart rate response EKG changes and the presence of arrhythmias (Gibbon et al 2002)
There are other non-invasive tests to screen for coronary artery disease One of the most promising appears to be coronary artery calcium (CAD) scoring by computed tomography In 2007 an expert committee published an update to their original guidance document The committeersquos consensus was that ldquoit may be reasonable to consider use of CAC measurement in such patients [between 10 and 20 10-year risk of estimated coronary event]helliprdquo The committee did not recommend CAC measurement in low risk patients [lt10 10-year risk of estimated coronary event] or in high risk patients [gt20 10-year risk of estimate coronary event] (Greenland et al 2007]
D22 Cardiology
Resting EKG and Stress Tests
46
Chobanian AV Bakris GL Black HR Cushman WC Green LA Izzo JL Jr Jones DW Materson BJ Oparil S Wright JT Jr Roccella EJ the National High Blood Pressure Education Program Coordinating Committee [2003] The seventh report of the Joint National Committee [JNC-7] on Prevention Detection Evaluation and Treatment of High Blood Pressure JAMA 2892560ndash2571
Gibbons RJ Balady GJ Bricker JT Chaitman BR Fletcher GF Froelicher VF Mark DB McCallister BD Mooss AN OrsquoReilly MG Winters WL Jr [2002] ACCAHA 2002 guideline update for exercise testing summary article a report of the ACCAHA Task Force on Practice Guidelines (Committee to Update the 1997 Exercise Testing guidelines) J Am Coll Cardiol 401531ndash 1540
Greenland et al [2007] ACCFAHA 2007 Clinical Expert Consensus Document on Coronary Artery Calcium Scoring By Computed Tomography in Global Cardiovascular Risk Assessment and in Evaluation of Patients With Chest Pain A Report of the American College of Cardiology Foundation Clinical Expert Consensus Task Force (ACCFAHA Writing Committee to Update the 2000 Expert Consensus Document on Electron Beam Computed Tomography) J Am Coll Cardiol 49378-402
Kales SN Tsismenakis AJ Zhang C Soteriades ES [2009] Blood pressure in fire fighters police officers and other emergency responders Am J Hypertens 2211-20
Schlant RC Adolph RJ DiMarco JP Dreifus LS Dunn MI Fisch C Garson A Jr Haywood LJ Levine HJ Murray JA Noble RJ Ronan JA Jr [1992] Guidelines for electrocardiography A report of the American College of CardiologyAmerican Heart Association Task Force on Assessment of Diagnostic and Therapeutic Cardiovascular Procedures (Committee on Electrocardiography) Circulation 85(3)1221-1228
Soteriades ES Kales SN Liarokapis D Christiani DC [2003] Prospective surveillance of hypertension in firefighters J Clin Hypertens 5315-320
47
ATTACHMENT F
48
1
Current 1582 (2007) language in reference to pregnancy 43 (4) Report to the fire department physician any medical condition that could interfere with the ability of the individual to safely perform essential job tasks such as illness or injury use of prescription or nonprescription drugs and pregnancy 6112 Category B medical conditions shall include the following (1) Pregnancy for its duration A7792 (e) If HIV prophylaxis is to be given the following tests should be done i CBC ii Glucose renal and hepatic chemical function iii Pregnancy test for females B121 Pregnancy and Reproduction Federal regulations as well as many court decisions including the US Supreme Courtrsquos decision in International Union et al v Johnson Controls Inc [499 US 187 111 S Ct 1196 (1991)] have interpreted the requirements of Title VII with respect to pregnancy and reproduction The AHJ should seek the advice of counsel in resolving specific questions concerning these requirements as well as other requirements that can be imposed by state or local laws C211 (4) Review health status with the individual being evaluated Contraindications for evaluations shall be reviewed addressing any changes in the individualrsquos health status since their last medical evaluation that would warrant deferring the evaluation including (g) Pregnancy Recommendations to language enhancement
A female employee who is assigned to regular fire line duty shall report a pregnancy immediately to their respective Supervisor and the fire department physician The employee will then be given the option of a non-hazardous alternative duty position for the duration of her pregnancy (can we say this or is it even appropriate) Any pregnant employee wishing to remain on regular line duty shall be informed of the possible risks and consequences to herself and her fetus that are associated with continued line fire fighting duty Among those risk factors are exposure to teratogens known to have negative effects on the developing fetus such as smoke diesel fumes hazardous chemicals and extreme heat
49
Page 2
appendix It is recommended that the pregnant employee complete a release of liability form signed by herself and her health care provider utilizing NFPArsquos 13 critical tasks as a reference This will inform the health care provider of specific job-related tasks that will need to be performed in order to continue regular line duty These tasks are basic physical standards that any entry level firefighter would have to be able to complete competently The employeersquos health condition will be kept confidential by the department in accordance with HIPAA standards Employees are allowed to remain on active regular duty until they are no longer able to perform their duties in a reasonable manner andor their protective gear no longer fits correctly It is the responsibility of the health care provider to evaluate the pregnant employee If at any time the health care provider feels the pregnant employee can no longer perform the job related tasks this should be reported to the employer by the employee immediately
50
ATTACHMENT G
51
From GLENN BENARICKTo Sawyer SteveSubject RE RE 7743Date Monday August 30 2010 21633 PM
Yes thats my understanding
Glenn P Benarick 211 Winged Elm CircleAiken SC 29803803-644-7093gbenarprodigynet
--- On Mon 83010 Sawyer Steve ltssawyerNFPAorggt wrote
From Sawyer Steve ltssawyerNFPAorggtSubject RE RE 7743To GLENN BENARICK ltgbenarprodigynetgtDate Monday August 30 2010 212 PM
So it should be ldquoorrdquo instead of ldquoandrdquo for now
Steven F Sawyer
Senior Fire Service Specialist
Executive Secretary IFMAFire Service Section
NFPA
1 Batterymarch Park
Quincy MA 02169
6179847423
Fax 6179847056
ssawyernfpaorg
From GLENN BENARICK [mailtogbenarprodigynet] Sent Monday August 30 2010 1202 PMTo Sawyer SteveSubject Fw RE 7743
52
Steve a couple of our docs agree with April Boyer
Glenn P Benarick 211 Winged Elm Circle
Aiken SC 29803
803-644-7093
gbenarprodigynet
--- On Mon 83010 David Prezant ltprezandfdnynycgovgt wrote
From David Prezant ltprezandfdnynycgovgtSubject RE 7743To Thomas R (CDCNIOSHDSHEFS) Hales lttrh1cdcgovgt GLENNBENARICK ltgbenarprodigynetgtCc Sandy Bogucki ltsandyboguckiyaleedugtDate Monday August 30 2010 1004 AM
agree
we should change this to NHANES III rather than Knudson we should alsomodify this to allow not only for predicted cutoffs but all for use of thelower limit of normal cutoff This is important to prevent false-classificationof spirometry as abnormal in older groups and in taller grps The latter ofparticular import to firefighter occupational health surveillance
thanks
David Prezant MDChief Medical Officer Office of Medical AffairsCo-Director WTC Medical Monitoring amp Treatment ProgramsNew York City Fire Department9 Metrotech Center - Rm 4W-1Brooklyn NY 11201Phone 718-999-2696Fax 718-999-0665
Life is full of twists and turns
53
This email may contain confidential information If you are the unintendedrecipient of this email please send it back and delete from your directory
gtgtgt Hales Thomas R (CDCNIOSHDSHEFS) lttrh1cdcgovgt 8302010955 AM gtgtgt
Glen
This seems like a very reasonable comment and illustrates the importance of having clinicians providefeedback on the std Im not familiar with the software program of the various spirometers (NHANES IIIvs KnudsonATS vs both) Given the large role both Dave Prezant and Sandy Bogucki had for thepulmonary section let me forward to them for clarification
Tom
From GLENN BENARICK [mailtogbenarprodigynet] Sent Sunday August 29 2010 456 PMTo Hales Thomas R (CDCNIOSHDSHEFS)Subject FW 7743
Tom is April Boyer correct
Glenn P Benarick 211 Winged Elm Circle
Aiken SC 29803
803-644-7093
gbenarprodigynet
--- On Thu 82610 Sawyer Steve ltssawyerNFPAorggt wrote
From Sawyer Steve ltssawyerNFPAorggtSubject FW 7743To GLENN BENARICK ltgbenarprodigynetgtDate Thursday August 26 2010 925 PM
FYI Do you have any answer She is write
Steven
54
Steven F Sawyer
Senior Fire Service Specialist
Executive Secretary IFMAFire Service Section
NFPA
1 Batterymarch Park
Quincy MA 02169
6179847423
Fax 6179847056
ssawyernfpaorg
From April Boyer [mailtoaboyerbicclinicorg] Sent Thursday August 26 2010 232 PMTo Sawyer SteveCc RobinMWebbmilstateorusSubject 7743
Steven
The spirometry tests cannot be corrected according to both references as the NFPA states because thereferences are contradictory The first part of 7743 states to follow the ATS guidelines and use theKnudsen (we at Basin Immediate Care use the Nhanes III) The second part states to follow the ACOEMguidelines and use the Nhanes III in the occupational setting if available with your unit (which is availableon ours) 7743 does not use the word OR regarding both requirements it uses the word AND whenreferring to the first and second parts thence making 7743 contradictory I realize the NFPA 1582 hasnot been updated since 2007 unless I have just not received an updated version
Our question to you is which part of 7743 do you want us to follow the first or the second part Anyfacility that has an updated computerized spirometry system (as we do) will not be able to follow bothrequired parts for obvious reasons We can either follow the first part of 7743 and use an oldercorrected version of the Knudson by going into our system and changing out of the Nhanes III conversionOR we can follow the second part of 7743 and use the newer corrected version of Nhanes III which ourunit offers too
If you have any questions you may contact me at anytime and I also have many references in regards toboth parts of 7743 if you would like to see them
55
Thank you~
April
Confidentiality NoticeThis message may contain information that isconfidential or privileged
If you are not the intended recipientPlease advise the sender immediately and delete this message
56
ATTACHMENT H
57
NFPA 1582 771(7) Proposed revisions
Why
Preliminary results of two prospective randomized trials on the PSA test were published in 2009 These studies resulted in medical organizations that previously providing guidance to modify their recommendations
Current language
771 Blood Tests Blood tests shall be performed annually and shall include the following
(7) Prostate specific antigen (PSA) after age 40 for positive family history if African American or if otherwise clinically indicated after age 50 for all other male member
Suggested Revision
771 Blood Tests Blood tests shall be performed annually and shall include the following
(7) Prostate specific antigen (PSA) after age 40 for positive family history if African American or if otherwise clinically indicated after age 50 for all other male member
772 Prostate-Specific Antigen (PSA) test At age 50 fire fighters shall have an opportunity to make an informed decision with either the Fire Department physician or their health care provider concerning the PSA test For fire fighters at increased risk of prostate cancer (African-Americans or those with a first degree relative diagnosed with prostate cancer before age 65) shall have the opportunity for this informed decision at age 40
A772 The PSA as a screening test for prostate cancer in asymptomatic men is controversial controversial for two reasons First there is no consensus that PSA screening actually saves lives For example the PSA test may detect small cancers that would never become life threatening Second it is unclear that the benefits of PSA screening outweigh the risks of follow-up diagnostic tests and cancer treatments For example the prostate biopsy used to diagnose prostate cancer may cause bleeding and infection And prostate cancer treatments such as surgery and radiation therapy may cause incontinence (inability to control urine flow) erectile dysfunction (erections inadequate for intercourse) and other complications For these reasons it is important that the benefits and risks of prostate diagnostic procedures and treatment be taken into account when considering the PSA screening test These considerations can be taken account during discussions with the fire department physician or onersquos health care provider
D211 Cancer Screening
Smith R A C J Mettlin K J Davis and H Eyre 2000 ldquoAmerican Cancer Society guidelines for the early detection of cancerrdquo CA J Clin 50(1)34ndash49
Added references
58
Carroll P Albertsen PC Greene K et al [2010] Prostate-specific antigen best practice statement 2009 update Am Urological Assoc Available at httpwwwauanetorgcontentguidelines-and-quality-careclinical-guidelinesmain-reportspsa09pdf Date accessed September 2010
Ferrini R Woolf SH [2009] Screening for prostate cancer in American men American College of Preventive Medicine Practice Policy Statement Available at httpwwwacpmorgprostatehtm Date accessed September 2010
National Cancer Institute [2009] Prostate-specific antigen test National Cancer Institute Fact Sheet Available at httpwwwcancergovcancertopicsfactsheetDetectionPSA Date accessed September 2010
Wolf AMD Wender RC Etzioni RB et al [2010] American Cancer Society guideline for the early detection of prostate cancer Update 2010 Available at httpcaonlineamcancersocorgcgicontentfullcaac20066v1 Date accessed September 2010
59
ATTACHMENT B
9
Technical Committee on Fire Service Occupational Safety and Health
Meeting Minutes May 13 ndash 14 2010
Holiday Inn Inner Harbor MD
Attendees Glenn Benarick Chairman Ken Holland Staff Liaison Michael Finkelman Craig Fry Joe Rivera Stephen Raynis Steve Kreis Dennis Childress Don Stewart Phil Stittleburg David Ross Michael Laton Kim Zagaris Tom Hillenbrand Dominic Colletti Andy Schwartz Brett Bowman Guest David Bernzweig Thursday May 13 NFPA 1500 task groups (Vehicle amp Safety OPS SCBA amp Air Mgt PPEProximity) met to discuss the work they have completed since the last meeting The task groups will present their report to the entire TC on May 14th Not enough 1582 task group members were able to make the meeting so there were no reports or work from those task groups Friday May 14 TC meeting called to order at approximately 0800 by Glenn Benarick TC Chair Ken Holland (NFPA Public Fire Protection Staff) in attendance filling in for Frank Florence Ken made two presentations one on the Codes and Standards Development Process and the other on the general procedures for this Pre-ROP meeting The Staff Liaison remains fluid as Frank is not expected back any time soon
10
One guest in attendance Dave Bernzweig (Columbus OH Fire) Dave is assisting TC with SCBAAir Mgt issues The document revision cycles remain as requested NFPA 1500 amp 1582 Annual 2012 NFPA 1521 amp 1561 Fall 2013 NFPA 1581 1583 1584 Annual 2014 The October 7-9 2010 dates are the primary request for our next meeting Location is San Diego Notice will be sent out as soon as approval is received Discussion on the next revision of 1561 will be held at the October meeting regarding changing the document title to ldquoCommand Safety for Fire Department Operationsrdquo This is a suggestion of the TC Chair Ken Holland conducted a briefing for the TC on how to access and use the committee web page Staff will be posting as much information as possible up on the e-committee page for the entire committee More use will be made of this tool Discussion on monocular vision Dennis Childress presented the current issue in Ventura County CA Further discussionwork may be necessary Don Stewart agreed to take the lead Brief discussion held on pregnancy and the need for fire departments to ensure policies match current law The rep from the Diabetes Association declined the invitation to participate at this meeting due to no discussion of the issue planned She has indicated a desire to attend the October meeting There were no reports from these and all other 1582 task groups It is very important for the 1582 TG Chairs to be ready to report in October The following task group reports will be posted on the ecommittee page PPEProximity New definition of proximity fire fighting
VehicleHighway OPS Discussion on use of vehicle data recorders Collapse Zones Submission from Jay Tarley SCBAAir Mgt New exit strategy for SCBA Discussion on having the low air alarm activate when the bottle volume reaches 600 liters Further discussion to take place on ldquobuddy breathingrdquo
On Day 2 Casey Grant (NFPA Fire Protection Research Foundation) made a presentation on Research Planning for FSOSH Dr Ellen Sogolow (DHSFEMA) also present during this presentation She discussed the role of the AFGRampD activities See ecommittee page for his presentation Chair
11
will be in contact with Mr Grant for future work between the TC and the Foundation Also on Day 2 Ken Willette (Division Manager ndash NFPA Public Fire Protection Division) delivered a presentation on the initiative developed by Kelvin Cochran (US Fire Administrator) to reduce fire fighter injuries and deaths NFPA 1500 is an integral part of this initiative See ecommittee page for presentation The Chair will be coordinating a committee conference call in the coming weeks The purpose will be to review the work which needs to be completed for the October meeting The primary focus of the call will be on 1582 issues NOTE Subsequent to the meeting I have had some discussions with a fire chief in Kentucky on the use of hearing aids The TC especially the doctors need to review the current language in 1582 and decide if revisions are needed Also most of you know that Kelvin Cochran has left the USFA unexpectedly to return to Atlanta as their fire chief I have been in contact with the Acting Administrator Glenn Gaines to inform him that our committee remains focused on the work to reduce fire fighter injuries and deaths I told him that I would keep him informed of our work He indicated that one of his primary goals is to bring fire service organizations together in order to create a safe working environment Of particular interest to him is reducing heart related injuries and deaths Submitted by Glenn Benarick
12
Technical Committee on Fire Service Occupational Safety and Health
Conference Call Meeting Minutes August 30th 2010
Members participating
Glenn Benarick TC Chair
Murrey Loflin Secretary Dr Sandy Bogucki
Thomas Cuff Stephen Foley
Scott Kerwood Tammy Lopes
David Love Dr David Prezant
Joe Rivera David Ross
Mario Rueda Phil Stittleburg
Phil Vorlander Dominic Colletti
Thomas Hillenbrand
Denise Smith Brett Bowman Alternate
Andrew Schwartz Alternate Mike Young Alternate
Dr Thomas Hales Non-Voting Member Ken Holland NFPA Staff Liaison
Casey Grant NFPAResearch Foundation Staff Katie Hathway Guest from ADA
Dr Jim Fleming Guest from Phoenix Fire Dept
The chair welcomed everyone to the conference call in which he hoped
would last only an hour The purpose was to discuss any task groups that had reports for proposed changes to NFPA 1582 for the
committee This is in hopes to ensure the committee is ready for their
pre-ROP meeting in October The following topics were discussed and are in no specific order
Comments from ADA Katie Hathaway and the group went into deep
discussion regarding ones medical history and diagnosis of diabetes
13
and some proposed changesremoval of text based on research
findings The specific proposed changes will be available for the committee at their next meeting Some members on the call felt that
this issue was covered in another law enforcement document which might better serve this issue
Research topics for FSOSH projects Casey Grant offered his time to
answer any questions regarding his presentation from the May meeting in Baltimore There was also discussion about further
involvement of the Research Foundation with this committee and some of the medical requirements within the documents Glenn and Casey
are going to be in contact offline to discuss this further
Prosthetics amp Amputees report Nothing new to report
Heart amp Hypertension report There was discussion about the need for
periodic EKGrsquos that were done both in resting and non-resting states as well as discussion about stress test requirements and frequency of
such tests The hopes were to develop text that would point to annual versus periodic evaluations of EKGrsquos and stress tests
Epilepsy report Nothing new to report
Pregnancy report The initial textlanguage has been provided to the
group through email and e-committee page posting
Coagulation amp Meds report Nothing new to report
Hearing Aid discussion Nothing new to report
The committee also discussed the evaluation and documentation of
PSA results and test requirements for the purposes of consistency The proposed text and changes have been posted on the e-committee
page as well
All of the proposed text changes from the May meeting in Baltimore have been emailed out and posted on the e-committee page If there
are any questions or concerns that something was missed please contact Glenn Steven Sawyer or Ken Holland to ensure they are
resolved
The conference call lasted approximately an hour and was adjourned at 1400 hours
14
ATTACHMENT C
15
2012 ANNUAL REVISION CYCLE
PROCESS STAGE PROCESS STEP DATES
FOR TC DATES
FOR TCC 1 PRELIMINARY 10 Notification of intent to enter cycle 7910 7910
2 REPORT ON
PROPOSALS (ROP)
21 Proposal closing date 112310 112310 22 Final date for ROP meeting 22511 2411 23 Final date for mailing TC ballots 31811 21811 24 Receipt of (TC) ballots by staff liaison 42211 31111 25 Receipt of TC recirculation ballots 5611 31811 26 Final date for TCC meeting 41511 27 Final date for mailing TCC ballots 42211 28 Receipt of TCC ballots 51311 29 Receipt of TCC recirculation ballots 52011 210 Final copy (w ballot statements) to Secretary Standards Council 51311 52711 211 Completion of Reports 52011 6311 212 ROP Published and Posted 62411 62411
3 REPORT ON
COMMENTS
(ROC)
31 Comment closing date 83011 83011 32 Final date for ROC meeting 11411 10711 33 Final date for mailing TC ballots 111811 102111 34 Receipt of (TC) ballots by staff liaison 12211 111111 35 Receipt of TC recirculation ballots 12911 111811 36 Final date for TCC meeting 121611 37 Final date for mailing TCC ballots 122311 38 Receipt of TCC ballots 11312 39 Receipt of TCC recirculation ballots 12012 310 Final copy (w ballot statements) to Secretary Standards Council 122311 12712 311 Completion of Reports 11312 2312 312 ROC Published and Posted 22412 22412
4 TECH SESSION
PREPARATION amp
ISSUANCE OF
CONSENT
DOCUMENTS
41 Notice of Intent to Make a Motion (NITMAM) Closing Date 4612 4612 42 Posting of Filed NITMAM 5412 5412
43 Council Issuance Date for Consent Documents 52912 52912
44 Appeal Closing Date for Consent Documents 61312 61312
5 TECHNICAL
SESSION 50 Association Meeting for Documents with Certified Amending Motions
64-712 64-712
6
APPEALS amp
ISSUANCE OF
DOCUMENTS
WCAMS
61 Appeal closing date for Documents with Certified Amending Motions
62712 62712
62 Council issuance for Documents with Certified Amending Motions 8912 8912
Proposal Closing Dates may vary according to documents and schedules for Revision Cycles may change Please check the NFPA website (wwwnfpaorg) for the most up-to-date information on proposal closing dates and schedules
16
ATTACHMENT D
17
This weekrsquos conference call mentioned the Diabetes chapter written for the ACOEM document Guidance for the Medical Evaluation of the Law Enforcement Officer The task group working on this chapter (led Richard Miller of the Secret Service and our very own Dan Samo) worked with the ADA or over 2-3 years to come up with a consensus document
Please find the Chapter attached ltltDiabetes Guidance Sept 2010pdfgtgt
Regarding Dan Loeberrsquos points
1) Physical Evaluation Form - We could modify the LEO form (see end of the attached Chapter)
2) Duration required for stable regiment
1582 for IDDM Type 1 1 yr
Type 2 6 m
Oral Agents None specifically
ACOEM Police for IDDM Type 1 6m
Type 2 3m
Oral Agents 1m
The police document is much clearer about the decision regarding medical fitness for duty is the responsibility of the police physician with the treating diabetes-expert physician providing the data to the police physician to make an informed decision In this regard the police officer must provide the police physician with downloaded self monitoring glucose data for the 1 3 and 6 month time periods (see section 433)
3) HA1C ndash NFPA lt 8 over 3 month period
ACOEM Police ndash (Section 4333) Specifies the frequency on measurement and if gt8 requires further evaluation
Some other discrepancies End organ complications
NFPA ndash end organ complications (eye kidney heart neuro) ndash restriction
ACOEM Police ndash end organ complication -- requires further evaluation
18
Hypoglycemia (incapacitating ndash defined differently between the two documents (434)
NFPA ndash 0 episodes in past year le1 in past 5 yrs
ACOEM Police ndash 0 episodes in past year le2 in past 3 yrs
Given Dan Samorsquos and Richard Millerrsquos work with the ADALoeber it would be helpful to get their opinions on whether any of the changes requested by Loeber are appropriate for FF with DM
Tom
Thomas Hales MD MPH
Senior Medical Epidemiologist
NIOSH CDC
4676 Columbia Pkwy R-9
Cincinnati OH 45241
(513) 841-4583
trh1cdcgov
19
43 ndash DIABETES MELLITUS
431 ndash INTRODUCTION
The educated and motivated law enforcement officer (LEO) with well-managed diabetes mellitus can be capable of
safe and effective job performance1 However diabetes mellitus may place LEOs at risk for sudden incapacitation
thus jeopardizing their ability to perform critical job functions (These job functions include those listed in Sections
32 333 351 352 36 and 37 and discussed in Appendix A)
Therefore an individualized assessment of the LEOrsquos diabetes should be performed using the following evaluative
criteria to determine whether the individuals condition permits safe and effective job performance Such evaluation
must include the following key elements which are discussed in detail below
history of blood glucose control
knowledge of diabetes and its management
current stability of blood glucose
risk for significant hypoglycemia or hyperglycemia and
presence of diabetic complications
432 ndash OVERVIEW OF MEDICAL EVALUATION
The treating endocrinologist or other physician knowledgeable regarding diabetes management should provide
a narrative report certifying whether the LEO has or has not met the criteria set out in Sections 4321 through
4354 below In addition the physician should include supporting data (see Appendix B for the Physician Evalu-
ation Form)
4321 The LEO is under the care of an endocrinologist or other physician knowledgeable regarding diabetes
management Outpatient and in-patient medical record(s) for the last 3 years or since date of diagnosis
(whichever is shorter) should be reviewed by the treating physician and provided to the police physician
4322 If the LEO has type 1 diabetes the individual has been on a basalbolus regimena or an insulin pump
using analogue insulins for the 6 months prior to evaluation2
4323 If the LEO has type 2 diabetes on insulin the individual has been on a stable medication regimenb
for the 3 months prior to evaluation3 If on oral agents alone the LEO has been on a stable medication regimen
for the month prior to evaluationc
ACOEM Guidance for the Medical Evaluation of Law Enforcement Officers 1
43 ndash DIABETES MELLITUS
aA basalbolus insulin regimen consists of the use of a basal insulin (Glargine NPH) in a once or twice daily regimen to provide between-
meal insulin combined with the use of a short acting insulin (Regular Lispro Aspart or Glulisine) at mealtimes Insulin pumps are small
(beeper sized) battery powered devices that deliver small amounts of short-acting insulin in a constant infusion to meet basal insulin
requirements The wearer selects an additional mealtime bolus to be infused at the time of meals For more information on pumps visit
the manufacturerrsquos web sites ndash wwwMinimedcom wwwcozmorecom wwwanimascorpcom wwwdisetroniccom
bA stable insulin regimen is defined as maintaining the same types of insulin (long acting intermediate acting short or rapid acting)
Changes in insulin dose are part of the appropriate self-management of diabetes and do not disqualify an applicant or incumbent under
this section
cChanges in dose within the evaluation period will be allowed but addition of a new class of medications or insulin should result in a new
period of observation
one month for addition of a sulfonylurea or metformin
two months for the addition of a thiazolidinedione to insulin or a sulfonylurea or
three months for the addition of insulin
20
4324 If the LEO uses an insulin pump documentation is needed as follows
proper understanding and education in the use of the insulin pump
start date for the use of the pump
history of insulin site infectionsd
history of pump cessation and pump malfunction
backup plan for pump malfunction including use of injectable insulin and
frequency of infusion set changes
4325 The LEO has been educated in diabetes and its management and thoroughly informed of and under-
stands the procedures that must be followed to monitor and manage hisher diabetes and what procedures
should be followed if complications arise3
433 ndash QUANTITATIVE GLUCOSE MONITORING
4331 The LEO has documentation of ongoing self-monitoring of blood glucose
4332 This must be done with a glucose meter that stores every reading records date and time of reading
and from which data can be downloaded (Most meters now have this capability)
4333 Monitoring logs must be available covering the time period (1 3 or 6 months) as described in
Sections 4322 and 4323 The frequency of glucose monitoring must follow a schedule acceptable to the
police physician in consultation with the treating physician
Testing schedules are individual What follows is a common pattern but individual patterns may differ
2 ACOEM Guidance for the Medical Evaluation of Law Enforcement Officers
43 ndash DIABETES MELLITUS
dIndividual has not had more than one pump-site infection that caused him or her to miss work or usual daily activities in the preceding 6
months
THERAPEUTIC REGIMEN GLUCOSE TESTING SCHEDULE
Diet alone Once or twice a week
Metformin Thiazolidinediones or Alpha
Glucosidase inhibitors alone or in
combination
Once or twice a week
Sulfonylureas meglitanides nateglinide ndash
alone or in combination with the above group
Twice a day ndash AM and at supper with any
suspected hypoglycemic episodes
Insulin ndash one shot in combination with orals Twice a day ndash AM and at supper with any
suspected hypoglycemic episodes
2 to 3 times AM once a week
Insulin ndash two or more shots Insulin pump 3 to 4 times a day ndash at meals and bedtime
2 to 3 times AM once a week with any
suspected hypoglycemic episodes
21
4334 The LEO has had hemoglobin A1C measured at least 4 times a year (intervals of 2 to 3 months) over
the last 12 months prior to evaluation if diagnosis has been present for more than a year4 If hemoglobin A1C is
gt8 this may signal a problem with the LEOrsquos diabetes management that warrants further assessment5
434 ndash INCAPACITATING EVENTS
4341 The LEO has not had any incapacitating episodes within the past 1 year and no more than 2 episodes
in the past 3 years or since diagnosis of diabetes (whichever is shorter) of
43411 Severe hypoglycemia (loss of consciousness seizures or coma requiring assistance of others or
needing urgent treatment [glucagon injectionIV glucose]) or
43412 Blood sugar lt60 mgdl with unawareness demonstrated in current glucose logs6
435 ndash CHRONIC COMPLICATION SCREENING
4351 Chronic complications of diabetes are associated with increased risk for severe hypoglycemic
episodes and warrant further assessmente
4352 The components of screening for chronic complications are
43521 A complete eye exam by a qualified ophthalmologist or optometrist including a dilated retinal
exam demonstrating no more than mild background diabetic retinopathyf7
43522 Normal vibratory testing with a 128 Hz tuning forkg normal testing with 10 gram Semmes-
Weinstein monofilamentg and normal orthostatic blood pressureh and pulse testing89
ACOEM Guidance for the Medical Evaluation of Law Enforcement Officers 3
43 ndash DIABETES MELLITUS
ePresence of chronic complications of diabetes in and of themselves may not require the implementation of work restrictions
fNo more than one dot blot or flame-shaped hemorrhages or microaneurysm in all four fundus quadrants
gThe Michigan Diabetes Research and Training Center of the University of Michigan Health System recommends the following guidance
(see wwwmedumichedumdrtcprofsdocumentssviMNSI_howtopdf) for conducting vibratory and monofilament testing8
Vibration Sensation Vibration sensation should be performed with the great toe unsupported Vibration sensation will be tested bi-
laterally using a 128 Hz tuning fork placed over the dorsum of the great toe on the boney prominence of the DIP joint Patients whose
eyes are closed will be asked to indicate when they can no longer sense the vibration from the vibrating tuning fork In general the
examiner should be able to feel vibration from the hand-held tuning fork for 5 seconds longer on his distal forefinger than a normal subject
can at the great toe (eg examiners DIP joint of the first finger versus patients toe) If the examiner feels vibration for 10 or more seconds
on his or her finger then vibration is considered decreased A trial should be given when the tuning fork is not vibrating to be certain that
the patient is responding to vibration and not pressure or some other clue Vibration is scored as 1) present if the examiner senses the
vibration on his or her finger for lt10 seconds 2) reduced if sensed for 10 seconds or 3) absent (no vibration detection)
Monofilament Testing For this examination it is important that the patients foot be supported (ie allow the sole of the foot to rest on
a flat warm surface) The filament should initially be pre-stressed (4-6 perpendicular applications to the dorsum of the examiner s first
finger) The filament is then applied to the dorsum of the great toe midway between the nail fold and the DIP joint Do not hold the toe
directly The filament is applied perpendicularly and briefly (lt1 second) with an even pressure When the filament bends the force of
10 grams has been applied The patient whose eyes are closed is asked to respond yes if heshe feels the filament Eight correct responses
out of 10 applications is considered normal 1 to 7 correct responses indicates reduced sensation and no correct answers translates into
absent sensation
hOrthostatic hypotension is a physical finding defined by the American Autonomic Society and the American Academy of Neurology as a
systolic blood pressure decrease of at least 20 mm Hg or a diastolic blood pressure decrease of at least 10 mm Hg within 3 minutes of
standing
22
43523 Normal cardiac physical exam Cardiac stress testing to at least 12 METS is recommended and
should begin based on either the criteria of the American Heart AssociationAmerican College of
Cardiologyi10 or those of the American Diabetes Associationj11
Diabetics who have a normal cardiac stress test will be retested every one to three years based on
individual clinical assessment This assessment should consider
the age of the individual
the number and persistence of coronary artery disease (CAD) risk factors
the severity of CAD risk factors
43524 Microalbumincreatinine ratio 301 measured or calculatedk creatinine clearance
gt60 mlmin12
436 ndash ONGOING EVALUATION AND REQUIREMENTS
4361 Should have medical records and glucose meter logs reviewed periodically Because of the nature of
diabetes it is important that regular medical follow up be provided to the LEO The frequency and content of
the evaluation should be determined on an individual basis by the police physician in consultation with the
treating physicianl
4362 Must advise police physician of any change in type of medication
4363 Must advise police physician of any episodes of significant hypoglycemia or hyperglycemia
Urine microalbumincreatinine ratio _________________
III Treating Physician Statement
The above named individual meets all of the criteria provided on this form
Yes No ndash not recommended for position
No but IS recommended for position (letter of explanation attached)
It is my opinion that the above named individual is well-educated and well-motivated in diabetes self-management and has
achieved a level of diabetes management to be capable of safe and effective job performance as a law enforcement officer
I have reached this opinion after careful review of the above criteria
___________________________________________________________ ___________________________Signature of Physician Date
______________________________________________________________ ___________________________Printed or Typed Name of Physician Telephone Number
10 ACOEM Guidance for the Medical Evaluation of Law Enforcement Officers
43 ndash DIABETES MELLITUS
29
439 ndash REFERENCES
1 American Diabetes Association Diagnosis and classification of diabetes mellitus Diabetes Care 200427 Suppl
1S5-S10 See httpcarediabetesjournalsorgcgicontentfull27suppl_1s5
2 American Diabetes Association Continuous subcutaneous insulin infusion Diabetes Care 200427 Suppl 1S110
See httpcarediabetesjournalsorgcgicontentfull27suppl_1s110
3 Mensing C Boucher J Cypress M et al National standards for diabetes self-management education Diabetes
Care 200528 Suppl 1S72-9 See httpcarediabetesjournalsorgcgicontentfull28suppl_1s72
4 Goldstein DE Little RR Lorenz RA Malone JI Nathan DM Peterson CM American Diabetes Association Tests
of glycemia in diabetes Diabetes Care 200427 Suppl 1S91-3
See httpcarediabetesjournalsorgcgicontentfull27suppl_1s91
5 The Diabetes Control and Complications Trial Research Group Hypoglycemia in the Diabetes Control and
Complications Trial Diabetes 199746(2)271-86 See wwwncbinlmnihgovpubmed9000705 for abstract
6 American Diabetes Association Hypoglycemia and employmentlicensure Diabetes Care 200528 Suppl 1S61
See httpcarediabetesjournalsorgcgicontentfull28suppl_1s61
7 Viswanath K McGavin DD Diabetic Retinopathy Clinical Findings and Management J Comm Eye Health
200316(46)21-4 See wwwcehjournalorg0953-683316jceh_16_46_021html
8 Michigan Diabetes Research and Training Center University of Michigan Health System How to use the Michigan
Neuropathy Screening Instrument See wwwmedumichedumdrtcprofsdocumentssviMNSI_howtopdf
9 Bradley JG Davis KA Orthostatic hypotension Am Fam Physician 200368(12)2393-8
See wwwaafporgafp200312152393html
10 Gibbons RJ Balady GJ Bricker JT et al ACCAHA 2002 guideline update for exercise testing a report of the
American College of CardiologyAmerican Heart Association Task Force on Practice Guidelines (Committee on
Exercise Testing) J Am Coll Cardiol 200240(8)1531-40
See wwwaccorgqualityandscienceclinicalguidelinesexerciseexercise_cleanpdf
11 American Diabetes Association Standards of medical care in diabetes Diabetes Care 200528 Suppl 1S4-S36
Erratum in Diabetes Care 200528(4)990 See httpcarediabetesjournalsorgcgicontentfull28suppl_1s4
12 Molitch ME DeFronzo RA Franz MJ et al American Diabetes Association Nephropathy in diabetes Diabetes
Care 200427 Suppl 1S79-83 See httpcarediabetesjournalsorgcgicontentfull27suppl_1s79
13 Kitabchi AE Umpierrez GE Murphy MB et al American Diabetes Association Hyperglycemic crises in diabetes
Diabetes Care 200427 Suppl 1S94-102 See httpcarediabetesjournalsorgcgicontentfull27suppl_1s94
14 US Centers for Disease Control and Prevention National Diabetes Fact Sheet 2007
See wwwcdcgovdiabetespubspdfndfs_2007pdf
ACOEM Guidance for the Medical Evaluation of Law Enforcement Officers 11
43 ndash DIABETES MELLITUS
30
ATTACHMENT E
31
Typos A6921(2) 7th line down test should be plural 94201 Paragraph 2 target organ damage is used though end organ damage was defined earlier and in the appendix for that paragraph
A94201 Para A (1) d Id suggest deleting the phrases in brackets Im not sure either are predictably true or politically wise
a) tests for left ventricular hypertrophy Unfortunately use of the EKG to detect left ventricular hypertrophy is very insensitive (eg 5 sensitivity) The echocardiogram is the best test for diagnosing left ventricular hypertrophy but [it is relatively expensive and not readily available in small rural communities ] conducting echocardiograms on asymptomatic fire fighters with Stage 1 hypertension should be reserved only for those with long-standing hypertension
In addition
7761 A resting EKG shall be performed as part of the baseline medical evaluation and shall be obtained periodically thereafter
Changing from annually to periodically is noted has the language in the wellness-fitness initiative been changed as well Our previous decision was that we would support the W-F language since there was no compelling evidence to either support or refute it
Thanks
Sandy
32
NFPA 1582‐ HTN Draft 1
Reason for Revision
1) New classification of BP by the Joint National Commission [Chobanian et al 2002]
2) A high prevalence of FF have either HTN (~20) and Pre‐HTN (~20) [Soteriades et al 2003]
3) Among FF studies have shown a strong association between HTN and a number of adverse
cardiovascular events [Kales et al 2009]
4) A large percentage of on‐duty FF fatalities were found to have left ventricular hypertrophy a
complication of HTN at autopsy
Language in 2007 Edition with draft revisions in Red (Track changes)
611 The medical evaluation of a candidate shall include a medical history examination and any laboratory tests required to detect physical or medical condition(s) that could adversely affect hisher ability to safely perform the essential job tasks outlined in 511 A611 The medical history should include the candidates known health problems such as major illnesses surgeries medication use and allergies Symptom review is also important for detecting early signs of illness A medical history should also include a personal health history a family health history a health habit history an immunization history and a reproductive history
An occupational history should also be obtained to collect information about the persons past occupational and environmental exposures
(a) BP should be measured according to the Joint National Commission (JNC) -7 recommendations BP should be measured with a properly calibrated and validated instrument Patients should be seated quietly for at least 5 minutes in a chair with feet on the floor and arm supported at heart level An appropriate-sized cuff (cuff bladder encircling at least 80 of the arm) should be used to ensure accuracy At least 2 measurements should be made Systolic BP is the point at which the first of 2 or more sounds is heard (phase 1) and diastolic BP is the point before the disappearance of sounds (phase 5) [Chobanian et al 2003]
(2) Head eyes ears nose and throat (HEENT)
Formatted Font (Default) Times New RomanFont color Black
33
692 Vascular System 6921 Category A medical conditions shall include the following
(1) Uncontrolled or poorly controlled hypertension
(2) Hypertension with evidence of end organ damage
or not controlled by approved medications
A6921(1) Uncontrolled or poorly controlled hHypertension increases the risk of a sudden cardiac event This sudden cardiac event would cause sudden incapacitation which that is uncontrolled poorly controlled or requires medication likely to interferes with the safe performance of essential job tasks Uncontrolled or poorly controlled hypertension can be defined as the presence of end organ damage (see below) or stage 2 hypertension (BP systolic gt160 mmHg or BP diastolic gt100 mmHg) is an illness that can lead to functional impairment and potential for sudden incapacitation Individuals with pre- stage 1 or stage 2 hypertension should be referred to their primary care physician for evaluation lifestyle modification and treatment [QUESTION FOR GROUP _- WHAT ABOUT HAVING CANDIDATE RETURN IN ONE MONTH UNDER TREATMENT WITH NORMAL BP]
A6921(2)
Chronic hypertension can damage the eye (retinopathy) the kidneys (nephropathy) the vascular system (stroke transient ischemic attack or peripheral artery disease) or the heart (left ventricular hypertrophy and heart failure) These hypertension complications are known as end organ damage The cardiac and vascular complications are associated with an increased risk of sudden incapacitation and sudden cardiac death (Koren et al 1991) Unfortunately the cardiac complications are frequently asymptomatic and valid screening tests are not fast and are not inexpensive Therefore determining who to screen for cardiac complications (such as echocardiogram for LVH or a measurement of left ventricular ejection fraction for heart failure) should be based on the severity and the duration of HTN
76 Physical Examination The annual physical examination shall include each of the following components
(a) BP shall be measured according to the Joint National Commission (JNC)-7 recommendations
A76(1)(a) BP should be measured with a properly calibrated and validated instrument Patients should be seated quietly for at least 5 minutes in a chair with feet on the floor and arm supported at heart level An appropriate-sized cuff (cuff bladder encircling at least 80 of the arm) should be used to ensure accuracy At least 2 measurements should be made Systolic BP is the point at which the first of 2 or more sounds is heard (phase 1) and diastolic BP is the point before the disappearance of sounds (phase 5) [Chobanian et al 2003]
(2) Head eyes ears nose and throat (HEENT)
34
9420 Uncontrolled Hypertension 94201 Physician Evaluation Severe uncontrolled hypertension [defined as systolic pressure greater than 180 mm Hg diastolic pressure greater than 100 mm Hg or mean systolic blood
pressure ( systolic + diastolic) greater than 120 mm Hg] or malignant hypertension (defined as hypertension with the presence of target organ damage) compromises the members ability to safely perform essential job tasks 1 5 7 9 and 13 and the physician shall report the applicable job limitations to the fire department
Members with Pre-hypertention (systolic 120-139 mmHg or diastolic 80-89 mmHg) Stage 1 hypertension (systolic 140-159 mmHg or diastolic 90-99 mmHg) or Stage 2 hypertension (systolic ge160 mmHg or diastolic ge100 mmHg) should be referred to their primary care physician for evaluation lifestyle modification and treatment
(1) Members with Stage I hypertension should be followed-up not only by their primary care physician but also by the FD physician every 3 to 6 months to ensure their blood pressure is under control and to determine whether screening tests for asymptomatic end organ damage are appropriate
(2) Members with Stage 2 hypertension or with end organ damage (retinopathy nephropathy vascular or cardiac complications) compromises the members ability to safely perform essential job tasks 1 5 7 9 and 130 and the physician shall report the applicable job limitations to the fire department
A94201 Severe uncontrolled hypertension is a significant risk factor for the development of coronary artery disease congestive heart failure and stroke Blood pressure increases as a normal response to exercise This response is further exaggerated by the emotional and physical stress of performing these critical tasks while operating in personal protective clothing at extremes of temperature This normal elevation of blood pressure under these response conditions can lead to life-threatening hypertensive emergencies if a members daily blood pressure is already elevated to high levels In addition hypertension is a progressive illness that when uncontrolled ultimately and inevitably leads to target organ damage Target organs that are sensitive to the effects of elevated blood pressure are the central nervous system vision heart major blood vessels and kidneys
Chronic hypertension can damage the eye (retinopathy) the kidneys (nephropathy) the vascular system (stroke transient ischemic attack or peripheral artery disease) or the heart (left ventricular hypertrophy and heart failure) These hypertension complications are known as end organ damage The cardiac and vascular complications are associated with an increased risk of sudden incapacitation and sudden cardiac death (Koren et al 1991) Fortunately with proper evaluation life style modification and treatment these complications can be avoided Life style modification includes weight reduction DASH eating plan reduction in dietary sodium an increase in aerobic physical activity and moderation in alcohol consumption [Chobanian 2003]
Formatted Font (Default) Times New Roman12 pt Font color Black
Formatted Font (Default) Times New Roman12 pt Font color Black
35
A94201 (1) Members with Stage I hypertension whose BP returns to either pre-hypertenion or normal with lifestyle modification andor treatment can return to an annual medical evaluation For members with long-standing Stage I hypertension whose BP has not been reduced additional evaluation for possible end organ damage should be considered This evaluation could include any or all of the following
a) a compete patient history for symptoms of heart failure (eg shortness of breath upon exertion) or transient ischemic attacks (TIAs)
b) dilated eye examination for retinopathy
c) blood creatinine measurement for nephropathy
d) tests for left ventricular hypertrophy Unfortunately use of the resting EKG to detect left ventricular hypertrophy is very insensitive (eg 5 sensitivity) The echocardiogram is the best test for diagnosing left ventricular hypertrophy
A 94201 (2) Due to the high risk of a sudden cardiovascular event members with Stage 2 hypertension should be restricted until their BP can be brought under control Once the BP is brought under control they should be followed in the same manner as a member with Stage I hypertension
Formatted Font (Default) Times New Roman12 pt
36
D22 Cardiology Gibbons R J GJ Balady J W Beasley et al 1997 ACCAHA guidelines for exercise testing a report of American College of CardiologyAmerican Heart Association Task Force on Practice Guidelines (Committee on Exercise Testing) J Am Coll Cardiol 30260ndash311
Gibbons RJ Balady GJ Bricker JT Chaitman BR Fletcher GF Froelicher VF Mark DB McCallister BD Mooss AN OrsquoReilly MG Winters WL Jr [2002] ACCAHA 2002 guideline update for exercise testing summary article a report of the ACCAHA Task Force on Practice Guidelines (Committee to Update the 1997 Exercise Testing guidelines) J Am Coll Cardiol 401531ndash 40
Chobanian AV Bakris GL Black HR Cushman WC Green LA Izzo JL Jr Jones DW Materson BJ Oparil S Wright JT Jr Roccella EJ the National High Blood Pressure Education Program Coordinating Committee [2003] The seventh report of the Joint National Committee [JNC-7] on Prevention Detection Evaluation and Treatment of High Blood Pressure JAMA 2892560ndash2571
Soteriades ES Kales SN Liarokapis D Christiani DC [2003] Prospective surveillance of hypertension in firefighters J Clin Hypertens 5315-320
Kales SN Tsismenakis AJ Zhang C Soteriades ES [2009] Blood pressure in fire fighters police officers and other emergency responders Am J Hypertens 2211-20
37
NFPA 1582‐ HTN Draft 1
Reason for Revision
1) New classification of BP by the Joint National Commission [Chobanian et al 2002]
2) A high prevalence of FF have either HTN (~20) and Pre‐HTN (~20) [Soteriades et al 2003]
3) Among FF studies have shown a strong association between HTN and a number of adverse
cardiovascular events [Kales et al 2009]
4) A large percentage of on‐duty FF fatalities were found to have left ventricular hypertrophy a
complication of HTN at autopsy
Language in 2007 Edition with draft revisions in Red (Track changes)
611 The medical evaluation of a candidate shall include a medical history examination and any laboratory tests required to detect physical or medical condition(s) that could adversely affect hisher ability to safely perform the essential job tasks outlined in 511 A611 The medical history should include the candidates known health problems such as major illnesses surgeries medication use and allergies Symptom review is also important for detecting early signs of illness A medical history should also include a personal health history a family health history a health habit history an immunization history and a reproductive history
An occupational history should also be obtained to collect information about the persons past occupational and environmental exposures
(a) BP should be measured according to the Joint National Commission (JNC) -7 recommendations BP should be measured with a properly calibrated and validated instrument Patients should be seated quietly for at least 5 minutes in a chair with feet on the floor and arm supported at heart level An appropriate-sized cuff (cuff bladder encircling at least 80 of the arm) should be used to ensure accuracy At least 2 measurements should be made Systolic BP is the point at which the first of 2 or more sounds is heard (phase 1) and diastolic BP is the point before the disappearance of sounds (phase 5) [Chobanian et al 2003]
(2) Head eyes ears nose and throat
38
692 Vascular System 6921 Category A medical conditions shall include the following
(1) Uncontrolled or poorly controlled hypertension
(2) Hypertension with evidence of end organ damage
A6921(1) Uncontrolled or poorly controlled hypertension increases the risk of a sudden cardiac event This sudden cardiac event would cause sudden incapacitation which interferes with the safe performance of essential job tasks Uncontrolled or poorly controlled hypertension can be defined as the presence of end organ damage (see below) or stage 2 hypertension (BP systolic gt160 mmHg or BP diastolic gt100 mmHg) Individuals with pre- stage 1 or stage 2 hypertension should be referred to their primary care physician for evaluation lifestyle modification and treatment [QUESTION FOR GROUP _- WHAT ABOUT HAVING CANDIDATE RETURN IN ONE MONTH UNDER TREATMENT WITH NORMAL BP]
A6921(2)Chronic hypertension can damage the eye (retinopathy) the kidneys (nephropathy) the vascular system (stroke transient ischemic attack or peripheral artery disease) or the heart (left ventricular hypertrophy and heart failure) These hypertension complications are known as end organ damage The cardiac and vascular complications are associated with an increased risk of sudden incapacitation and sudden cardiac death (Koren et al 1991) Unfortunately the cardiac complications are frequently asymptomatic and valid screening tests are not fast and are not inexpensive Therefore determining who to screen for cardiac complications (such as echocardiogram for LVH or a measurement of left ventricular ejection fraction for heart failure) should be based on the severity and the duration of HTN
76 Physical Examination The annual physical examination shall include each of the following components
(a) BP shall be measured according to the Joint National Commission (JNC)-7 recommendations
A76(1)(a) BP should be measured with a properly calibrated and validated instrument Patients should be seated quietly for at least 5 minutes in a chair with feet on the floor and arm supported at heart level An appropriate-sized cuff (cuff bladder encircling at least 80 of the arm) should be used to ensure accuracy At least 2 measurements should be made Systolic BP is the point at which the first of 2 or more sounds is heard (phase 1) and diastolic BP is the point before the disappearance of sounds (phase 5) [Chobanian et al 2003]
(2) Head eyes ears nose and throat9420 Hypertension 94201 Physician Evaluation Members with Pre-hypertention (systolic 120-139 mmHg or diastolic 80-89 mmHg) Stage 1 hypertension (systolic 140-159 mmHg or diastolic 90-99 mmHg) or Stage 2 hypertension (systolic ge160 mmHg or diastolic ge100 mmHg) should be referred to their primary care physician for evaluation lifestyle modification and treatment
39
(1) Members with Stage I hypertension should be followed-up not only by their primary care physician but also by the FD physician every 3 to 6 months to ensure their blood pressure is under control and to determine whether screening tests for asymptomatic end organ damage are appropriate
(2) Members with Stage 2 hypertension or with end organ damage (retinopathy nephropathy vascular or cardiac complications) compromises the members ability to safely perform essential job tasks 1 5 7 9 and 130 and the physician shall report the applicable job limitations to the fire department
A94201 Chronic hypertension can damage the eye (retinopathy) the kidneys (nephropathy) the vascular system (stroke transient ischemic attack or peripheral artery disease) or the heart (left ventricular hypertrophy and heart failure) These hypertension complications are known as end organ damage The cardiac and vascular complications are associated with an increased risk of sudden incapacitation and sudden cardiac death (Koren et al 1991) Fortunately with proper evaluation life style modification and treatment these complications can be avoided Life style modification includes weight reduction DASH eating plan reduction in dietary sodium an increase in aerobic physical activity and moderation in alcohol consumption [Chobanian 2003]
A94201 (1) Members with Stage I hypertension whose BP returns to either pre-hypertenion or normal with lifestyle modification andor treatment can return to an annual medical evaluation For members with long-standing Stage I hypertension whose BP has not been reduced additional evaluation for possible end organ damage should be considered This evaluation could include any or all of the following
a) a compete patient history for symptoms of heart failure (eg shortness of breath upon exertion) or transient ischemic attacks (TIAs)
b) dilated eye examination for retinopathy
c) blood creatinine measurement for nephropathy
d) tests for left ventricular hypertrophy Unfortunately use of the resting EKG to detect left ventricular hypertrophy is very insensitive (eg 5 sensitivity) The echocardiogram is the best test for diagnosing left ventricular hypertrophy
A 94201 (2) Due to the high risk of a sudden cardiovascular event members with Stage 2 hypertension should be restricted until their BP can be brought under control Once the BP is brought under control they should be followed in the same manner as a member with Stage I hypertension
D22 Cardiology
40
Hypertension
Gibbons RJ Balady GJ Bricker JT Chaitman BR Fletcher GF Froelicher VF Mark DB McCallister BD Mooss AN OrsquoReilly MG Winters WL Jr [2002] ACCAHA 2002 guideline update for exercise testing summary article a report of the ACCAHA Task Force on Practice Guidelines (Committee to Update the 1997 Exercise Testing guidelines) J Am Coll Cardiol 401531ndash 40
Chobanian AV Bakris GL Black HR Cushman WC Green LA Izzo JL Jr Jones DW Materson BJ Oparil S Wright JT Jr Roccella EJ the National High Blood Pressure Education Program Coordinating Committee [2003] The seventh report of the Joint National Committee [JNC-7] on Prevention Detection Evaluation and Treatment of High Blood Pressure JAMA 2892560ndash2571
Soteriades ES Kales SN Liarokapis D Christiani DC [2003] Prospective surveillance of hypertension in firefighters J Clin Hypertens 5315-320
Kales SN Tsismenakis AJ Zhang C Soteriades ES [2009] Blood pressure in fire fighters police officers and other emergency responders Am J Hypertens 2211-20
41
NFPA 1582‐ Draft Revisions for CVDHTN
EKG and stress tests
Reason for Revision
1) Change requirement for annual resting EKG to periodically to be more consistent with ACCAHA
recommendation (Schlant et al 1992)
2) Add language to clarify what constitutes a positive ST
3) Make criteria for conducting diagnostic ST in asymptomatic patients consistent with the
ACCAHA
Language in 2007 Edition with draft revisions in Red (Track changes)
776 Electrocardiograms (EKG)) and Stress Tests 7761 A resting EKG shall be performed as part of the baseline medical evaluation and shall be obtained periodically (every 1 to 5 years) annually thereafter
A7761 A baseline resting EKGs shall be conducted Follow-up resting EKGs should be conducted as clinically indicated but at a minimum of every 1 to 5 years The frequency of these follow-up resting EKGs should increase as a members age increases or with increasing number andor severity of coronary heart disease risk factors Members above the age of 40 should have annual resting EKGs (Schlant et al 1992)
7762 The fire department physician or other qualified medical evaluator shall compare EKGs obtained during yearly evaluations with baseline and subsequent EKGs
7763 Stress testing EKG with or without echocardiography or radionuclide scanning shall be performed as clinically indicated by history or symptoms
A7761 Baseline electrocardiography should be conducted (Periodic resting electrocardiograms have not been shown to be useful but can be reasonable as a members agefactors increase)
A7763 No firm guidelines for stress testingelectrocardiography in asymptomatic individuals have been developed Stress testingelectrocardiography as a screening tool is used as part of an evaluation of aerobic capacity during the annual occupational fitness evaluation Submaximal stress testingelectrocardiography testing to 85 percent is commonly used as part of this screening
Submaximal stress electrocardiography testing should not be used for diagnostic purposes Cardiology evaluation with maximal stress testingelectrocardiography together with imaging techniques (eg echocardiography technetium Tc99m sestamibi study andor coronary angiography) is necessary for diagnosticprognostic purposes for the following
42
(1) Fire fighters with positive or questionably positive changes on screening submaximal stress tests
(2) Fire fighters with new onset chest pain or other symptoms suggestive of coronary artery disease (CAD)
(3) Fire fighters with diabetes mellitus who
(a) are gt35 years old or
(b) have type I diabetes for more than 15 years or
(c) have type II diabetes for more than 10 years or
(d) have any other CHD risk factor (see below) or
(e) have the presence of microvascular disease (proliferative retinopathy)
(4) Fire fighters over the age of 45 (for men) and 55 (for women) with onetwo or more risk factors for CAD Risk factors for CAD include hypercholesterolemia (total cholesterol greater than 240 mgdL) hypertension (systolic gt140 mmHg or diastolic gt90 mmHg) smoking or family history of premature CAD (heart attack or sudden cardiac death in a first degree relative less than 60 years of age)
as defined below if stress electrocardiography with imaging is negative then repeat as clinically indicated or at least every 5 years
(5) Fire fighters with a Framingham Risk Score gt10 Risk calculator is available at [httphp2010nhlbihinnetatpiiicalculatorasp]
(6) Fire fighters identified in 9431
Negative stress tests should be repeated as clinically indicated or at least every 2 to 5 years
Interpreting stress tests as ldquopositiverdquo or ldquonegativerdquo is beyond the scope of this document However factors that should be taken into consideration should include the individualrsquos exercise capacity symptoms blood pressure response heart rate response EKG changes and the presence of arrhythmias (Gibbon et al 2002)
Risk factors for CAD include hypercholesterolemia (total cholesterol greater than 240 mgdL) hypertension (systolic greater than 140 andor diastolic greater than 90) smoking diabetes mellitus or family history of premature CAD (heart attack or sudden cardiac death in a first degree relative less than 60 years of age)
There are other non-invasive tests to screen for coronary artery disease One of the most promising appears to be coronary artery calcium (CAD) scoring by computed tomography In 2007 an expert committee published an update to their original guidance document The committeersquos consensus was that ldquoit may be reasonable to consider use of CAC measurement in such patients [between 10 and 20 10-year risk of estimated coronary event]helliprdquo The committee did not recommend CAC measurement in low risk patients [lt10 10-year risk of estimated coronary event] or in high risk patients [gt20 10-year risk of estimate coronary event] (Greenland et al 2007]
43
D22 Cardiology
Chobanian AV Bakris GL Black HR Cushman WC Green LA Izzo JL Jr Jones DW Materson BJ Oparil S Wright JT Jr Roccella EJ the National High Blood Pressure Education Program Coordinating Committee [2003] The seventh report of the Joint National Committee [JNC-7] on Prevention Detection Evaluation and Treatment of High Blood Pressure JAMA 2892560ndash2571
Gibbons RJ Balady GJ Bricker JT Chaitman BR Fletcher GF Froelicher VF Mark DB McCallister BD Mooss AN OrsquoReilly MG Winters WL Jr [2002] ACCAHA 2002 guideline update for exercise testing summary article a report of the ACCAHA Task Force on Practice Guidelines (Committee to Update the 1997 Exercise Testing guidelines) J Am Coll Cardiol 401531ndash 1540
Greenland et al [2007] ACCFAHA 2007 Clinical Expert Consensus Document on Coronary Artery Calcium Scoring By Computed Tomography in Global Cardiovascular Risk Assessment and in Evaluation of Patients With Chest Pain A Report of the American College of Cardiology Foundation Clinical Expert Consensus Task Force (ACCFAHA Writing Committee to Update the 2000 Expert Consensus Document on Electron Beam Computed Tomography) J Am Coll Cardiol 49378-402
Kales SN Tsismenakis AJ Zhang C Soteriades ES [2009] Blood pressure in fire fighters police officers and other emergency responders Am J Hypertens 2211-20
Schlant RC Adolph RJ DiMarco JP Dreifus LS Dunn MI Fisch C Garson A Jr Haywood LJ Levine HJ Murray JA Noble RJ Ronan JA Jr [1992] Guidelines for electrocardiography A report of the American College of CardiologyAmerican Heart Association Task Force on Assessment of Diagnostic and Therapeutic Cardiovascular Procedures (Committee on Electrocardiography) Circulation 85(3)1221-1228
Soteriades ES Kales SN Liarokapis D Christiani DC [2003] Prospective surveillance of hypertension in firefighters J Clin Hypertens 5315-320
Formatted Font Italic
Formatted Line spacing single
Formatted Font Italic
Formatted Font Italic
44
NFPA 1582‐ Draft Revisions for CVDHTN
EKG and stress tests
Reason for Revision
1) Change requirement for annual resting EKG to periodically to be more consistent with ACCAHA
recommendation (Schlant et al 1992)
2) Add language to clarify what constitutes a positive ST
3) Make criteria for conducting diagnostic ST in asymptomatic patients consistent with the
ACCAHA
Language in 2007 Edition with draft revisions in Red (Track changes)
776 Electrocardiograms (EKG) and Stress Tests 7761 A resting EKG shall be performed as part of the baseline medical evaluation and shall be obtained periodically (every 1 to 5 years) thereafter
A7761 A baseline resting EKGs shall be conducted Follow-up resting EKGs should be conducted as clinically indicated but at a minimum of every 1 to 5 years The frequency of these follow-up resting EKGs should increase as a members age increases or with increasing number andor severity of coronary heart disease risk factors Members above the age of 40 should have annual resting EKGs (Schlant et al 1992)
7762 The fire department physician or other qualified medical evaluator shall compare baseline and subsequent EKGs
7763 Stress testing with or without echocardiography or radionuclide scanning shall be performed as clinically indicated by history or symptoms
A7763 No firm guidelines for stress testing in asymptomatic individuals have been developed Stress testing as a screening tool is used as part of an evaluation of aerobic capacity during the annual occupational fitness evaluation Submaximal stress testing testing to 85 percent is commonly used as part of this screening
Submaximal stress testing should not be used for diagnostic purposes Cardiology evaluation with maximal stress testing together with imaging techniques (eg echocardiography technetium Tc99m sestamibi study) is necessary for diagnosticprognostic purposes for the following
(1) Fire fighters with positive or questionably positive changes on screening submaximal stress tests
(2) Fire fighters with new onset chest pain or other symptoms suggestive of coronary artery disease (CAD)
45
(3) Fire fighters with diabetes mellitus who
(a) are gt35 years old or
(b) have type I diabetes for more than 15 years or
(c) have type II diabetes for more than 10 years or
(d) have any other CHD risk factor (see below) or
(e) have the presence of microvascular disease (proliferative retinopathy)
(4) Fire fighters over the age of 45 (for men) and 55 (for women) with one or more risk factors for CAD Risk factors for CAD include hypercholesterolemia (total cholesterol greater than 240 mgdL) hypertension (systolic gt140 mmHg or diastolic gt90 mmHg) smoking or family history of premature CAD (heart attack or sudden cardiac death in a first degree relative less than 60 years of age)
(5) Fire fighters with a Framingham Risk Score gt10 Risk calculator is available at [httphp2010nhlbihinnetatpiiicalculatorasp]
(6) Fire fighters identified in 9431
Negative stress tests should be repeated as clinically indicated or at least every 2 to 5 years
Interpreting stress tests as ldquopositiverdquo or ldquonegativerdquo is beyond the scope of this document However factors that should be taken into consideration should include the individualrsquos exercise capacity symptoms blood pressure response heart rate response EKG changes and the presence of arrhythmias (Gibbon et al 2002)
There are other non-invasive tests to screen for coronary artery disease One of the most promising appears to be coronary artery calcium (CAD) scoring by computed tomography In 2007 an expert committee published an update to their original guidance document The committeersquos consensus was that ldquoit may be reasonable to consider use of CAC measurement in such patients [between 10 and 20 10-year risk of estimated coronary event]helliprdquo The committee did not recommend CAC measurement in low risk patients [lt10 10-year risk of estimated coronary event] or in high risk patients [gt20 10-year risk of estimate coronary event] (Greenland et al 2007]
D22 Cardiology
Resting EKG and Stress Tests
46
Chobanian AV Bakris GL Black HR Cushman WC Green LA Izzo JL Jr Jones DW Materson BJ Oparil S Wright JT Jr Roccella EJ the National High Blood Pressure Education Program Coordinating Committee [2003] The seventh report of the Joint National Committee [JNC-7] on Prevention Detection Evaluation and Treatment of High Blood Pressure JAMA 2892560ndash2571
Gibbons RJ Balady GJ Bricker JT Chaitman BR Fletcher GF Froelicher VF Mark DB McCallister BD Mooss AN OrsquoReilly MG Winters WL Jr [2002] ACCAHA 2002 guideline update for exercise testing summary article a report of the ACCAHA Task Force on Practice Guidelines (Committee to Update the 1997 Exercise Testing guidelines) J Am Coll Cardiol 401531ndash 1540
Greenland et al [2007] ACCFAHA 2007 Clinical Expert Consensus Document on Coronary Artery Calcium Scoring By Computed Tomography in Global Cardiovascular Risk Assessment and in Evaluation of Patients With Chest Pain A Report of the American College of Cardiology Foundation Clinical Expert Consensus Task Force (ACCFAHA Writing Committee to Update the 2000 Expert Consensus Document on Electron Beam Computed Tomography) J Am Coll Cardiol 49378-402
Kales SN Tsismenakis AJ Zhang C Soteriades ES [2009] Blood pressure in fire fighters police officers and other emergency responders Am J Hypertens 2211-20
Schlant RC Adolph RJ DiMarco JP Dreifus LS Dunn MI Fisch C Garson A Jr Haywood LJ Levine HJ Murray JA Noble RJ Ronan JA Jr [1992] Guidelines for electrocardiography A report of the American College of CardiologyAmerican Heart Association Task Force on Assessment of Diagnostic and Therapeutic Cardiovascular Procedures (Committee on Electrocardiography) Circulation 85(3)1221-1228
Soteriades ES Kales SN Liarokapis D Christiani DC [2003] Prospective surveillance of hypertension in firefighters J Clin Hypertens 5315-320
47
ATTACHMENT F
48
1
Current 1582 (2007) language in reference to pregnancy 43 (4) Report to the fire department physician any medical condition that could interfere with the ability of the individual to safely perform essential job tasks such as illness or injury use of prescription or nonprescription drugs and pregnancy 6112 Category B medical conditions shall include the following (1) Pregnancy for its duration A7792 (e) If HIV prophylaxis is to be given the following tests should be done i CBC ii Glucose renal and hepatic chemical function iii Pregnancy test for females B121 Pregnancy and Reproduction Federal regulations as well as many court decisions including the US Supreme Courtrsquos decision in International Union et al v Johnson Controls Inc [499 US 187 111 S Ct 1196 (1991)] have interpreted the requirements of Title VII with respect to pregnancy and reproduction The AHJ should seek the advice of counsel in resolving specific questions concerning these requirements as well as other requirements that can be imposed by state or local laws C211 (4) Review health status with the individual being evaluated Contraindications for evaluations shall be reviewed addressing any changes in the individualrsquos health status since their last medical evaluation that would warrant deferring the evaluation including (g) Pregnancy Recommendations to language enhancement
A female employee who is assigned to regular fire line duty shall report a pregnancy immediately to their respective Supervisor and the fire department physician The employee will then be given the option of a non-hazardous alternative duty position for the duration of her pregnancy (can we say this or is it even appropriate) Any pregnant employee wishing to remain on regular line duty shall be informed of the possible risks and consequences to herself and her fetus that are associated with continued line fire fighting duty Among those risk factors are exposure to teratogens known to have negative effects on the developing fetus such as smoke diesel fumes hazardous chemicals and extreme heat
49
Page 2
appendix It is recommended that the pregnant employee complete a release of liability form signed by herself and her health care provider utilizing NFPArsquos 13 critical tasks as a reference This will inform the health care provider of specific job-related tasks that will need to be performed in order to continue regular line duty These tasks are basic physical standards that any entry level firefighter would have to be able to complete competently The employeersquos health condition will be kept confidential by the department in accordance with HIPAA standards Employees are allowed to remain on active regular duty until they are no longer able to perform their duties in a reasonable manner andor their protective gear no longer fits correctly It is the responsibility of the health care provider to evaluate the pregnant employee If at any time the health care provider feels the pregnant employee can no longer perform the job related tasks this should be reported to the employer by the employee immediately
50
ATTACHMENT G
51
From GLENN BENARICKTo Sawyer SteveSubject RE RE 7743Date Monday August 30 2010 21633 PM
Yes thats my understanding
Glenn P Benarick 211 Winged Elm CircleAiken SC 29803803-644-7093gbenarprodigynet
--- On Mon 83010 Sawyer Steve ltssawyerNFPAorggt wrote
From Sawyer Steve ltssawyerNFPAorggtSubject RE RE 7743To GLENN BENARICK ltgbenarprodigynetgtDate Monday August 30 2010 212 PM
So it should be ldquoorrdquo instead of ldquoandrdquo for now
Steven F Sawyer
Senior Fire Service Specialist
Executive Secretary IFMAFire Service Section
NFPA
1 Batterymarch Park
Quincy MA 02169
6179847423
Fax 6179847056
ssawyernfpaorg
From GLENN BENARICK [mailtogbenarprodigynet] Sent Monday August 30 2010 1202 PMTo Sawyer SteveSubject Fw RE 7743
52
Steve a couple of our docs agree with April Boyer
Glenn P Benarick 211 Winged Elm Circle
Aiken SC 29803
803-644-7093
gbenarprodigynet
--- On Mon 83010 David Prezant ltprezandfdnynycgovgt wrote
From David Prezant ltprezandfdnynycgovgtSubject RE 7743To Thomas R (CDCNIOSHDSHEFS) Hales lttrh1cdcgovgt GLENNBENARICK ltgbenarprodigynetgtCc Sandy Bogucki ltsandyboguckiyaleedugtDate Monday August 30 2010 1004 AM
agree
we should change this to NHANES III rather than Knudson we should alsomodify this to allow not only for predicted cutoffs but all for use of thelower limit of normal cutoff This is important to prevent false-classificationof spirometry as abnormal in older groups and in taller grps The latter ofparticular import to firefighter occupational health surveillance
thanks
David Prezant MDChief Medical Officer Office of Medical AffairsCo-Director WTC Medical Monitoring amp Treatment ProgramsNew York City Fire Department9 Metrotech Center - Rm 4W-1Brooklyn NY 11201Phone 718-999-2696Fax 718-999-0665
Life is full of twists and turns
53
This email may contain confidential information If you are the unintendedrecipient of this email please send it back and delete from your directory
gtgtgt Hales Thomas R (CDCNIOSHDSHEFS) lttrh1cdcgovgt 8302010955 AM gtgtgt
Glen
This seems like a very reasonable comment and illustrates the importance of having clinicians providefeedback on the std Im not familiar with the software program of the various spirometers (NHANES IIIvs KnudsonATS vs both) Given the large role both Dave Prezant and Sandy Bogucki had for thepulmonary section let me forward to them for clarification
Tom
From GLENN BENARICK [mailtogbenarprodigynet] Sent Sunday August 29 2010 456 PMTo Hales Thomas R (CDCNIOSHDSHEFS)Subject FW 7743
Tom is April Boyer correct
Glenn P Benarick 211 Winged Elm Circle
Aiken SC 29803
803-644-7093
gbenarprodigynet
--- On Thu 82610 Sawyer Steve ltssawyerNFPAorggt wrote
From Sawyer Steve ltssawyerNFPAorggtSubject FW 7743To GLENN BENARICK ltgbenarprodigynetgtDate Thursday August 26 2010 925 PM
FYI Do you have any answer She is write
Steven
54
Steven F Sawyer
Senior Fire Service Specialist
Executive Secretary IFMAFire Service Section
NFPA
1 Batterymarch Park
Quincy MA 02169
6179847423
Fax 6179847056
ssawyernfpaorg
From April Boyer [mailtoaboyerbicclinicorg] Sent Thursday August 26 2010 232 PMTo Sawyer SteveCc RobinMWebbmilstateorusSubject 7743
Steven
The spirometry tests cannot be corrected according to both references as the NFPA states because thereferences are contradictory The first part of 7743 states to follow the ATS guidelines and use theKnudsen (we at Basin Immediate Care use the Nhanes III) The second part states to follow the ACOEMguidelines and use the Nhanes III in the occupational setting if available with your unit (which is availableon ours) 7743 does not use the word OR regarding both requirements it uses the word AND whenreferring to the first and second parts thence making 7743 contradictory I realize the NFPA 1582 hasnot been updated since 2007 unless I have just not received an updated version
Our question to you is which part of 7743 do you want us to follow the first or the second part Anyfacility that has an updated computerized spirometry system (as we do) will not be able to follow bothrequired parts for obvious reasons We can either follow the first part of 7743 and use an oldercorrected version of the Knudson by going into our system and changing out of the Nhanes III conversionOR we can follow the second part of 7743 and use the newer corrected version of Nhanes III which ourunit offers too
If you have any questions you may contact me at anytime and I also have many references in regards toboth parts of 7743 if you would like to see them
55
Thank you~
April
Confidentiality NoticeThis message may contain information that isconfidential or privileged
If you are not the intended recipientPlease advise the sender immediately and delete this message
56
ATTACHMENT H
57
NFPA 1582 771(7) Proposed revisions
Why
Preliminary results of two prospective randomized trials on the PSA test were published in 2009 These studies resulted in medical organizations that previously providing guidance to modify their recommendations
Current language
771 Blood Tests Blood tests shall be performed annually and shall include the following
(7) Prostate specific antigen (PSA) after age 40 for positive family history if African American or if otherwise clinically indicated after age 50 for all other male member
Suggested Revision
771 Blood Tests Blood tests shall be performed annually and shall include the following
(7) Prostate specific antigen (PSA) after age 40 for positive family history if African American or if otherwise clinically indicated after age 50 for all other male member
772 Prostate-Specific Antigen (PSA) test At age 50 fire fighters shall have an opportunity to make an informed decision with either the Fire Department physician or their health care provider concerning the PSA test For fire fighters at increased risk of prostate cancer (African-Americans or those with a first degree relative diagnosed with prostate cancer before age 65) shall have the opportunity for this informed decision at age 40
A772 The PSA as a screening test for prostate cancer in asymptomatic men is controversial controversial for two reasons First there is no consensus that PSA screening actually saves lives For example the PSA test may detect small cancers that would never become life threatening Second it is unclear that the benefits of PSA screening outweigh the risks of follow-up diagnostic tests and cancer treatments For example the prostate biopsy used to diagnose prostate cancer may cause bleeding and infection And prostate cancer treatments such as surgery and radiation therapy may cause incontinence (inability to control urine flow) erectile dysfunction (erections inadequate for intercourse) and other complications For these reasons it is important that the benefits and risks of prostate diagnostic procedures and treatment be taken into account when considering the PSA screening test These considerations can be taken account during discussions with the fire department physician or onersquos health care provider
D211 Cancer Screening
Smith R A C J Mettlin K J Davis and H Eyre 2000 ldquoAmerican Cancer Society guidelines for the early detection of cancerrdquo CA J Clin 50(1)34ndash49
Added references
58
Carroll P Albertsen PC Greene K et al [2010] Prostate-specific antigen best practice statement 2009 update Am Urological Assoc Available at httpwwwauanetorgcontentguidelines-and-quality-careclinical-guidelinesmain-reportspsa09pdf Date accessed September 2010
Ferrini R Woolf SH [2009] Screening for prostate cancer in American men American College of Preventive Medicine Practice Policy Statement Available at httpwwwacpmorgprostatehtm Date accessed September 2010
National Cancer Institute [2009] Prostate-specific antigen test National Cancer Institute Fact Sheet Available at httpwwwcancergovcancertopicsfactsheetDetectionPSA Date accessed September 2010
Wolf AMD Wender RC Etzioni RB et al [2010] American Cancer Society guideline for the early detection of prostate cancer Update 2010 Available at httpcaonlineamcancersocorgcgicontentfullcaac20066v1 Date accessed September 2010
59
Technical Committee on Fire Service Occupational Safety and Health
Meeting Minutes May 13 ndash 14 2010
Holiday Inn Inner Harbor MD
Attendees Glenn Benarick Chairman Ken Holland Staff Liaison Michael Finkelman Craig Fry Joe Rivera Stephen Raynis Steve Kreis Dennis Childress Don Stewart Phil Stittleburg David Ross Michael Laton Kim Zagaris Tom Hillenbrand Dominic Colletti Andy Schwartz Brett Bowman Guest David Bernzweig Thursday May 13 NFPA 1500 task groups (Vehicle amp Safety OPS SCBA amp Air Mgt PPEProximity) met to discuss the work they have completed since the last meeting The task groups will present their report to the entire TC on May 14th Not enough 1582 task group members were able to make the meeting so there were no reports or work from those task groups Friday May 14 TC meeting called to order at approximately 0800 by Glenn Benarick TC Chair Ken Holland (NFPA Public Fire Protection Staff) in attendance filling in for Frank Florence Ken made two presentations one on the Codes and Standards Development Process and the other on the general procedures for this Pre-ROP meeting The Staff Liaison remains fluid as Frank is not expected back any time soon
10
One guest in attendance Dave Bernzweig (Columbus OH Fire) Dave is assisting TC with SCBAAir Mgt issues The document revision cycles remain as requested NFPA 1500 amp 1582 Annual 2012 NFPA 1521 amp 1561 Fall 2013 NFPA 1581 1583 1584 Annual 2014 The October 7-9 2010 dates are the primary request for our next meeting Location is San Diego Notice will be sent out as soon as approval is received Discussion on the next revision of 1561 will be held at the October meeting regarding changing the document title to ldquoCommand Safety for Fire Department Operationsrdquo This is a suggestion of the TC Chair Ken Holland conducted a briefing for the TC on how to access and use the committee web page Staff will be posting as much information as possible up on the e-committee page for the entire committee More use will be made of this tool Discussion on monocular vision Dennis Childress presented the current issue in Ventura County CA Further discussionwork may be necessary Don Stewart agreed to take the lead Brief discussion held on pregnancy and the need for fire departments to ensure policies match current law The rep from the Diabetes Association declined the invitation to participate at this meeting due to no discussion of the issue planned She has indicated a desire to attend the October meeting There were no reports from these and all other 1582 task groups It is very important for the 1582 TG Chairs to be ready to report in October The following task group reports will be posted on the ecommittee page PPEProximity New definition of proximity fire fighting
VehicleHighway OPS Discussion on use of vehicle data recorders Collapse Zones Submission from Jay Tarley SCBAAir Mgt New exit strategy for SCBA Discussion on having the low air alarm activate when the bottle volume reaches 600 liters Further discussion to take place on ldquobuddy breathingrdquo
On Day 2 Casey Grant (NFPA Fire Protection Research Foundation) made a presentation on Research Planning for FSOSH Dr Ellen Sogolow (DHSFEMA) also present during this presentation She discussed the role of the AFGRampD activities See ecommittee page for his presentation Chair
11
will be in contact with Mr Grant for future work between the TC and the Foundation Also on Day 2 Ken Willette (Division Manager ndash NFPA Public Fire Protection Division) delivered a presentation on the initiative developed by Kelvin Cochran (US Fire Administrator) to reduce fire fighter injuries and deaths NFPA 1500 is an integral part of this initiative See ecommittee page for presentation The Chair will be coordinating a committee conference call in the coming weeks The purpose will be to review the work which needs to be completed for the October meeting The primary focus of the call will be on 1582 issues NOTE Subsequent to the meeting I have had some discussions with a fire chief in Kentucky on the use of hearing aids The TC especially the doctors need to review the current language in 1582 and decide if revisions are needed Also most of you know that Kelvin Cochran has left the USFA unexpectedly to return to Atlanta as their fire chief I have been in contact with the Acting Administrator Glenn Gaines to inform him that our committee remains focused on the work to reduce fire fighter injuries and deaths I told him that I would keep him informed of our work He indicated that one of his primary goals is to bring fire service organizations together in order to create a safe working environment Of particular interest to him is reducing heart related injuries and deaths Submitted by Glenn Benarick
12
Technical Committee on Fire Service Occupational Safety and Health
Conference Call Meeting Minutes August 30th 2010
Members participating
Glenn Benarick TC Chair
Murrey Loflin Secretary Dr Sandy Bogucki
Thomas Cuff Stephen Foley
Scott Kerwood Tammy Lopes
David Love Dr David Prezant
Joe Rivera David Ross
Mario Rueda Phil Stittleburg
Phil Vorlander Dominic Colletti
Thomas Hillenbrand
Denise Smith Brett Bowman Alternate
Andrew Schwartz Alternate Mike Young Alternate
Dr Thomas Hales Non-Voting Member Ken Holland NFPA Staff Liaison
Casey Grant NFPAResearch Foundation Staff Katie Hathway Guest from ADA
Dr Jim Fleming Guest from Phoenix Fire Dept
The chair welcomed everyone to the conference call in which he hoped
would last only an hour The purpose was to discuss any task groups that had reports for proposed changes to NFPA 1582 for the
committee This is in hopes to ensure the committee is ready for their
pre-ROP meeting in October The following topics were discussed and are in no specific order
Comments from ADA Katie Hathaway and the group went into deep
discussion regarding ones medical history and diagnosis of diabetes
13
and some proposed changesremoval of text based on research
findings The specific proposed changes will be available for the committee at their next meeting Some members on the call felt that
this issue was covered in another law enforcement document which might better serve this issue
Research topics for FSOSH projects Casey Grant offered his time to
answer any questions regarding his presentation from the May meeting in Baltimore There was also discussion about further
involvement of the Research Foundation with this committee and some of the medical requirements within the documents Glenn and Casey
are going to be in contact offline to discuss this further
Prosthetics amp Amputees report Nothing new to report
Heart amp Hypertension report There was discussion about the need for
periodic EKGrsquos that were done both in resting and non-resting states as well as discussion about stress test requirements and frequency of
such tests The hopes were to develop text that would point to annual versus periodic evaluations of EKGrsquos and stress tests
Epilepsy report Nothing new to report
Pregnancy report The initial textlanguage has been provided to the
group through email and e-committee page posting
Coagulation amp Meds report Nothing new to report
Hearing Aid discussion Nothing new to report
The committee also discussed the evaluation and documentation of
PSA results and test requirements for the purposes of consistency The proposed text and changes have been posted on the e-committee
page as well
All of the proposed text changes from the May meeting in Baltimore have been emailed out and posted on the e-committee page If there
are any questions or concerns that something was missed please contact Glenn Steven Sawyer or Ken Holland to ensure they are
resolved
The conference call lasted approximately an hour and was adjourned at 1400 hours
14
ATTACHMENT C
15
2012 ANNUAL REVISION CYCLE
PROCESS STAGE PROCESS STEP DATES
FOR TC DATES
FOR TCC 1 PRELIMINARY 10 Notification of intent to enter cycle 7910 7910
2 REPORT ON
PROPOSALS (ROP)
21 Proposal closing date 112310 112310 22 Final date for ROP meeting 22511 2411 23 Final date for mailing TC ballots 31811 21811 24 Receipt of (TC) ballots by staff liaison 42211 31111 25 Receipt of TC recirculation ballots 5611 31811 26 Final date for TCC meeting 41511 27 Final date for mailing TCC ballots 42211 28 Receipt of TCC ballots 51311 29 Receipt of TCC recirculation ballots 52011 210 Final copy (w ballot statements) to Secretary Standards Council 51311 52711 211 Completion of Reports 52011 6311 212 ROP Published and Posted 62411 62411
3 REPORT ON
COMMENTS
(ROC)
31 Comment closing date 83011 83011 32 Final date for ROC meeting 11411 10711 33 Final date for mailing TC ballots 111811 102111 34 Receipt of (TC) ballots by staff liaison 12211 111111 35 Receipt of TC recirculation ballots 12911 111811 36 Final date for TCC meeting 121611 37 Final date for mailing TCC ballots 122311 38 Receipt of TCC ballots 11312 39 Receipt of TCC recirculation ballots 12012 310 Final copy (w ballot statements) to Secretary Standards Council 122311 12712 311 Completion of Reports 11312 2312 312 ROC Published and Posted 22412 22412
4 TECH SESSION
PREPARATION amp
ISSUANCE OF
CONSENT
DOCUMENTS
41 Notice of Intent to Make a Motion (NITMAM) Closing Date 4612 4612 42 Posting of Filed NITMAM 5412 5412
43 Council Issuance Date for Consent Documents 52912 52912
44 Appeal Closing Date for Consent Documents 61312 61312
5 TECHNICAL
SESSION 50 Association Meeting for Documents with Certified Amending Motions
64-712 64-712
6
APPEALS amp
ISSUANCE OF
DOCUMENTS
WCAMS
61 Appeal closing date for Documents with Certified Amending Motions
62712 62712
62 Council issuance for Documents with Certified Amending Motions 8912 8912
Proposal Closing Dates may vary according to documents and schedules for Revision Cycles may change Please check the NFPA website (wwwnfpaorg) for the most up-to-date information on proposal closing dates and schedules
16
ATTACHMENT D
17
This weekrsquos conference call mentioned the Diabetes chapter written for the ACOEM document Guidance for the Medical Evaluation of the Law Enforcement Officer The task group working on this chapter (led Richard Miller of the Secret Service and our very own Dan Samo) worked with the ADA or over 2-3 years to come up with a consensus document
Please find the Chapter attached ltltDiabetes Guidance Sept 2010pdfgtgt
Regarding Dan Loeberrsquos points
1) Physical Evaluation Form - We could modify the LEO form (see end of the attached Chapter)
2) Duration required for stable regiment
1582 for IDDM Type 1 1 yr
Type 2 6 m
Oral Agents None specifically
ACOEM Police for IDDM Type 1 6m
Type 2 3m
Oral Agents 1m
The police document is much clearer about the decision regarding medical fitness for duty is the responsibility of the police physician with the treating diabetes-expert physician providing the data to the police physician to make an informed decision In this regard the police officer must provide the police physician with downloaded self monitoring glucose data for the 1 3 and 6 month time periods (see section 433)
3) HA1C ndash NFPA lt 8 over 3 month period
ACOEM Police ndash (Section 4333) Specifies the frequency on measurement and if gt8 requires further evaluation
Some other discrepancies End organ complications
NFPA ndash end organ complications (eye kidney heart neuro) ndash restriction
ACOEM Police ndash end organ complication -- requires further evaluation
18
Hypoglycemia (incapacitating ndash defined differently between the two documents (434)
NFPA ndash 0 episodes in past year le1 in past 5 yrs
ACOEM Police ndash 0 episodes in past year le2 in past 3 yrs
Given Dan Samorsquos and Richard Millerrsquos work with the ADALoeber it would be helpful to get their opinions on whether any of the changes requested by Loeber are appropriate for FF with DM
Tom
Thomas Hales MD MPH
Senior Medical Epidemiologist
NIOSH CDC
4676 Columbia Pkwy R-9
Cincinnati OH 45241
(513) 841-4583
trh1cdcgov
19
43 ndash DIABETES MELLITUS
431 ndash INTRODUCTION
The educated and motivated law enforcement officer (LEO) with well-managed diabetes mellitus can be capable of
safe and effective job performance1 However diabetes mellitus may place LEOs at risk for sudden incapacitation
thus jeopardizing their ability to perform critical job functions (These job functions include those listed in Sections
32 333 351 352 36 and 37 and discussed in Appendix A)
Therefore an individualized assessment of the LEOrsquos diabetes should be performed using the following evaluative
criteria to determine whether the individuals condition permits safe and effective job performance Such evaluation
must include the following key elements which are discussed in detail below
history of blood glucose control
knowledge of diabetes and its management
current stability of blood glucose
risk for significant hypoglycemia or hyperglycemia and
presence of diabetic complications
432 ndash OVERVIEW OF MEDICAL EVALUATION
The treating endocrinologist or other physician knowledgeable regarding diabetes management should provide
a narrative report certifying whether the LEO has or has not met the criteria set out in Sections 4321 through
4354 below In addition the physician should include supporting data (see Appendix B for the Physician Evalu-
ation Form)
4321 The LEO is under the care of an endocrinologist or other physician knowledgeable regarding diabetes
management Outpatient and in-patient medical record(s) for the last 3 years or since date of diagnosis
(whichever is shorter) should be reviewed by the treating physician and provided to the police physician
4322 If the LEO has type 1 diabetes the individual has been on a basalbolus regimena or an insulin pump
using analogue insulins for the 6 months prior to evaluation2
4323 If the LEO has type 2 diabetes on insulin the individual has been on a stable medication regimenb
for the 3 months prior to evaluation3 If on oral agents alone the LEO has been on a stable medication regimen
for the month prior to evaluationc
ACOEM Guidance for the Medical Evaluation of Law Enforcement Officers 1
43 ndash DIABETES MELLITUS
aA basalbolus insulin regimen consists of the use of a basal insulin (Glargine NPH) in a once or twice daily regimen to provide between-
meal insulin combined with the use of a short acting insulin (Regular Lispro Aspart or Glulisine) at mealtimes Insulin pumps are small
(beeper sized) battery powered devices that deliver small amounts of short-acting insulin in a constant infusion to meet basal insulin
requirements The wearer selects an additional mealtime bolus to be infused at the time of meals For more information on pumps visit
the manufacturerrsquos web sites ndash wwwMinimedcom wwwcozmorecom wwwanimascorpcom wwwdisetroniccom
bA stable insulin regimen is defined as maintaining the same types of insulin (long acting intermediate acting short or rapid acting)
Changes in insulin dose are part of the appropriate self-management of diabetes and do not disqualify an applicant or incumbent under
this section
cChanges in dose within the evaluation period will be allowed but addition of a new class of medications or insulin should result in a new
period of observation
one month for addition of a sulfonylurea or metformin
two months for the addition of a thiazolidinedione to insulin or a sulfonylurea or
three months for the addition of insulin
20
4324 If the LEO uses an insulin pump documentation is needed as follows
proper understanding and education in the use of the insulin pump
start date for the use of the pump
history of insulin site infectionsd
history of pump cessation and pump malfunction
backup plan for pump malfunction including use of injectable insulin and
frequency of infusion set changes
4325 The LEO has been educated in diabetes and its management and thoroughly informed of and under-
stands the procedures that must be followed to monitor and manage hisher diabetes and what procedures
should be followed if complications arise3
433 ndash QUANTITATIVE GLUCOSE MONITORING
4331 The LEO has documentation of ongoing self-monitoring of blood glucose
4332 This must be done with a glucose meter that stores every reading records date and time of reading
and from which data can be downloaded (Most meters now have this capability)
4333 Monitoring logs must be available covering the time period (1 3 or 6 months) as described in
Sections 4322 and 4323 The frequency of glucose monitoring must follow a schedule acceptable to the
police physician in consultation with the treating physician
Testing schedules are individual What follows is a common pattern but individual patterns may differ
2 ACOEM Guidance for the Medical Evaluation of Law Enforcement Officers
43 ndash DIABETES MELLITUS
dIndividual has not had more than one pump-site infection that caused him or her to miss work or usual daily activities in the preceding 6
months
THERAPEUTIC REGIMEN GLUCOSE TESTING SCHEDULE
Diet alone Once or twice a week
Metformin Thiazolidinediones or Alpha
Glucosidase inhibitors alone or in
combination
Once or twice a week
Sulfonylureas meglitanides nateglinide ndash
alone or in combination with the above group
Twice a day ndash AM and at supper with any
suspected hypoglycemic episodes
Insulin ndash one shot in combination with orals Twice a day ndash AM and at supper with any
suspected hypoglycemic episodes
2 to 3 times AM once a week
Insulin ndash two or more shots Insulin pump 3 to 4 times a day ndash at meals and bedtime
2 to 3 times AM once a week with any
suspected hypoglycemic episodes
21
4334 The LEO has had hemoglobin A1C measured at least 4 times a year (intervals of 2 to 3 months) over
the last 12 months prior to evaluation if diagnosis has been present for more than a year4 If hemoglobin A1C is
gt8 this may signal a problem with the LEOrsquos diabetes management that warrants further assessment5
434 ndash INCAPACITATING EVENTS
4341 The LEO has not had any incapacitating episodes within the past 1 year and no more than 2 episodes
in the past 3 years or since diagnosis of diabetes (whichever is shorter) of
43411 Severe hypoglycemia (loss of consciousness seizures or coma requiring assistance of others or
needing urgent treatment [glucagon injectionIV glucose]) or
43412 Blood sugar lt60 mgdl with unawareness demonstrated in current glucose logs6
435 ndash CHRONIC COMPLICATION SCREENING
4351 Chronic complications of diabetes are associated with increased risk for severe hypoglycemic
episodes and warrant further assessmente
4352 The components of screening for chronic complications are
43521 A complete eye exam by a qualified ophthalmologist or optometrist including a dilated retinal
exam demonstrating no more than mild background diabetic retinopathyf7
43522 Normal vibratory testing with a 128 Hz tuning forkg normal testing with 10 gram Semmes-
Weinstein monofilamentg and normal orthostatic blood pressureh and pulse testing89
ACOEM Guidance for the Medical Evaluation of Law Enforcement Officers 3
43 ndash DIABETES MELLITUS
ePresence of chronic complications of diabetes in and of themselves may not require the implementation of work restrictions
fNo more than one dot blot or flame-shaped hemorrhages or microaneurysm in all four fundus quadrants
gThe Michigan Diabetes Research and Training Center of the University of Michigan Health System recommends the following guidance
(see wwwmedumichedumdrtcprofsdocumentssviMNSI_howtopdf) for conducting vibratory and monofilament testing8
Vibration Sensation Vibration sensation should be performed with the great toe unsupported Vibration sensation will be tested bi-
laterally using a 128 Hz tuning fork placed over the dorsum of the great toe on the boney prominence of the DIP joint Patients whose
eyes are closed will be asked to indicate when they can no longer sense the vibration from the vibrating tuning fork In general the
examiner should be able to feel vibration from the hand-held tuning fork for 5 seconds longer on his distal forefinger than a normal subject
can at the great toe (eg examiners DIP joint of the first finger versus patients toe) If the examiner feels vibration for 10 or more seconds
on his or her finger then vibration is considered decreased A trial should be given when the tuning fork is not vibrating to be certain that
the patient is responding to vibration and not pressure or some other clue Vibration is scored as 1) present if the examiner senses the
vibration on his or her finger for lt10 seconds 2) reduced if sensed for 10 seconds or 3) absent (no vibration detection)
Monofilament Testing For this examination it is important that the patients foot be supported (ie allow the sole of the foot to rest on
a flat warm surface) The filament should initially be pre-stressed (4-6 perpendicular applications to the dorsum of the examiner s first
finger) The filament is then applied to the dorsum of the great toe midway between the nail fold and the DIP joint Do not hold the toe
directly The filament is applied perpendicularly and briefly (lt1 second) with an even pressure When the filament bends the force of
10 grams has been applied The patient whose eyes are closed is asked to respond yes if heshe feels the filament Eight correct responses
out of 10 applications is considered normal 1 to 7 correct responses indicates reduced sensation and no correct answers translates into
absent sensation
hOrthostatic hypotension is a physical finding defined by the American Autonomic Society and the American Academy of Neurology as a
systolic blood pressure decrease of at least 20 mm Hg or a diastolic blood pressure decrease of at least 10 mm Hg within 3 minutes of
standing
22
43523 Normal cardiac physical exam Cardiac stress testing to at least 12 METS is recommended and
should begin based on either the criteria of the American Heart AssociationAmerican College of
Cardiologyi10 or those of the American Diabetes Associationj11
Diabetics who have a normal cardiac stress test will be retested every one to three years based on
individual clinical assessment This assessment should consider
the age of the individual
the number and persistence of coronary artery disease (CAD) risk factors
the severity of CAD risk factors
43524 Microalbumincreatinine ratio 301 measured or calculatedk creatinine clearance
gt60 mlmin12
436 ndash ONGOING EVALUATION AND REQUIREMENTS
4361 Should have medical records and glucose meter logs reviewed periodically Because of the nature of
diabetes it is important that regular medical follow up be provided to the LEO The frequency and content of
the evaluation should be determined on an individual basis by the police physician in consultation with the
treating physicianl
4362 Must advise police physician of any change in type of medication
4363 Must advise police physician of any episodes of significant hypoglycemia or hyperglycemia
Urine microalbumincreatinine ratio _________________
III Treating Physician Statement
The above named individual meets all of the criteria provided on this form
Yes No ndash not recommended for position
No but IS recommended for position (letter of explanation attached)
It is my opinion that the above named individual is well-educated and well-motivated in diabetes self-management and has
achieved a level of diabetes management to be capable of safe and effective job performance as a law enforcement officer
I have reached this opinion after careful review of the above criteria
___________________________________________________________ ___________________________Signature of Physician Date
______________________________________________________________ ___________________________Printed or Typed Name of Physician Telephone Number
10 ACOEM Guidance for the Medical Evaluation of Law Enforcement Officers
43 ndash DIABETES MELLITUS
29
439 ndash REFERENCES
1 American Diabetes Association Diagnosis and classification of diabetes mellitus Diabetes Care 200427 Suppl
1S5-S10 See httpcarediabetesjournalsorgcgicontentfull27suppl_1s5
2 American Diabetes Association Continuous subcutaneous insulin infusion Diabetes Care 200427 Suppl 1S110
See httpcarediabetesjournalsorgcgicontentfull27suppl_1s110
3 Mensing C Boucher J Cypress M et al National standards for diabetes self-management education Diabetes
Care 200528 Suppl 1S72-9 See httpcarediabetesjournalsorgcgicontentfull28suppl_1s72
4 Goldstein DE Little RR Lorenz RA Malone JI Nathan DM Peterson CM American Diabetes Association Tests
of glycemia in diabetes Diabetes Care 200427 Suppl 1S91-3
See httpcarediabetesjournalsorgcgicontentfull27suppl_1s91
5 The Diabetes Control and Complications Trial Research Group Hypoglycemia in the Diabetes Control and
Complications Trial Diabetes 199746(2)271-86 See wwwncbinlmnihgovpubmed9000705 for abstract
6 American Diabetes Association Hypoglycemia and employmentlicensure Diabetes Care 200528 Suppl 1S61
See httpcarediabetesjournalsorgcgicontentfull28suppl_1s61
7 Viswanath K McGavin DD Diabetic Retinopathy Clinical Findings and Management J Comm Eye Health
200316(46)21-4 See wwwcehjournalorg0953-683316jceh_16_46_021html
8 Michigan Diabetes Research and Training Center University of Michigan Health System How to use the Michigan
Neuropathy Screening Instrument See wwwmedumichedumdrtcprofsdocumentssviMNSI_howtopdf
9 Bradley JG Davis KA Orthostatic hypotension Am Fam Physician 200368(12)2393-8
See wwwaafporgafp200312152393html
10 Gibbons RJ Balady GJ Bricker JT et al ACCAHA 2002 guideline update for exercise testing a report of the
American College of CardiologyAmerican Heart Association Task Force on Practice Guidelines (Committee on
Exercise Testing) J Am Coll Cardiol 200240(8)1531-40
See wwwaccorgqualityandscienceclinicalguidelinesexerciseexercise_cleanpdf
11 American Diabetes Association Standards of medical care in diabetes Diabetes Care 200528 Suppl 1S4-S36
Erratum in Diabetes Care 200528(4)990 See httpcarediabetesjournalsorgcgicontentfull28suppl_1s4
12 Molitch ME DeFronzo RA Franz MJ et al American Diabetes Association Nephropathy in diabetes Diabetes
Care 200427 Suppl 1S79-83 See httpcarediabetesjournalsorgcgicontentfull27suppl_1s79
13 Kitabchi AE Umpierrez GE Murphy MB et al American Diabetes Association Hyperglycemic crises in diabetes
Diabetes Care 200427 Suppl 1S94-102 See httpcarediabetesjournalsorgcgicontentfull27suppl_1s94
14 US Centers for Disease Control and Prevention National Diabetes Fact Sheet 2007
See wwwcdcgovdiabetespubspdfndfs_2007pdf
ACOEM Guidance for the Medical Evaluation of Law Enforcement Officers 11
43 ndash DIABETES MELLITUS
30
ATTACHMENT E
31
Typos A6921(2) 7th line down test should be plural 94201 Paragraph 2 target organ damage is used though end organ damage was defined earlier and in the appendix for that paragraph
A94201 Para A (1) d Id suggest deleting the phrases in brackets Im not sure either are predictably true or politically wise
a) tests for left ventricular hypertrophy Unfortunately use of the EKG to detect left ventricular hypertrophy is very insensitive (eg 5 sensitivity) The echocardiogram is the best test for diagnosing left ventricular hypertrophy but [it is relatively expensive and not readily available in small rural communities ] conducting echocardiograms on asymptomatic fire fighters with Stage 1 hypertension should be reserved only for those with long-standing hypertension
In addition
7761 A resting EKG shall be performed as part of the baseline medical evaluation and shall be obtained periodically thereafter
Changing from annually to periodically is noted has the language in the wellness-fitness initiative been changed as well Our previous decision was that we would support the W-F language since there was no compelling evidence to either support or refute it
Thanks
Sandy
32
NFPA 1582‐ HTN Draft 1
Reason for Revision
1) New classification of BP by the Joint National Commission [Chobanian et al 2002]
2) A high prevalence of FF have either HTN (~20) and Pre‐HTN (~20) [Soteriades et al 2003]
3) Among FF studies have shown a strong association between HTN and a number of adverse
cardiovascular events [Kales et al 2009]
4) A large percentage of on‐duty FF fatalities were found to have left ventricular hypertrophy a
complication of HTN at autopsy
Language in 2007 Edition with draft revisions in Red (Track changes)
611 The medical evaluation of a candidate shall include a medical history examination and any laboratory tests required to detect physical or medical condition(s) that could adversely affect hisher ability to safely perform the essential job tasks outlined in 511 A611 The medical history should include the candidates known health problems such as major illnesses surgeries medication use and allergies Symptom review is also important for detecting early signs of illness A medical history should also include a personal health history a family health history a health habit history an immunization history and a reproductive history
An occupational history should also be obtained to collect information about the persons past occupational and environmental exposures
(a) BP should be measured according to the Joint National Commission (JNC) -7 recommendations BP should be measured with a properly calibrated and validated instrument Patients should be seated quietly for at least 5 minutes in a chair with feet on the floor and arm supported at heart level An appropriate-sized cuff (cuff bladder encircling at least 80 of the arm) should be used to ensure accuracy At least 2 measurements should be made Systolic BP is the point at which the first of 2 or more sounds is heard (phase 1) and diastolic BP is the point before the disappearance of sounds (phase 5) [Chobanian et al 2003]
(2) Head eyes ears nose and throat (HEENT)
Formatted Font (Default) Times New RomanFont color Black
33
692 Vascular System 6921 Category A medical conditions shall include the following
(1) Uncontrolled or poorly controlled hypertension
(2) Hypertension with evidence of end organ damage
or not controlled by approved medications
A6921(1) Uncontrolled or poorly controlled hHypertension increases the risk of a sudden cardiac event This sudden cardiac event would cause sudden incapacitation which that is uncontrolled poorly controlled or requires medication likely to interferes with the safe performance of essential job tasks Uncontrolled or poorly controlled hypertension can be defined as the presence of end organ damage (see below) or stage 2 hypertension (BP systolic gt160 mmHg or BP diastolic gt100 mmHg) is an illness that can lead to functional impairment and potential for sudden incapacitation Individuals with pre- stage 1 or stage 2 hypertension should be referred to their primary care physician for evaluation lifestyle modification and treatment [QUESTION FOR GROUP _- WHAT ABOUT HAVING CANDIDATE RETURN IN ONE MONTH UNDER TREATMENT WITH NORMAL BP]
A6921(2)
Chronic hypertension can damage the eye (retinopathy) the kidneys (nephropathy) the vascular system (stroke transient ischemic attack or peripheral artery disease) or the heart (left ventricular hypertrophy and heart failure) These hypertension complications are known as end organ damage The cardiac and vascular complications are associated with an increased risk of sudden incapacitation and sudden cardiac death (Koren et al 1991) Unfortunately the cardiac complications are frequently asymptomatic and valid screening tests are not fast and are not inexpensive Therefore determining who to screen for cardiac complications (such as echocardiogram for LVH or a measurement of left ventricular ejection fraction for heart failure) should be based on the severity and the duration of HTN
76 Physical Examination The annual physical examination shall include each of the following components
(a) BP shall be measured according to the Joint National Commission (JNC)-7 recommendations
A76(1)(a) BP should be measured with a properly calibrated and validated instrument Patients should be seated quietly for at least 5 minutes in a chair with feet on the floor and arm supported at heart level An appropriate-sized cuff (cuff bladder encircling at least 80 of the arm) should be used to ensure accuracy At least 2 measurements should be made Systolic BP is the point at which the first of 2 or more sounds is heard (phase 1) and diastolic BP is the point before the disappearance of sounds (phase 5) [Chobanian et al 2003]
(2) Head eyes ears nose and throat (HEENT)
34
9420 Uncontrolled Hypertension 94201 Physician Evaluation Severe uncontrolled hypertension [defined as systolic pressure greater than 180 mm Hg diastolic pressure greater than 100 mm Hg or mean systolic blood
pressure ( systolic + diastolic) greater than 120 mm Hg] or malignant hypertension (defined as hypertension with the presence of target organ damage) compromises the members ability to safely perform essential job tasks 1 5 7 9 and 13 and the physician shall report the applicable job limitations to the fire department
Members with Pre-hypertention (systolic 120-139 mmHg or diastolic 80-89 mmHg) Stage 1 hypertension (systolic 140-159 mmHg or diastolic 90-99 mmHg) or Stage 2 hypertension (systolic ge160 mmHg or diastolic ge100 mmHg) should be referred to their primary care physician for evaluation lifestyle modification and treatment
(1) Members with Stage I hypertension should be followed-up not only by their primary care physician but also by the FD physician every 3 to 6 months to ensure their blood pressure is under control and to determine whether screening tests for asymptomatic end organ damage are appropriate
(2) Members with Stage 2 hypertension or with end organ damage (retinopathy nephropathy vascular or cardiac complications) compromises the members ability to safely perform essential job tasks 1 5 7 9 and 130 and the physician shall report the applicable job limitations to the fire department
A94201 Severe uncontrolled hypertension is a significant risk factor for the development of coronary artery disease congestive heart failure and stroke Blood pressure increases as a normal response to exercise This response is further exaggerated by the emotional and physical stress of performing these critical tasks while operating in personal protective clothing at extremes of temperature This normal elevation of blood pressure under these response conditions can lead to life-threatening hypertensive emergencies if a members daily blood pressure is already elevated to high levels In addition hypertension is a progressive illness that when uncontrolled ultimately and inevitably leads to target organ damage Target organs that are sensitive to the effects of elevated blood pressure are the central nervous system vision heart major blood vessels and kidneys
Chronic hypertension can damage the eye (retinopathy) the kidneys (nephropathy) the vascular system (stroke transient ischemic attack or peripheral artery disease) or the heart (left ventricular hypertrophy and heart failure) These hypertension complications are known as end organ damage The cardiac and vascular complications are associated with an increased risk of sudden incapacitation and sudden cardiac death (Koren et al 1991) Fortunately with proper evaluation life style modification and treatment these complications can be avoided Life style modification includes weight reduction DASH eating plan reduction in dietary sodium an increase in aerobic physical activity and moderation in alcohol consumption [Chobanian 2003]
Formatted Font (Default) Times New Roman12 pt Font color Black
Formatted Font (Default) Times New Roman12 pt Font color Black
35
A94201 (1) Members with Stage I hypertension whose BP returns to either pre-hypertenion or normal with lifestyle modification andor treatment can return to an annual medical evaluation For members with long-standing Stage I hypertension whose BP has not been reduced additional evaluation for possible end organ damage should be considered This evaluation could include any or all of the following
a) a compete patient history for symptoms of heart failure (eg shortness of breath upon exertion) or transient ischemic attacks (TIAs)
b) dilated eye examination for retinopathy
c) blood creatinine measurement for nephropathy
d) tests for left ventricular hypertrophy Unfortunately use of the resting EKG to detect left ventricular hypertrophy is very insensitive (eg 5 sensitivity) The echocardiogram is the best test for diagnosing left ventricular hypertrophy
A 94201 (2) Due to the high risk of a sudden cardiovascular event members with Stage 2 hypertension should be restricted until their BP can be brought under control Once the BP is brought under control they should be followed in the same manner as a member with Stage I hypertension
Formatted Font (Default) Times New Roman12 pt
36
D22 Cardiology Gibbons R J GJ Balady J W Beasley et al 1997 ACCAHA guidelines for exercise testing a report of American College of CardiologyAmerican Heart Association Task Force on Practice Guidelines (Committee on Exercise Testing) J Am Coll Cardiol 30260ndash311
Gibbons RJ Balady GJ Bricker JT Chaitman BR Fletcher GF Froelicher VF Mark DB McCallister BD Mooss AN OrsquoReilly MG Winters WL Jr [2002] ACCAHA 2002 guideline update for exercise testing summary article a report of the ACCAHA Task Force on Practice Guidelines (Committee to Update the 1997 Exercise Testing guidelines) J Am Coll Cardiol 401531ndash 40
Chobanian AV Bakris GL Black HR Cushman WC Green LA Izzo JL Jr Jones DW Materson BJ Oparil S Wright JT Jr Roccella EJ the National High Blood Pressure Education Program Coordinating Committee [2003] The seventh report of the Joint National Committee [JNC-7] on Prevention Detection Evaluation and Treatment of High Blood Pressure JAMA 2892560ndash2571
Soteriades ES Kales SN Liarokapis D Christiani DC [2003] Prospective surveillance of hypertension in firefighters J Clin Hypertens 5315-320
Kales SN Tsismenakis AJ Zhang C Soteriades ES [2009] Blood pressure in fire fighters police officers and other emergency responders Am J Hypertens 2211-20
37
NFPA 1582‐ HTN Draft 1
Reason for Revision
1) New classification of BP by the Joint National Commission [Chobanian et al 2002]
2) A high prevalence of FF have either HTN (~20) and Pre‐HTN (~20) [Soteriades et al 2003]
3) Among FF studies have shown a strong association between HTN and a number of adverse
cardiovascular events [Kales et al 2009]
4) A large percentage of on‐duty FF fatalities were found to have left ventricular hypertrophy a
complication of HTN at autopsy
Language in 2007 Edition with draft revisions in Red (Track changes)
611 The medical evaluation of a candidate shall include a medical history examination and any laboratory tests required to detect physical or medical condition(s) that could adversely affect hisher ability to safely perform the essential job tasks outlined in 511 A611 The medical history should include the candidates known health problems such as major illnesses surgeries medication use and allergies Symptom review is also important for detecting early signs of illness A medical history should also include a personal health history a family health history a health habit history an immunization history and a reproductive history
An occupational history should also be obtained to collect information about the persons past occupational and environmental exposures
(a) BP should be measured according to the Joint National Commission (JNC) -7 recommendations BP should be measured with a properly calibrated and validated instrument Patients should be seated quietly for at least 5 minutes in a chair with feet on the floor and arm supported at heart level An appropriate-sized cuff (cuff bladder encircling at least 80 of the arm) should be used to ensure accuracy At least 2 measurements should be made Systolic BP is the point at which the first of 2 or more sounds is heard (phase 1) and diastolic BP is the point before the disappearance of sounds (phase 5) [Chobanian et al 2003]
(2) Head eyes ears nose and throat
38
692 Vascular System 6921 Category A medical conditions shall include the following
(1) Uncontrolled or poorly controlled hypertension
(2) Hypertension with evidence of end organ damage
A6921(1) Uncontrolled or poorly controlled hypertension increases the risk of a sudden cardiac event This sudden cardiac event would cause sudden incapacitation which interferes with the safe performance of essential job tasks Uncontrolled or poorly controlled hypertension can be defined as the presence of end organ damage (see below) or stage 2 hypertension (BP systolic gt160 mmHg or BP diastolic gt100 mmHg) Individuals with pre- stage 1 or stage 2 hypertension should be referred to their primary care physician for evaluation lifestyle modification and treatment [QUESTION FOR GROUP _- WHAT ABOUT HAVING CANDIDATE RETURN IN ONE MONTH UNDER TREATMENT WITH NORMAL BP]
A6921(2)Chronic hypertension can damage the eye (retinopathy) the kidneys (nephropathy) the vascular system (stroke transient ischemic attack or peripheral artery disease) or the heart (left ventricular hypertrophy and heart failure) These hypertension complications are known as end organ damage The cardiac and vascular complications are associated with an increased risk of sudden incapacitation and sudden cardiac death (Koren et al 1991) Unfortunately the cardiac complications are frequently asymptomatic and valid screening tests are not fast and are not inexpensive Therefore determining who to screen for cardiac complications (such as echocardiogram for LVH or a measurement of left ventricular ejection fraction for heart failure) should be based on the severity and the duration of HTN
76 Physical Examination The annual physical examination shall include each of the following components
(a) BP shall be measured according to the Joint National Commission (JNC)-7 recommendations
A76(1)(a) BP should be measured with a properly calibrated and validated instrument Patients should be seated quietly for at least 5 minutes in a chair with feet on the floor and arm supported at heart level An appropriate-sized cuff (cuff bladder encircling at least 80 of the arm) should be used to ensure accuracy At least 2 measurements should be made Systolic BP is the point at which the first of 2 or more sounds is heard (phase 1) and diastolic BP is the point before the disappearance of sounds (phase 5) [Chobanian et al 2003]
(2) Head eyes ears nose and throat9420 Hypertension 94201 Physician Evaluation Members with Pre-hypertention (systolic 120-139 mmHg or diastolic 80-89 mmHg) Stage 1 hypertension (systolic 140-159 mmHg or diastolic 90-99 mmHg) or Stage 2 hypertension (systolic ge160 mmHg or diastolic ge100 mmHg) should be referred to their primary care physician for evaluation lifestyle modification and treatment
39
(1) Members with Stage I hypertension should be followed-up not only by their primary care physician but also by the FD physician every 3 to 6 months to ensure their blood pressure is under control and to determine whether screening tests for asymptomatic end organ damage are appropriate
(2) Members with Stage 2 hypertension or with end organ damage (retinopathy nephropathy vascular or cardiac complications) compromises the members ability to safely perform essential job tasks 1 5 7 9 and 130 and the physician shall report the applicable job limitations to the fire department
A94201 Chronic hypertension can damage the eye (retinopathy) the kidneys (nephropathy) the vascular system (stroke transient ischemic attack or peripheral artery disease) or the heart (left ventricular hypertrophy and heart failure) These hypertension complications are known as end organ damage The cardiac and vascular complications are associated with an increased risk of sudden incapacitation and sudden cardiac death (Koren et al 1991) Fortunately with proper evaluation life style modification and treatment these complications can be avoided Life style modification includes weight reduction DASH eating plan reduction in dietary sodium an increase in aerobic physical activity and moderation in alcohol consumption [Chobanian 2003]
A94201 (1) Members with Stage I hypertension whose BP returns to either pre-hypertenion or normal with lifestyle modification andor treatment can return to an annual medical evaluation For members with long-standing Stage I hypertension whose BP has not been reduced additional evaluation for possible end organ damage should be considered This evaluation could include any or all of the following
a) a compete patient history for symptoms of heart failure (eg shortness of breath upon exertion) or transient ischemic attacks (TIAs)
b) dilated eye examination for retinopathy
c) blood creatinine measurement for nephropathy
d) tests for left ventricular hypertrophy Unfortunately use of the resting EKG to detect left ventricular hypertrophy is very insensitive (eg 5 sensitivity) The echocardiogram is the best test for diagnosing left ventricular hypertrophy
A 94201 (2) Due to the high risk of a sudden cardiovascular event members with Stage 2 hypertension should be restricted until their BP can be brought under control Once the BP is brought under control they should be followed in the same manner as a member with Stage I hypertension
D22 Cardiology
40
Hypertension
Gibbons RJ Balady GJ Bricker JT Chaitman BR Fletcher GF Froelicher VF Mark DB McCallister BD Mooss AN OrsquoReilly MG Winters WL Jr [2002] ACCAHA 2002 guideline update for exercise testing summary article a report of the ACCAHA Task Force on Practice Guidelines (Committee to Update the 1997 Exercise Testing guidelines) J Am Coll Cardiol 401531ndash 40
Chobanian AV Bakris GL Black HR Cushman WC Green LA Izzo JL Jr Jones DW Materson BJ Oparil S Wright JT Jr Roccella EJ the National High Blood Pressure Education Program Coordinating Committee [2003] The seventh report of the Joint National Committee [JNC-7] on Prevention Detection Evaluation and Treatment of High Blood Pressure JAMA 2892560ndash2571
Soteriades ES Kales SN Liarokapis D Christiani DC [2003] Prospective surveillance of hypertension in firefighters J Clin Hypertens 5315-320
Kales SN Tsismenakis AJ Zhang C Soteriades ES [2009] Blood pressure in fire fighters police officers and other emergency responders Am J Hypertens 2211-20
41
NFPA 1582‐ Draft Revisions for CVDHTN
EKG and stress tests
Reason for Revision
1) Change requirement for annual resting EKG to periodically to be more consistent with ACCAHA
recommendation (Schlant et al 1992)
2) Add language to clarify what constitutes a positive ST
3) Make criteria for conducting diagnostic ST in asymptomatic patients consistent with the
ACCAHA
Language in 2007 Edition with draft revisions in Red (Track changes)
776 Electrocardiograms (EKG)) and Stress Tests 7761 A resting EKG shall be performed as part of the baseline medical evaluation and shall be obtained periodically (every 1 to 5 years) annually thereafter
A7761 A baseline resting EKGs shall be conducted Follow-up resting EKGs should be conducted as clinically indicated but at a minimum of every 1 to 5 years The frequency of these follow-up resting EKGs should increase as a members age increases or with increasing number andor severity of coronary heart disease risk factors Members above the age of 40 should have annual resting EKGs (Schlant et al 1992)
7762 The fire department physician or other qualified medical evaluator shall compare EKGs obtained during yearly evaluations with baseline and subsequent EKGs
7763 Stress testing EKG with or without echocardiography or radionuclide scanning shall be performed as clinically indicated by history or symptoms
A7761 Baseline electrocardiography should be conducted (Periodic resting electrocardiograms have not been shown to be useful but can be reasonable as a members agefactors increase)
A7763 No firm guidelines for stress testingelectrocardiography in asymptomatic individuals have been developed Stress testingelectrocardiography as a screening tool is used as part of an evaluation of aerobic capacity during the annual occupational fitness evaluation Submaximal stress testingelectrocardiography testing to 85 percent is commonly used as part of this screening
Submaximal stress electrocardiography testing should not be used for diagnostic purposes Cardiology evaluation with maximal stress testingelectrocardiography together with imaging techniques (eg echocardiography technetium Tc99m sestamibi study andor coronary angiography) is necessary for diagnosticprognostic purposes for the following
42
(1) Fire fighters with positive or questionably positive changes on screening submaximal stress tests
(2) Fire fighters with new onset chest pain or other symptoms suggestive of coronary artery disease (CAD)
(3) Fire fighters with diabetes mellitus who
(a) are gt35 years old or
(b) have type I diabetes for more than 15 years or
(c) have type II diabetes for more than 10 years or
(d) have any other CHD risk factor (see below) or
(e) have the presence of microvascular disease (proliferative retinopathy)
(4) Fire fighters over the age of 45 (for men) and 55 (for women) with onetwo or more risk factors for CAD Risk factors for CAD include hypercholesterolemia (total cholesterol greater than 240 mgdL) hypertension (systolic gt140 mmHg or diastolic gt90 mmHg) smoking or family history of premature CAD (heart attack or sudden cardiac death in a first degree relative less than 60 years of age)
as defined below if stress electrocardiography with imaging is negative then repeat as clinically indicated or at least every 5 years
(5) Fire fighters with a Framingham Risk Score gt10 Risk calculator is available at [httphp2010nhlbihinnetatpiiicalculatorasp]
(6) Fire fighters identified in 9431
Negative stress tests should be repeated as clinically indicated or at least every 2 to 5 years
Interpreting stress tests as ldquopositiverdquo or ldquonegativerdquo is beyond the scope of this document However factors that should be taken into consideration should include the individualrsquos exercise capacity symptoms blood pressure response heart rate response EKG changes and the presence of arrhythmias (Gibbon et al 2002)
Risk factors for CAD include hypercholesterolemia (total cholesterol greater than 240 mgdL) hypertension (systolic greater than 140 andor diastolic greater than 90) smoking diabetes mellitus or family history of premature CAD (heart attack or sudden cardiac death in a first degree relative less than 60 years of age)
There are other non-invasive tests to screen for coronary artery disease One of the most promising appears to be coronary artery calcium (CAD) scoring by computed tomography In 2007 an expert committee published an update to their original guidance document The committeersquos consensus was that ldquoit may be reasonable to consider use of CAC measurement in such patients [between 10 and 20 10-year risk of estimated coronary event]helliprdquo The committee did not recommend CAC measurement in low risk patients [lt10 10-year risk of estimated coronary event] or in high risk patients [gt20 10-year risk of estimate coronary event] (Greenland et al 2007]
43
D22 Cardiology
Chobanian AV Bakris GL Black HR Cushman WC Green LA Izzo JL Jr Jones DW Materson BJ Oparil S Wright JT Jr Roccella EJ the National High Blood Pressure Education Program Coordinating Committee [2003] The seventh report of the Joint National Committee [JNC-7] on Prevention Detection Evaluation and Treatment of High Blood Pressure JAMA 2892560ndash2571
Gibbons RJ Balady GJ Bricker JT Chaitman BR Fletcher GF Froelicher VF Mark DB McCallister BD Mooss AN OrsquoReilly MG Winters WL Jr [2002] ACCAHA 2002 guideline update for exercise testing summary article a report of the ACCAHA Task Force on Practice Guidelines (Committee to Update the 1997 Exercise Testing guidelines) J Am Coll Cardiol 401531ndash 1540
Greenland et al [2007] ACCFAHA 2007 Clinical Expert Consensus Document on Coronary Artery Calcium Scoring By Computed Tomography in Global Cardiovascular Risk Assessment and in Evaluation of Patients With Chest Pain A Report of the American College of Cardiology Foundation Clinical Expert Consensus Task Force (ACCFAHA Writing Committee to Update the 2000 Expert Consensus Document on Electron Beam Computed Tomography) J Am Coll Cardiol 49378-402
Kales SN Tsismenakis AJ Zhang C Soteriades ES [2009] Blood pressure in fire fighters police officers and other emergency responders Am J Hypertens 2211-20
Schlant RC Adolph RJ DiMarco JP Dreifus LS Dunn MI Fisch C Garson A Jr Haywood LJ Levine HJ Murray JA Noble RJ Ronan JA Jr [1992] Guidelines for electrocardiography A report of the American College of CardiologyAmerican Heart Association Task Force on Assessment of Diagnostic and Therapeutic Cardiovascular Procedures (Committee on Electrocardiography) Circulation 85(3)1221-1228
Soteriades ES Kales SN Liarokapis D Christiani DC [2003] Prospective surveillance of hypertension in firefighters J Clin Hypertens 5315-320
Formatted Font Italic
Formatted Line spacing single
Formatted Font Italic
Formatted Font Italic
44
NFPA 1582‐ Draft Revisions for CVDHTN
EKG and stress tests
Reason for Revision
1) Change requirement for annual resting EKG to periodically to be more consistent with ACCAHA
recommendation (Schlant et al 1992)
2) Add language to clarify what constitutes a positive ST
3) Make criteria for conducting diagnostic ST in asymptomatic patients consistent with the
ACCAHA
Language in 2007 Edition with draft revisions in Red (Track changes)
776 Electrocardiograms (EKG) and Stress Tests 7761 A resting EKG shall be performed as part of the baseline medical evaluation and shall be obtained periodically (every 1 to 5 years) thereafter
A7761 A baseline resting EKGs shall be conducted Follow-up resting EKGs should be conducted as clinically indicated but at a minimum of every 1 to 5 years The frequency of these follow-up resting EKGs should increase as a members age increases or with increasing number andor severity of coronary heart disease risk factors Members above the age of 40 should have annual resting EKGs (Schlant et al 1992)
7762 The fire department physician or other qualified medical evaluator shall compare baseline and subsequent EKGs
7763 Stress testing with or without echocardiography or radionuclide scanning shall be performed as clinically indicated by history or symptoms
A7763 No firm guidelines for stress testing in asymptomatic individuals have been developed Stress testing as a screening tool is used as part of an evaluation of aerobic capacity during the annual occupational fitness evaluation Submaximal stress testing testing to 85 percent is commonly used as part of this screening
Submaximal stress testing should not be used for diagnostic purposes Cardiology evaluation with maximal stress testing together with imaging techniques (eg echocardiography technetium Tc99m sestamibi study) is necessary for diagnosticprognostic purposes for the following
(1) Fire fighters with positive or questionably positive changes on screening submaximal stress tests
(2) Fire fighters with new onset chest pain or other symptoms suggestive of coronary artery disease (CAD)
45
(3) Fire fighters with diabetes mellitus who
(a) are gt35 years old or
(b) have type I diabetes for more than 15 years or
(c) have type II diabetes for more than 10 years or
(d) have any other CHD risk factor (see below) or
(e) have the presence of microvascular disease (proliferative retinopathy)
(4) Fire fighters over the age of 45 (for men) and 55 (for women) with one or more risk factors for CAD Risk factors for CAD include hypercholesterolemia (total cholesterol greater than 240 mgdL) hypertension (systolic gt140 mmHg or diastolic gt90 mmHg) smoking or family history of premature CAD (heart attack or sudden cardiac death in a first degree relative less than 60 years of age)
(5) Fire fighters with a Framingham Risk Score gt10 Risk calculator is available at [httphp2010nhlbihinnetatpiiicalculatorasp]
(6) Fire fighters identified in 9431
Negative stress tests should be repeated as clinically indicated or at least every 2 to 5 years
Interpreting stress tests as ldquopositiverdquo or ldquonegativerdquo is beyond the scope of this document However factors that should be taken into consideration should include the individualrsquos exercise capacity symptoms blood pressure response heart rate response EKG changes and the presence of arrhythmias (Gibbon et al 2002)
There are other non-invasive tests to screen for coronary artery disease One of the most promising appears to be coronary artery calcium (CAD) scoring by computed tomography In 2007 an expert committee published an update to their original guidance document The committeersquos consensus was that ldquoit may be reasonable to consider use of CAC measurement in such patients [between 10 and 20 10-year risk of estimated coronary event]helliprdquo The committee did not recommend CAC measurement in low risk patients [lt10 10-year risk of estimated coronary event] or in high risk patients [gt20 10-year risk of estimate coronary event] (Greenland et al 2007]
D22 Cardiology
Resting EKG and Stress Tests
46
Chobanian AV Bakris GL Black HR Cushman WC Green LA Izzo JL Jr Jones DW Materson BJ Oparil S Wright JT Jr Roccella EJ the National High Blood Pressure Education Program Coordinating Committee [2003] The seventh report of the Joint National Committee [JNC-7] on Prevention Detection Evaluation and Treatment of High Blood Pressure JAMA 2892560ndash2571
Gibbons RJ Balady GJ Bricker JT Chaitman BR Fletcher GF Froelicher VF Mark DB McCallister BD Mooss AN OrsquoReilly MG Winters WL Jr [2002] ACCAHA 2002 guideline update for exercise testing summary article a report of the ACCAHA Task Force on Practice Guidelines (Committee to Update the 1997 Exercise Testing guidelines) J Am Coll Cardiol 401531ndash 1540
Greenland et al [2007] ACCFAHA 2007 Clinical Expert Consensus Document on Coronary Artery Calcium Scoring By Computed Tomography in Global Cardiovascular Risk Assessment and in Evaluation of Patients With Chest Pain A Report of the American College of Cardiology Foundation Clinical Expert Consensus Task Force (ACCFAHA Writing Committee to Update the 2000 Expert Consensus Document on Electron Beam Computed Tomography) J Am Coll Cardiol 49378-402
Kales SN Tsismenakis AJ Zhang C Soteriades ES [2009] Blood pressure in fire fighters police officers and other emergency responders Am J Hypertens 2211-20
Schlant RC Adolph RJ DiMarco JP Dreifus LS Dunn MI Fisch C Garson A Jr Haywood LJ Levine HJ Murray JA Noble RJ Ronan JA Jr [1992] Guidelines for electrocardiography A report of the American College of CardiologyAmerican Heart Association Task Force on Assessment of Diagnostic and Therapeutic Cardiovascular Procedures (Committee on Electrocardiography) Circulation 85(3)1221-1228
Soteriades ES Kales SN Liarokapis D Christiani DC [2003] Prospective surveillance of hypertension in firefighters J Clin Hypertens 5315-320
47
ATTACHMENT F
48
1
Current 1582 (2007) language in reference to pregnancy 43 (4) Report to the fire department physician any medical condition that could interfere with the ability of the individual to safely perform essential job tasks such as illness or injury use of prescription or nonprescription drugs and pregnancy 6112 Category B medical conditions shall include the following (1) Pregnancy for its duration A7792 (e) If HIV prophylaxis is to be given the following tests should be done i CBC ii Glucose renal and hepatic chemical function iii Pregnancy test for females B121 Pregnancy and Reproduction Federal regulations as well as many court decisions including the US Supreme Courtrsquos decision in International Union et al v Johnson Controls Inc [499 US 187 111 S Ct 1196 (1991)] have interpreted the requirements of Title VII with respect to pregnancy and reproduction The AHJ should seek the advice of counsel in resolving specific questions concerning these requirements as well as other requirements that can be imposed by state or local laws C211 (4) Review health status with the individual being evaluated Contraindications for evaluations shall be reviewed addressing any changes in the individualrsquos health status since their last medical evaluation that would warrant deferring the evaluation including (g) Pregnancy Recommendations to language enhancement
A female employee who is assigned to regular fire line duty shall report a pregnancy immediately to their respective Supervisor and the fire department physician The employee will then be given the option of a non-hazardous alternative duty position for the duration of her pregnancy (can we say this or is it even appropriate) Any pregnant employee wishing to remain on regular line duty shall be informed of the possible risks and consequences to herself and her fetus that are associated with continued line fire fighting duty Among those risk factors are exposure to teratogens known to have negative effects on the developing fetus such as smoke diesel fumes hazardous chemicals and extreme heat
49
Page 2
appendix It is recommended that the pregnant employee complete a release of liability form signed by herself and her health care provider utilizing NFPArsquos 13 critical tasks as a reference This will inform the health care provider of specific job-related tasks that will need to be performed in order to continue regular line duty These tasks are basic physical standards that any entry level firefighter would have to be able to complete competently The employeersquos health condition will be kept confidential by the department in accordance with HIPAA standards Employees are allowed to remain on active regular duty until they are no longer able to perform their duties in a reasonable manner andor their protective gear no longer fits correctly It is the responsibility of the health care provider to evaluate the pregnant employee If at any time the health care provider feels the pregnant employee can no longer perform the job related tasks this should be reported to the employer by the employee immediately
50
ATTACHMENT G
51
From GLENN BENARICKTo Sawyer SteveSubject RE RE 7743Date Monday August 30 2010 21633 PM
Yes thats my understanding
Glenn P Benarick 211 Winged Elm CircleAiken SC 29803803-644-7093gbenarprodigynet
--- On Mon 83010 Sawyer Steve ltssawyerNFPAorggt wrote
From Sawyer Steve ltssawyerNFPAorggtSubject RE RE 7743To GLENN BENARICK ltgbenarprodigynetgtDate Monday August 30 2010 212 PM
So it should be ldquoorrdquo instead of ldquoandrdquo for now
Steven F Sawyer
Senior Fire Service Specialist
Executive Secretary IFMAFire Service Section
NFPA
1 Batterymarch Park
Quincy MA 02169
6179847423
Fax 6179847056
ssawyernfpaorg
From GLENN BENARICK [mailtogbenarprodigynet] Sent Monday August 30 2010 1202 PMTo Sawyer SteveSubject Fw RE 7743
52
Steve a couple of our docs agree with April Boyer
Glenn P Benarick 211 Winged Elm Circle
Aiken SC 29803
803-644-7093
gbenarprodigynet
--- On Mon 83010 David Prezant ltprezandfdnynycgovgt wrote
From David Prezant ltprezandfdnynycgovgtSubject RE 7743To Thomas R (CDCNIOSHDSHEFS) Hales lttrh1cdcgovgt GLENNBENARICK ltgbenarprodigynetgtCc Sandy Bogucki ltsandyboguckiyaleedugtDate Monday August 30 2010 1004 AM
agree
we should change this to NHANES III rather than Knudson we should alsomodify this to allow not only for predicted cutoffs but all for use of thelower limit of normal cutoff This is important to prevent false-classificationof spirometry as abnormal in older groups and in taller grps The latter ofparticular import to firefighter occupational health surveillance
thanks
David Prezant MDChief Medical Officer Office of Medical AffairsCo-Director WTC Medical Monitoring amp Treatment ProgramsNew York City Fire Department9 Metrotech Center - Rm 4W-1Brooklyn NY 11201Phone 718-999-2696Fax 718-999-0665
Life is full of twists and turns
53
This email may contain confidential information If you are the unintendedrecipient of this email please send it back and delete from your directory
gtgtgt Hales Thomas R (CDCNIOSHDSHEFS) lttrh1cdcgovgt 8302010955 AM gtgtgt
Glen
This seems like a very reasonable comment and illustrates the importance of having clinicians providefeedback on the std Im not familiar with the software program of the various spirometers (NHANES IIIvs KnudsonATS vs both) Given the large role both Dave Prezant and Sandy Bogucki had for thepulmonary section let me forward to them for clarification
Tom
From GLENN BENARICK [mailtogbenarprodigynet] Sent Sunday August 29 2010 456 PMTo Hales Thomas R (CDCNIOSHDSHEFS)Subject FW 7743
Tom is April Boyer correct
Glenn P Benarick 211 Winged Elm Circle
Aiken SC 29803
803-644-7093
gbenarprodigynet
--- On Thu 82610 Sawyer Steve ltssawyerNFPAorggt wrote
From Sawyer Steve ltssawyerNFPAorggtSubject FW 7743To GLENN BENARICK ltgbenarprodigynetgtDate Thursday August 26 2010 925 PM
FYI Do you have any answer She is write
Steven
54
Steven F Sawyer
Senior Fire Service Specialist
Executive Secretary IFMAFire Service Section
NFPA
1 Batterymarch Park
Quincy MA 02169
6179847423
Fax 6179847056
ssawyernfpaorg
From April Boyer [mailtoaboyerbicclinicorg] Sent Thursday August 26 2010 232 PMTo Sawyer SteveCc RobinMWebbmilstateorusSubject 7743
Steven
The spirometry tests cannot be corrected according to both references as the NFPA states because thereferences are contradictory The first part of 7743 states to follow the ATS guidelines and use theKnudsen (we at Basin Immediate Care use the Nhanes III) The second part states to follow the ACOEMguidelines and use the Nhanes III in the occupational setting if available with your unit (which is availableon ours) 7743 does not use the word OR regarding both requirements it uses the word AND whenreferring to the first and second parts thence making 7743 contradictory I realize the NFPA 1582 hasnot been updated since 2007 unless I have just not received an updated version
Our question to you is which part of 7743 do you want us to follow the first or the second part Anyfacility that has an updated computerized spirometry system (as we do) will not be able to follow bothrequired parts for obvious reasons We can either follow the first part of 7743 and use an oldercorrected version of the Knudson by going into our system and changing out of the Nhanes III conversionOR we can follow the second part of 7743 and use the newer corrected version of Nhanes III which ourunit offers too
If you have any questions you may contact me at anytime and I also have many references in regards toboth parts of 7743 if you would like to see them
55
Thank you~
April
Confidentiality NoticeThis message may contain information that isconfidential or privileged
If you are not the intended recipientPlease advise the sender immediately and delete this message
56
ATTACHMENT H
57
NFPA 1582 771(7) Proposed revisions
Why
Preliminary results of two prospective randomized trials on the PSA test were published in 2009 These studies resulted in medical organizations that previously providing guidance to modify their recommendations
Current language
771 Blood Tests Blood tests shall be performed annually and shall include the following
(7) Prostate specific antigen (PSA) after age 40 for positive family history if African American or if otherwise clinically indicated after age 50 for all other male member
Suggested Revision
771 Blood Tests Blood tests shall be performed annually and shall include the following
(7) Prostate specific antigen (PSA) after age 40 for positive family history if African American or if otherwise clinically indicated after age 50 for all other male member
772 Prostate-Specific Antigen (PSA) test At age 50 fire fighters shall have an opportunity to make an informed decision with either the Fire Department physician or their health care provider concerning the PSA test For fire fighters at increased risk of prostate cancer (African-Americans or those with a first degree relative diagnosed with prostate cancer before age 65) shall have the opportunity for this informed decision at age 40
A772 The PSA as a screening test for prostate cancer in asymptomatic men is controversial controversial for two reasons First there is no consensus that PSA screening actually saves lives For example the PSA test may detect small cancers that would never become life threatening Second it is unclear that the benefits of PSA screening outweigh the risks of follow-up diagnostic tests and cancer treatments For example the prostate biopsy used to diagnose prostate cancer may cause bleeding and infection And prostate cancer treatments such as surgery and radiation therapy may cause incontinence (inability to control urine flow) erectile dysfunction (erections inadequate for intercourse) and other complications For these reasons it is important that the benefits and risks of prostate diagnostic procedures and treatment be taken into account when considering the PSA screening test These considerations can be taken account during discussions with the fire department physician or onersquos health care provider
D211 Cancer Screening
Smith R A C J Mettlin K J Davis and H Eyre 2000 ldquoAmerican Cancer Society guidelines for the early detection of cancerrdquo CA J Clin 50(1)34ndash49
Added references
58
Carroll P Albertsen PC Greene K et al [2010] Prostate-specific antigen best practice statement 2009 update Am Urological Assoc Available at httpwwwauanetorgcontentguidelines-and-quality-careclinical-guidelinesmain-reportspsa09pdf Date accessed September 2010
Ferrini R Woolf SH [2009] Screening for prostate cancer in American men American College of Preventive Medicine Practice Policy Statement Available at httpwwwacpmorgprostatehtm Date accessed September 2010
National Cancer Institute [2009] Prostate-specific antigen test National Cancer Institute Fact Sheet Available at httpwwwcancergovcancertopicsfactsheetDetectionPSA Date accessed September 2010
Wolf AMD Wender RC Etzioni RB et al [2010] American Cancer Society guideline for the early detection of prostate cancer Update 2010 Available at httpcaonlineamcancersocorgcgicontentfullcaac20066v1 Date accessed September 2010
59
One guest in attendance Dave Bernzweig (Columbus OH Fire) Dave is assisting TC with SCBAAir Mgt issues The document revision cycles remain as requested NFPA 1500 amp 1582 Annual 2012 NFPA 1521 amp 1561 Fall 2013 NFPA 1581 1583 1584 Annual 2014 The October 7-9 2010 dates are the primary request for our next meeting Location is San Diego Notice will be sent out as soon as approval is received Discussion on the next revision of 1561 will be held at the October meeting regarding changing the document title to ldquoCommand Safety for Fire Department Operationsrdquo This is a suggestion of the TC Chair Ken Holland conducted a briefing for the TC on how to access and use the committee web page Staff will be posting as much information as possible up on the e-committee page for the entire committee More use will be made of this tool Discussion on monocular vision Dennis Childress presented the current issue in Ventura County CA Further discussionwork may be necessary Don Stewart agreed to take the lead Brief discussion held on pregnancy and the need for fire departments to ensure policies match current law The rep from the Diabetes Association declined the invitation to participate at this meeting due to no discussion of the issue planned She has indicated a desire to attend the October meeting There were no reports from these and all other 1582 task groups It is very important for the 1582 TG Chairs to be ready to report in October The following task group reports will be posted on the ecommittee page PPEProximity New definition of proximity fire fighting
VehicleHighway OPS Discussion on use of vehicle data recorders Collapse Zones Submission from Jay Tarley SCBAAir Mgt New exit strategy for SCBA Discussion on having the low air alarm activate when the bottle volume reaches 600 liters Further discussion to take place on ldquobuddy breathingrdquo
On Day 2 Casey Grant (NFPA Fire Protection Research Foundation) made a presentation on Research Planning for FSOSH Dr Ellen Sogolow (DHSFEMA) also present during this presentation She discussed the role of the AFGRampD activities See ecommittee page for his presentation Chair
11
will be in contact with Mr Grant for future work between the TC and the Foundation Also on Day 2 Ken Willette (Division Manager ndash NFPA Public Fire Protection Division) delivered a presentation on the initiative developed by Kelvin Cochran (US Fire Administrator) to reduce fire fighter injuries and deaths NFPA 1500 is an integral part of this initiative See ecommittee page for presentation The Chair will be coordinating a committee conference call in the coming weeks The purpose will be to review the work which needs to be completed for the October meeting The primary focus of the call will be on 1582 issues NOTE Subsequent to the meeting I have had some discussions with a fire chief in Kentucky on the use of hearing aids The TC especially the doctors need to review the current language in 1582 and decide if revisions are needed Also most of you know that Kelvin Cochran has left the USFA unexpectedly to return to Atlanta as their fire chief I have been in contact with the Acting Administrator Glenn Gaines to inform him that our committee remains focused on the work to reduce fire fighter injuries and deaths I told him that I would keep him informed of our work He indicated that one of his primary goals is to bring fire service organizations together in order to create a safe working environment Of particular interest to him is reducing heart related injuries and deaths Submitted by Glenn Benarick
12
Technical Committee on Fire Service Occupational Safety and Health
Conference Call Meeting Minutes August 30th 2010
Members participating
Glenn Benarick TC Chair
Murrey Loflin Secretary Dr Sandy Bogucki
Thomas Cuff Stephen Foley
Scott Kerwood Tammy Lopes
David Love Dr David Prezant
Joe Rivera David Ross
Mario Rueda Phil Stittleburg
Phil Vorlander Dominic Colletti
Thomas Hillenbrand
Denise Smith Brett Bowman Alternate
Andrew Schwartz Alternate Mike Young Alternate
Dr Thomas Hales Non-Voting Member Ken Holland NFPA Staff Liaison
Casey Grant NFPAResearch Foundation Staff Katie Hathway Guest from ADA
Dr Jim Fleming Guest from Phoenix Fire Dept
The chair welcomed everyone to the conference call in which he hoped
would last only an hour The purpose was to discuss any task groups that had reports for proposed changes to NFPA 1582 for the
committee This is in hopes to ensure the committee is ready for their
pre-ROP meeting in October The following topics were discussed and are in no specific order
Comments from ADA Katie Hathaway and the group went into deep
discussion regarding ones medical history and diagnosis of diabetes
13
and some proposed changesremoval of text based on research
findings The specific proposed changes will be available for the committee at their next meeting Some members on the call felt that
this issue was covered in another law enforcement document which might better serve this issue
Research topics for FSOSH projects Casey Grant offered his time to
answer any questions regarding his presentation from the May meeting in Baltimore There was also discussion about further
involvement of the Research Foundation with this committee and some of the medical requirements within the documents Glenn and Casey
are going to be in contact offline to discuss this further
Prosthetics amp Amputees report Nothing new to report
Heart amp Hypertension report There was discussion about the need for
periodic EKGrsquos that were done both in resting and non-resting states as well as discussion about stress test requirements and frequency of
such tests The hopes were to develop text that would point to annual versus periodic evaluations of EKGrsquos and stress tests
Epilepsy report Nothing new to report
Pregnancy report The initial textlanguage has been provided to the
group through email and e-committee page posting
Coagulation amp Meds report Nothing new to report
Hearing Aid discussion Nothing new to report
The committee also discussed the evaluation and documentation of
PSA results and test requirements for the purposes of consistency The proposed text and changes have been posted on the e-committee
page as well
All of the proposed text changes from the May meeting in Baltimore have been emailed out and posted on the e-committee page If there
are any questions or concerns that something was missed please contact Glenn Steven Sawyer or Ken Holland to ensure they are
resolved
The conference call lasted approximately an hour and was adjourned at 1400 hours
14
ATTACHMENT C
15
2012 ANNUAL REVISION CYCLE
PROCESS STAGE PROCESS STEP DATES
FOR TC DATES
FOR TCC 1 PRELIMINARY 10 Notification of intent to enter cycle 7910 7910
2 REPORT ON
PROPOSALS (ROP)
21 Proposal closing date 112310 112310 22 Final date for ROP meeting 22511 2411 23 Final date for mailing TC ballots 31811 21811 24 Receipt of (TC) ballots by staff liaison 42211 31111 25 Receipt of TC recirculation ballots 5611 31811 26 Final date for TCC meeting 41511 27 Final date for mailing TCC ballots 42211 28 Receipt of TCC ballots 51311 29 Receipt of TCC recirculation ballots 52011 210 Final copy (w ballot statements) to Secretary Standards Council 51311 52711 211 Completion of Reports 52011 6311 212 ROP Published and Posted 62411 62411
3 REPORT ON
COMMENTS
(ROC)
31 Comment closing date 83011 83011 32 Final date for ROC meeting 11411 10711 33 Final date for mailing TC ballots 111811 102111 34 Receipt of (TC) ballots by staff liaison 12211 111111 35 Receipt of TC recirculation ballots 12911 111811 36 Final date for TCC meeting 121611 37 Final date for mailing TCC ballots 122311 38 Receipt of TCC ballots 11312 39 Receipt of TCC recirculation ballots 12012 310 Final copy (w ballot statements) to Secretary Standards Council 122311 12712 311 Completion of Reports 11312 2312 312 ROC Published and Posted 22412 22412
4 TECH SESSION
PREPARATION amp
ISSUANCE OF
CONSENT
DOCUMENTS
41 Notice of Intent to Make a Motion (NITMAM) Closing Date 4612 4612 42 Posting of Filed NITMAM 5412 5412
43 Council Issuance Date for Consent Documents 52912 52912
44 Appeal Closing Date for Consent Documents 61312 61312
5 TECHNICAL
SESSION 50 Association Meeting for Documents with Certified Amending Motions
64-712 64-712
6
APPEALS amp
ISSUANCE OF
DOCUMENTS
WCAMS
61 Appeal closing date for Documents with Certified Amending Motions
62712 62712
62 Council issuance for Documents with Certified Amending Motions 8912 8912
Proposal Closing Dates may vary according to documents and schedules for Revision Cycles may change Please check the NFPA website (wwwnfpaorg) for the most up-to-date information on proposal closing dates and schedules
16
ATTACHMENT D
17
This weekrsquos conference call mentioned the Diabetes chapter written for the ACOEM document Guidance for the Medical Evaluation of the Law Enforcement Officer The task group working on this chapter (led Richard Miller of the Secret Service and our very own Dan Samo) worked with the ADA or over 2-3 years to come up with a consensus document
Please find the Chapter attached ltltDiabetes Guidance Sept 2010pdfgtgt
Regarding Dan Loeberrsquos points
1) Physical Evaluation Form - We could modify the LEO form (see end of the attached Chapter)
2) Duration required for stable regiment
1582 for IDDM Type 1 1 yr
Type 2 6 m
Oral Agents None specifically
ACOEM Police for IDDM Type 1 6m
Type 2 3m
Oral Agents 1m
The police document is much clearer about the decision regarding medical fitness for duty is the responsibility of the police physician with the treating diabetes-expert physician providing the data to the police physician to make an informed decision In this regard the police officer must provide the police physician with downloaded self monitoring glucose data for the 1 3 and 6 month time periods (see section 433)
3) HA1C ndash NFPA lt 8 over 3 month period
ACOEM Police ndash (Section 4333) Specifies the frequency on measurement and if gt8 requires further evaluation
Some other discrepancies End organ complications
NFPA ndash end organ complications (eye kidney heart neuro) ndash restriction
ACOEM Police ndash end organ complication -- requires further evaluation
18
Hypoglycemia (incapacitating ndash defined differently between the two documents (434)
NFPA ndash 0 episodes in past year le1 in past 5 yrs
ACOEM Police ndash 0 episodes in past year le2 in past 3 yrs
Given Dan Samorsquos and Richard Millerrsquos work with the ADALoeber it would be helpful to get their opinions on whether any of the changes requested by Loeber are appropriate for FF with DM
Tom
Thomas Hales MD MPH
Senior Medical Epidemiologist
NIOSH CDC
4676 Columbia Pkwy R-9
Cincinnati OH 45241
(513) 841-4583
trh1cdcgov
19
43 ndash DIABETES MELLITUS
431 ndash INTRODUCTION
The educated and motivated law enforcement officer (LEO) with well-managed diabetes mellitus can be capable of
safe and effective job performance1 However diabetes mellitus may place LEOs at risk for sudden incapacitation
thus jeopardizing their ability to perform critical job functions (These job functions include those listed in Sections
32 333 351 352 36 and 37 and discussed in Appendix A)
Therefore an individualized assessment of the LEOrsquos diabetes should be performed using the following evaluative
criteria to determine whether the individuals condition permits safe and effective job performance Such evaluation
must include the following key elements which are discussed in detail below
history of blood glucose control
knowledge of diabetes and its management
current stability of blood glucose
risk for significant hypoglycemia or hyperglycemia and
presence of diabetic complications
432 ndash OVERVIEW OF MEDICAL EVALUATION
The treating endocrinologist or other physician knowledgeable regarding diabetes management should provide
a narrative report certifying whether the LEO has or has not met the criteria set out in Sections 4321 through
4354 below In addition the physician should include supporting data (see Appendix B for the Physician Evalu-
ation Form)
4321 The LEO is under the care of an endocrinologist or other physician knowledgeable regarding diabetes
management Outpatient and in-patient medical record(s) for the last 3 years or since date of diagnosis
(whichever is shorter) should be reviewed by the treating physician and provided to the police physician
4322 If the LEO has type 1 diabetes the individual has been on a basalbolus regimena or an insulin pump
using analogue insulins for the 6 months prior to evaluation2
4323 If the LEO has type 2 diabetes on insulin the individual has been on a stable medication regimenb
for the 3 months prior to evaluation3 If on oral agents alone the LEO has been on a stable medication regimen
for the month prior to evaluationc
ACOEM Guidance for the Medical Evaluation of Law Enforcement Officers 1
43 ndash DIABETES MELLITUS
aA basalbolus insulin regimen consists of the use of a basal insulin (Glargine NPH) in a once or twice daily regimen to provide between-
meal insulin combined with the use of a short acting insulin (Regular Lispro Aspart or Glulisine) at mealtimes Insulin pumps are small
(beeper sized) battery powered devices that deliver small amounts of short-acting insulin in a constant infusion to meet basal insulin
requirements The wearer selects an additional mealtime bolus to be infused at the time of meals For more information on pumps visit
the manufacturerrsquos web sites ndash wwwMinimedcom wwwcozmorecom wwwanimascorpcom wwwdisetroniccom
bA stable insulin regimen is defined as maintaining the same types of insulin (long acting intermediate acting short or rapid acting)
Changes in insulin dose are part of the appropriate self-management of diabetes and do not disqualify an applicant or incumbent under
this section
cChanges in dose within the evaluation period will be allowed but addition of a new class of medications or insulin should result in a new
period of observation
one month for addition of a sulfonylurea or metformin
two months for the addition of a thiazolidinedione to insulin or a sulfonylurea or
three months for the addition of insulin
20
4324 If the LEO uses an insulin pump documentation is needed as follows
proper understanding and education in the use of the insulin pump
start date for the use of the pump
history of insulin site infectionsd
history of pump cessation and pump malfunction
backup plan for pump malfunction including use of injectable insulin and
frequency of infusion set changes
4325 The LEO has been educated in diabetes and its management and thoroughly informed of and under-
stands the procedures that must be followed to monitor and manage hisher diabetes and what procedures
should be followed if complications arise3
433 ndash QUANTITATIVE GLUCOSE MONITORING
4331 The LEO has documentation of ongoing self-monitoring of blood glucose
4332 This must be done with a glucose meter that stores every reading records date and time of reading
and from which data can be downloaded (Most meters now have this capability)
4333 Monitoring logs must be available covering the time period (1 3 or 6 months) as described in
Sections 4322 and 4323 The frequency of glucose monitoring must follow a schedule acceptable to the
police physician in consultation with the treating physician
Testing schedules are individual What follows is a common pattern but individual patterns may differ
2 ACOEM Guidance for the Medical Evaluation of Law Enforcement Officers
43 ndash DIABETES MELLITUS
dIndividual has not had more than one pump-site infection that caused him or her to miss work or usual daily activities in the preceding 6
months
THERAPEUTIC REGIMEN GLUCOSE TESTING SCHEDULE
Diet alone Once or twice a week
Metformin Thiazolidinediones or Alpha
Glucosidase inhibitors alone or in
combination
Once or twice a week
Sulfonylureas meglitanides nateglinide ndash
alone or in combination with the above group
Twice a day ndash AM and at supper with any
suspected hypoglycemic episodes
Insulin ndash one shot in combination with orals Twice a day ndash AM and at supper with any
suspected hypoglycemic episodes
2 to 3 times AM once a week
Insulin ndash two or more shots Insulin pump 3 to 4 times a day ndash at meals and bedtime
2 to 3 times AM once a week with any
suspected hypoglycemic episodes
21
4334 The LEO has had hemoglobin A1C measured at least 4 times a year (intervals of 2 to 3 months) over
the last 12 months prior to evaluation if diagnosis has been present for more than a year4 If hemoglobin A1C is
gt8 this may signal a problem with the LEOrsquos diabetes management that warrants further assessment5
434 ndash INCAPACITATING EVENTS
4341 The LEO has not had any incapacitating episodes within the past 1 year and no more than 2 episodes
in the past 3 years or since diagnosis of diabetes (whichever is shorter) of
43411 Severe hypoglycemia (loss of consciousness seizures or coma requiring assistance of others or
needing urgent treatment [glucagon injectionIV glucose]) or
43412 Blood sugar lt60 mgdl with unawareness demonstrated in current glucose logs6
435 ndash CHRONIC COMPLICATION SCREENING
4351 Chronic complications of diabetes are associated with increased risk for severe hypoglycemic
episodes and warrant further assessmente
4352 The components of screening for chronic complications are
43521 A complete eye exam by a qualified ophthalmologist or optometrist including a dilated retinal
exam demonstrating no more than mild background diabetic retinopathyf7
43522 Normal vibratory testing with a 128 Hz tuning forkg normal testing with 10 gram Semmes-
Weinstein monofilamentg and normal orthostatic blood pressureh and pulse testing89
ACOEM Guidance for the Medical Evaluation of Law Enforcement Officers 3
43 ndash DIABETES MELLITUS
ePresence of chronic complications of diabetes in and of themselves may not require the implementation of work restrictions
fNo more than one dot blot or flame-shaped hemorrhages or microaneurysm in all four fundus quadrants
gThe Michigan Diabetes Research and Training Center of the University of Michigan Health System recommends the following guidance
(see wwwmedumichedumdrtcprofsdocumentssviMNSI_howtopdf) for conducting vibratory and monofilament testing8
Vibration Sensation Vibration sensation should be performed with the great toe unsupported Vibration sensation will be tested bi-
laterally using a 128 Hz tuning fork placed over the dorsum of the great toe on the boney prominence of the DIP joint Patients whose
eyes are closed will be asked to indicate when they can no longer sense the vibration from the vibrating tuning fork In general the
examiner should be able to feel vibration from the hand-held tuning fork for 5 seconds longer on his distal forefinger than a normal subject
can at the great toe (eg examiners DIP joint of the first finger versus patients toe) If the examiner feels vibration for 10 or more seconds
on his or her finger then vibration is considered decreased A trial should be given when the tuning fork is not vibrating to be certain that
the patient is responding to vibration and not pressure or some other clue Vibration is scored as 1) present if the examiner senses the
vibration on his or her finger for lt10 seconds 2) reduced if sensed for 10 seconds or 3) absent (no vibration detection)
Monofilament Testing For this examination it is important that the patients foot be supported (ie allow the sole of the foot to rest on
a flat warm surface) The filament should initially be pre-stressed (4-6 perpendicular applications to the dorsum of the examiner s first
finger) The filament is then applied to the dorsum of the great toe midway between the nail fold and the DIP joint Do not hold the toe
directly The filament is applied perpendicularly and briefly (lt1 second) with an even pressure When the filament bends the force of
10 grams has been applied The patient whose eyes are closed is asked to respond yes if heshe feels the filament Eight correct responses
out of 10 applications is considered normal 1 to 7 correct responses indicates reduced sensation and no correct answers translates into
absent sensation
hOrthostatic hypotension is a physical finding defined by the American Autonomic Society and the American Academy of Neurology as a
systolic blood pressure decrease of at least 20 mm Hg or a diastolic blood pressure decrease of at least 10 mm Hg within 3 minutes of
standing
22
43523 Normal cardiac physical exam Cardiac stress testing to at least 12 METS is recommended and
should begin based on either the criteria of the American Heart AssociationAmerican College of
Cardiologyi10 or those of the American Diabetes Associationj11
Diabetics who have a normal cardiac stress test will be retested every one to three years based on
individual clinical assessment This assessment should consider
the age of the individual
the number and persistence of coronary artery disease (CAD) risk factors
the severity of CAD risk factors
43524 Microalbumincreatinine ratio 301 measured or calculatedk creatinine clearance
gt60 mlmin12
436 ndash ONGOING EVALUATION AND REQUIREMENTS
4361 Should have medical records and glucose meter logs reviewed periodically Because of the nature of
diabetes it is important that regular medical follow up be provided to the LEO The frequency and content of
the evaluation should be determined on an individual basis by the police physician in consultation with the
treating physicianl
4362 Must advise police physician of any change in type of medication
4363 Must advise police physician of any episodes of significant hypoglycemia or hyperglycemia
Urine microalbumincreatinine ratio _________________
III Treating Physician Statement
The above named individual meets all of the criteria provided on this form
Yes No ndash not recommended for position
No but IS recommended for position (letter of explanation attached)
It is my opinion that the above named individual is well-educated and well-motivated in diabetes self-management and has
achieved a level of diabetes management to be capable of safe and effective job performance as a law enforcement officer
I have reached this opinion after careful review of the above criteria
___________________________________________________________ ___________________________Signature of Physician Date
______________________________________________________________ ___________________________Printed or Typed Name of Physician Telephone Number
10 ACOEM Guidance for the Medical Evaluation of Law Enforcement Officers
43 ndash DIABETES MELLITUS
29
439 ndash REFERENCES
1 American Diabetes Association Diagnosis and classification of diabetes mellitus Diabetes Care 200427 Suppl
1S5-S10 See httpcarediabetesjournalsorgcgicontentfull27suppl_1s5
2 American Diabetes Association Continuous subcutaneous insulin infusion Diabetes Care 200427 Suppl 1S110
See httpcarediabetesjournalsorgcgicontentfull27suppl_1s110
3 Mensing C Boucher J Cypress M et al National standards for diabetes self-management education Diabetes
Care 200528 Suppl 1S72-9 See httpcarediabetesjournalsorgcgicontentfull28suppl_1s72
4 Goldstein DE Little RR Lorenz RA Malone JI Nathan DM Peterson CM American Diabetes Association Tests
of glycemia in diabetes Diabetes Care 200427 Suppl 1S91-3
See httpcarediabetesjournalsorgcgicontentfull27suppl_1s91
5 The Diabetes Control and Complications Trial Research Group Hypoglycemia in the Diabetes Control and
Complications Trial Diabetes 199746(2)271-86 See wwwncbinlmnihgovpubmed9000705 for abstract
6 American Diabetes Association Hypoglycemia and employmentlicensure Diabetes Care 200528 Suppl 1S61
See httpcarediabetesjournalsorgcgicontentfull28suppl_1s61
7 Viswanath K McGavin DD Diabetic Retinopathy Clinical Findings and Management J Comm Eye Health
200316(46)21-4 See wwwcehjournalorg0953-683316jceh_16_46_021html
8 Michigan Diabetes Research and Training Center University of Michigan Health System How to use the Michigan
Neuropathy Screening Instrument See wwwmedumichedumdrtcprofsdocumentssviMNSI_howtopdf
9 Bradley JG Davis KA Orthostatic hypotension Am Fam Physician 200368(12)2393-8
See wwwaafporgafp200312152393html
10 Gibbons RJ Balady GJ Bricker JT et al ACCAHA 2002 guideline update for exercise testing a report of the
American College of CardiologyAmerican Heart Association Task Force on Practice Guidelines (Committee on
Exercise Testing) J Am Coll Cardiol 200240(8)1531-40
See wwwaccorgqualityandscienceclinicalguidelinesexerciseexercise_cleanpdf
11 American Diabetes Association Standards of medical care in diabetes Diabetes Care 200528 Suppl 1S4-S36
Erratum in Diabetes Care 200528(4)990 See httpcarediabetesjournalsorgcgicontentfull28suppl_1s4
12 Molitch ME DeFronzo RA Franz MJ et al American Diabetes Association Nephropathy in diabetes Diabetes
Care 200427 Suppl 1S79-83 See httpcarediabetesjournalsorgcgicontentfull27suppl_1s79
13 Kitabchi AE Umpierrez GE Murphy MB et al American Diabetes Association Hyperglycemic crises in diabetes
Diabetes Care 200427 Suppl 1S94-102 See httpcarediabetesjournalsorgcgicontentfull27suppl_1s94
14 US Centers for Disease Control and Prevention National Diabetes Fact Sheet 2007
See wwwcdcgovdiabetespubspdfndfs_2007pdf
ACOEM Guidance for the Medical Evaluation of Law Enforcement Officers 11
43 ndash DIABETES MELLITUS
30
ATTACHMENT E
31
Typos A6921(2) 7th line down test should be plural 94201 Paragraph 2 target organ damage is used though end organ damage was defined earlier and in the appendix for that paragraph
A94201 Para A (1) d Id suggest deleting the phrases in brackets Im not sure either are predictably true or politically wise
a) tests for left ventricular hypertrophy Unfortunately use of the EKG to detect left ventricular hypertrophy is very insensitive (eg 5 sensitivity) The echocardiogram is the best test for diagnosing left ventricular hypertrophy but [it is relatively expensive and not readily available in small rural communities ] conducting echocardiograms on asymptomatic fire fighters with Stage 1 hypertension should be reserved only for those with long-standing hypertension
In addition
7761 A resting EKG shall be performed as part of the baseline medical evaluation and shall be obtained periodically thereafter
Changing from annually to periodically is noted has the language in the wellness-fitness initiative been changed as well Our previous decision was that we would support the W-F language since there was no compelling evidence to either support or refute it
Thanks
Sandy
32
NFPA 1582‐ HTN Draft 1
Reason for Revision
1) New classification of BP by the Joint National Commission [Chobanian et al 2002]
2) A high prevalence of FF have either HTN (~20) and Pre‐HTN (~20) [Soteriades et al 2003]
3) Among FF studies have shown a strong association between HTN and a number of adverse
cardiovascular events [Kales et al 2009]
4) A large percentage of on‐duty FF fatalities were found to have left ventricular hypertrophy a
complication of HTN at autopsy
Language in 2007 Edition with draft revisions in Red (Track changes)
611 The medical evaluation of a candidate shall include a medical history examination and any laboratory tests required to detect physical or medical condition(s) that could adversely affect hisher ability to safely perform the essential job tasks outlined in 511 A611 The medical history should include the candidates known health problems such as major illnesses surgeries medication use and allergies Symptom review is also important for detecting early signs of illness A medical history should also include a personal health history a family health history a health habit history an immunization history and a reproductive history
An occupational history should also be obtained to collect information about the persons past occupational and environmental exposures
(a) BP should be measured according to the Joint National Commission (JNC) -7 recommendations BP should be measured with a properly calibrated and validated instrument Patients should be seated quietly for at least 5 minutes in a chair with feet on the floor and arm supported at heart level An appropriate-sized cuff (cuff bladder encircling at least 80 of the arm) should be used to ensure accuracy At least 2 measurements should be made Systolic BP is the point at which the first of 2 or more sounds is heard (phase 1) and diastolic BP is the point before the disappearance of sounds (phase 5) [Chobanian et al 2003]
(2) Head eyes ears nose and throat (HEENT)
Formatted Font (Default) Times New RomanFont color Black
33
692 Vascular System 6921 Category A medical conditions shall include the following
(1) Uncontrolled or poorly controlled hypertension
(2) Hypertension with evidence of end organ damage
or not controlled by approved medications
A6921(1) Uncontrolled or poorly controlled hHypertension increases the risk of a sudden cardiac event This sudden cardiac event would cause sudden incapacitation which that is uncontrolled poorly controlled or requires medication likely to interferes with the safe performance of essential job tasks Uncontrolled or poorly controlled hypertension can be defined as the presence of end organ damage (see below) or stage 2 hypertension (BP systolic gt160 mmHg or BP diastolic gt100 mmHg) is an illness that can lead to functional impairment and potential for sudden incapacitation Individuals with pre- stage 1 or stage 2 hypertension should be referred to their primary care physician for evaluation lifestyle modification and treatment [QUESTION FOR GROUP _- WHAT ABOUT HAVING CANDIDATE RETURN IN ONE MONTH UNDER TREATMENT WITH NORMAL BP]
A6921(2)
Chronic hypertension can damage the eye (retinopathy) the kidneys (nephropathy) the vascular system (stroke transient ischemic attack or peripheral artery disease) or the heart (left ventricular hypertrophy and heart failure) These hypertension complications are known as end organ damage The cardiac and vascular complications are associated with an increased risk of sudden incapacitation and sudden cardiac death (Koren et al 1991) Unfortunately the cardiac complications are frequently asymptomatic and valid screening tests are not fast and are not inexpensive Therefore determining who to screen for cardiac complications (such as echocardiogram for LVH or a measurement of left ventricular ejection fraction for heart failure) should be based on the severity and the duration of HTN
76 Physical Examination The annual physical examination shall include each of the following components
(a) BP shall be measured according to the Joint National Commission (JNC)-7 recommendations
A76(1)(a) BP should be measured with a properly calibrated and validated instrument Patients should be seated quietly for at least 5 minutes in a chair with feet on the floor and arm supported at heart level An appropriate-sized cuff (cuff bladder encircling at least 80 of the arm) should be used to ensure accuracy At least 2 measurements should be made Systolic BP is the point at which the first of 2 or more sounds is heard (phase 1) and diastolic BP is the point before the disappearance of sounds (phase 5) [Chobanian et al 2003]
(2) Head eyes ears nose and throat (HEENT)
34
9420 Uncontrolled Hypertension 94201 Physician Evaluation Severe uncontrolled hypertension [defined as systolic pressure greater than 180 mm Hg diastolic pressure greater than 100 mm Hg or mean systolic blood
pressure ( systolic + diastolic) greater than 120 mm Hg] or malignant hypertension (defined as hypertension with the presence of target organ damage) compromises the members ability to safely perform essential job tasks 1 5 7 9 and 13 and the physician shall report the applicable job limitations to the fire department
Members with Pre-hypertention (systolic 120-139 mmHg or diastolic 80-89 mmHg) Stage 1 hypertension (systolic 140-159 mmHg or diastolic 90-99 mmHg) or Stage 2 hypertension (systolic ge160 mmHg or diastolic ge100 mmHg) should be referred to their primary care physician for evaluation lifestyle modification and treatment
(1) Members with Stage I hypertension should be followed-up not only by their primary care physician but also by the FD physician every 3 to 6 months to ensure their blood pressure is under control and to determine whether screening tests for asymptomatic end organ damage are appropriate
(2) Members with Stage 2 hypertension or with end organ damage (retinopathy nephropathy vascular or cardiac complications) compromises the members ability to safely perform essential job tasks 1 5 7 9 and 130 and the physician shall report the applicable job limitations to the fire department
A94201 Severe uncontrolled hypertension is a significant risk factor for the development of coronary artery disease congestive heart failure and stroke Blood pressure increases as a normal response to exercise This response is further exaggerated by the emotional and physical stress of performing these critical tasks while operating in personal protective clothing at extremes of temperature This normal elevation of blood pressure under these response conditions can lead to life-threatening hypertensive emergencies if a members daily blood pressure is already elevated to high levels In addition hypertension is a progressive illness that when uncontrolled ultimately and inevitably leads to target organ damage Target organs that are sensitive to the effects of elevated blood pressure are the central nervous system vision heart major blood vessels and kidneys
Chronic hypertension can damage the eye (retinopathy) the kidneys (nephropathy) the vascular system (stroke transient ischemic attack or peripheral artery disease) or the heart (left ventricular hypertrophy and heart failure) These hypertension complications are known as end organ damage The cardiac and vascular complications are associated with an increased risk of sudden incapacitation and sudden cardiac death (Koren et al 1991) Fortunately with proper evaluation life style modification and treatment these complications can be avoided Life style modification includes weight reduction DASH eating plan reduction in dietary sodium an increase in aerobic physical activity and moderation in alcohol consumption [Chobanian 2003]
Formatted Font (Default) Times New Roman12 pt Font color Black
Formatted Font (Default) Times New Roman12 pt Font color Black
35
A94201 (1) Members with Stage I hypertension whose BP returns to either pre-hypertenion or normal with lifestyle modification andor treatment can return to an annual medical evaluation For members with long-standing Stage I hypertension whose BP has not been reduced additional evaluation for possible end organ damage should be considered This evaluation could include any or all of the following
a) a compete patient history for symptoms of heart failure (eg shortness of breath upon exertion) or transient ischemic attacks (TIAs)
b) dilated eye examination for retinopathy
c) blood creatinine measurement for nephropathy
d) tests for left ventricular hypertrophy Unfortunately use of the resting EKG to detect left ventricular hypertrophy is very insensitive (eg 5 sensitivity) The echocardiogram is the best test for diagnosing left ventricular hypertrophy
A 94201 (2) Due to the high risk of a sudden cardiovascular event members with Stage 2 hypertension should be restricted until their BP can be brought under control Once the BP is brought under control they should be followed in the same manner as a member with Stage I hypertension
Formatted Font (Default) Times New Roman12 pt
36
D22 Cardiology Gibbons R J GJ Balady J W Beasley et al 1997 ACCAHA guidelines for exercise testing a report of American College of CardiologyAmerican Heart Association Task Force on Practice Guidelines (Committee on Exercise Testing) J Am Coll Cardiol 30260ndash311
Gibbons RJ Balady GJ Bricker JT Chaitman BR Fletcher GF Froelicher VF Mark DB McCallister BD Mooss AN OrsquoReilly MG Winters WL Jr [2002] ACCAHA 2002 guideline update for exercise testing summary article a report of the ACCAHA Task Force on Practice Guidelines (Committee to Update the 1997 Exercise Testing guidelines) J Am Coll Cardiol 401531ndash 40
Chobanian AV Bakris GL Black HR Cushman WC Green LA Izzo JL Jr Jones DW Materson BJ Oparil S Wright JT Jr Roccella EJ the National High Blood Pressure Education Program Coordinating Committee [2003] The seventh report of the Joint National Committee [JNC-7] on Prevention Detection Evaluation and Treatment of High Blood Pressure JAMA 2892560ndash2571
Soteriades ES Kales SN Liarokapis D Christiani DC [2003] Prospective surveillance of hypertension in firefighters J Clin Hypertens 5315-320
Kales SN Tsismenakis AJ Zhang C Soteriades ES [2009] Blood pressure in fire fighters police officers and other emergency responders Am J Hypertens 2211-20
37
NFPA 1582‐ HTN Draft 1
Reason for Revision
1) New classification of BP by the Joint National Commission [Chobanian et al 2002]
2) A high prevalence of FF have either HTN (~20) and Pre‐HTN (~20) [Soteriades et al 2003]
3) Among FF studies have shown a strong association between HTN and a number of adverse
cardiovascular events [Kales et al 2009]
4) A large percentage of on‐duty FF fatalities were found to have left ventricular hypertrophy a
complication of HTN at autopsy
Language in 2007 Edition with draft revisions in Red (Track changes)
611 The medical evaluation of a candidate shall include a medical history examination and any laboratory tests required to detect physical or medical condition(s) that could adversely affect hisher ability to safely perform the essential job tasks outlined in 511 A611 The medical history should include the candidates known health problems such as major illnesses surgeries medication use and allergies Symptom review is also important for detecting early signs of illness A medical history should also include a personal health history a family health history a health habit history an immunization history and a reproductive history
An occupational history should also be obtained to collect information about the persons past occupational and environmental exposures
(a) BP should be measured according to the Joint National Commission (JNC) -7 recommendations BP should be measured with a properly calibrated and validated instrument Patients should be seated quietly for at least 5 minutes in a chair with feet on the floor and arm supported at heart level An appropriate-sized cuff (cuff bladder encircling at least 80 of the arm) should be used to ensure accuracy At least 2 measurements should be made Systolic BP is the point at which the first of 2 or more sounds is heard (phase 1) and diastolic BP is the point before the disappearance of sounds (phase 5) [Chobanian et al 2003]
(2) Head eyes ears nose and throat
38
692 Vascular System 6921 Category A medical conditions shall include the following
(1) Uncontrolled or poorly controlled hypertension
(2) Hypertension with evidence of end organ damage
A6921(1) Uncontrolled or poorly controlled hypertension increases the risk of a sudden cardiac event This sudden cardiac event would cause sudden incapacitation which interferes with the safe performance of essential job tasks Uncontrolled or poorly controlled hypertension can be defined as the presence of end organ damage (see below) or stage 2 hypertension (BP systolic gt160 mmHg or BP diastolic gt100 mmHg) Individuals with pre- stage 1 or stage 2 hypertension should be referred to their primary care physician for evaluation lifestyle modification and treatment [QUESTION FOR GROUP _- WHAT ABOUT HAVING CANDIDATE RETURN IN ONE MONTH UNDER TREATMENT WITH NORMAL BP]
A6921(2)Chronic hypertension can damage the eye (retinopathy) the kidneys (nephropathy) the vascular system (stroke transient ischemic attack or peripheral artery disease) or the heart (left ventricular hypertrophy and heart failure) These hypertension complications are known as end organ damage The cardiac and vascular complications are associated with an increased risk of sudden incapacitation and sudden cardiac death (Koren et al 1991) Unfortunately the cardiac complications are frequently asymptomatic and valid screening tests are not fast and are not inexpensive Therefore determining who to screen for cardiac complications (such as echocardiogram for LVH or a measurement of left ventricular ejection fraction for heart failure) should be based on the severity and the duration of HTN
76 Physical Examination The annual physical examination shall include each of the following components
(a) BP shall be measured according to the Joint National Commission (JNC)-7 recommendations
A76(1)(a) BP should be measured with a properly calibrated and validated instrument Patients should be seated quietly for at least 5 minutes in a chair with feet on the floor and arm supported at heart level An appropriate-sized cuff (cuff bladder encircling at least 80 of the arm) should be used to ensure accuracy At least 2 measurements should be made Systolic BP is the point at which the first of 2 or more sounds is heard (phase 1) and diastolic BP is the point before the disappearance of sounds (phase 5) [Chobanian et al 2003]
(2) Head eyes ears nose and throat9420 Hypertension 94201 Physician Evaluation Members with Pre-hypertention (systolic 120-139 mmHg or diastolic 80-89 mmHg) Stage 1 hypertension (systolic 140-159 mmHg or diastolic 90-99 mmHg) or Stage 2 hypertension (systolic ge160 mmHg or diastolic ge100 mmHg) should be referred to their primary care physician for evaluation lifestyle modification and treatment
39
(1) Members with Stage I hypertension should be followed-up not only by their primary care physician but also by the FD physician every 3 to 6 months to ensure their blood pressure is under control and to determine whether screening tests for asymptomatic end organ damage are appropriate
(2) Members with Stage 2 hypertension or with end organ damage (retinopathy nephropathy vascular or cardiac complications) compromises the members ability to safely perform essential job tasks 1 5 7 9 and 130 and the physician shall report the applicable job limitations to the fire department
A94201 Chronic hypertension can damage the eye (retinopathy) the kidneys (nephropathy) the vascular system (stroke transient ischemic attack or peripheral artery disease) or the heart (left ventricular hypertrophy and heart failure) These hypertension complications are known as end organ damage The cardiac and vascular complications are associated with an increased risk of sudden incapacitation and sudden cardiac death (Koren et al 1991) Fortunately with proper evaluation life style modification and treatment these complications can be avoided Life style modification includes weight reduction DASH eating plan reduction in dietary sodium an increase in aerobic physical activity and moderation in alcohol consumption [Chobanian 2003]
A94201 (1) Members with Stage I hypertension whose BP returns to either pre-hypertenion or normal with lifestyle modification andor treatment can return to an annual medical evaluation For members with long-standing Stage I hypertension whose BP has not been reduced additional evaluation for possible end organ damage should be considered This evaluation could include any or all of the following
a) a compete patient history for symptoms of heart failure (eg shortness of breath upon exertion) or transient ischemic attacks (TIAs)
b) dilated eye examination for retinopathy
c) blood creatinine measurement for nephropathy
d) tests for left ventricular hypertrophy Unfortunately use of the resting EKG to detect left ventricular hypertrophy is very insensitive (eg 5 sensitivity) The echocardiogram is the best test for diagnosing left ventricular hypertrophy
A 94201 (2) Due to the high risk of a sudden cardiovascular event members with Stage 2 hypertension should be restricted until their BP can be brought under control Once the BP is brought under control they should be followed in the same manner as a member with Stage I hypertension
D22 Cardiology
40
Hypertension
Gibbons RJ Balady GJ Bricker JT Chaitman BR Fletcher GF Froelicher VF Mark DB McCallister BD Mooss AN OrsquoReilly MG Winters WL Jr [2002] ACCAHA 2002 guideline update for exercise testing summary article a report of the ACCAHA Task Force on Practice Guidelines (Committee to Update the 1997 Exercise Testing guidelines) J Am Coll Cardiol 401531ndash 40
Chobanian AV Bakris GL Black HR Cushman WC Green LA Izzo JL Jr Jones DW Materson BJ Oparil S Wright JT Jr Roccella EJ the National High Blood Pressure Education Program Coordinating Committee [2003] The seventh report of the Joint National Committee [JNC-7] on Prevention Detection Evaluation and Treatment of High Blood Pressure JAMA 2892560ndash2571
Soteriades ES Kales SN Liarokapis D Christiani DC [2003] Prospective surveillance of hypertension in firefighters J Clin Hypertens 5315-320
Kales SN Tsismenakis AJ Zhang C Soteriades ES [2009] Blood pressure in fire fighters police officers and other emergency responders Am J Hypertens 2211-20
41
NFPA 1582‐ Draft Revisions for CVDHTN
EKG and stress tests
Reason for Revision
1) Change requirement for annual resting EKG to periodically to be more consistent with ACCAHA
recommendation (Schlant et al 1992)
2) Add language to clarify what constitutes a positive ST
3) Make criteria for conducting diagnostic ST in asymptomatic patients consistent with the
ACCAHA
Language in 2007 Edition with draft revisions in Red (Track changes)
776 Electrocardiograms (EKG)) and Stress Tests 7761 A resting EKG shall be performed as part of the baseline medical evaluation and shall be obtained periodically (every 1 to 5 years) annually thereafter
A7761 A baseline resting EKGs shall be conducted Follow-up resting EKGs should be conducted as clinically indicated but at a minimum of every 1 to 5 years The frequency of these follow-up resting EKGs should increase as a members age increases or with increasing number andor severity of coronary heart disease risk factors Members above the age of 40 should have annual resting EKGs (Schlant et al 1992)
7762 The fire department physician or other qualified medical evaluator shall compare EKGs obtained during yearly evaluations with baseline and subsequent EKGs
7763 Stress testing EKG with or without echocardiography or radionuclide scanning shall be performed as clinically indicated by history or symptoms
A7761 Baseline electrocardiography should be conducted (Periodic resting electrocardiograms have not been shown to be useful but can be reasonable as a members agefactors increase)
A7763 No firm guidelines for stress testingelectrocardiography in asymptomatic individuals have been developed Stress testingelectrocardiography as a screening tool is used as part of an evaluation of aerobic capacity during the annual occupational fitness evaluation Submaximal stress testingelectrocardiography testing to 85 percent is commonly used as part of this screening
Submaximal stress electrocardiography testing should not be used for diagnostic purposes Cardiology evaluation with maximal stress testingelectrocardiography together with imaging techniques (eg echocardiography technetium Tc99m sestamibi study andor coronary angiography) is necessary for diagnosticprognostic purposes for the following
42
(1) Fire fighters with positive or questionably positive changes on screening submaximal stress tests
(2) Fire fighters with new onset chest pain or other symptoms suggestive of coronary artery disease (CAD)
(3) Fire fighters with diabetes mellitus who
(a) are gt35 years old or
(b) have type I diabetes for more than 15 years or
(c) have type II diabetes for more than 10 years or
(d) have any other CHD risk factor (see below) or
(e) have the presence of microvascular disease (proliferative retinopathy)
(4) Fire fighters over the age of 45 (for men) and 55 (for women) with onetwo or more risk factors for CAD Risk factors for CAD include hypercholesterolemia (total cholesterol greater than 240 mgdL) hypertension (systolic gt140 mmHg or diastolic gt90 mmHg) smoking or family history of premature CAD (heart attack or sudden cardiac death in a first degree relative less than 60 years of age)
as defined below if stress electrocardiography with imaging is negative then repeat as clinically indicated or at least every 5 years
(5) Fire fighters with a Framingham Risk Score gt10 Risk calculator is available at [httphp2010nhlbihinnetatpiiicalculatorasp]
(6) Fire fighters identified in 9431
Negative stress tests should be repeated as clinically indicated or at least every 2 to 5 years
Interpreting stress tests as ldquopositiverdquo or ldquonegativerdquo is beyond the scope of this document However factors that should be taken into consideration should include the individualrsquos exercise capacity symptoms blood pressure response heart rate response EKG changes and the presence of arrhythmias (Gibbon et al 2002)
Risk factors for CAD include hypercholesterolemia (total cholesterol greater than 240 mgdL) hypertension (systolic greater than 140 andor diastolic greater than 90) smoking diabetes mellitus or family history of premature CAD (heart attack or sudden cardiac death in a first degree relative less than 60 years of age)
There are other non-invasive tests to screen for coronary artery disease One of the most promising appears to be coronary artery calcium (CAD) scoring by computed tomography In 2007 an expert committee published an update to their original guidance document The committeersquos consensus was that ldquoit may be reasonable to consider use of CAC measurement in such patients [between 10 and 20 10-year risk of estimated coronary event]helliprdquo The committee did not recommend CAC measurement in low risk patients [lt10 10-year risk of estimated coronary event] or in high risk patients [gt20 10-year risk of estimate coronary event] (Greenland et al 2007]
43
D22 Cardiology
Chobanian AV Bakris GL Black HR Cushman WC Green LA Izzo JL Jr Jones DW Materson BJ Oparil S Wright JT Jr Roccella EJ the National High Blood Pressure Education Program Coordinating Committee [2003] The seventh report of the Joint National Committee [JNC-7] on Prevention Detection Evaluation and Treatment of High Blood Pressure JAMA 2892560ndash2571
Gibbons RJ Balady GJ Bricker JT Chaitman BR Fletcher GF Froelicher VF Mark DB McCallister BD Mooss AN OrsquoReilly MG Winters WL Jr [2002] ACCAHA 2002 guideline update for exercise testing summary article a report of the ACCAHA Task Force on Practice Guidelines (Committee to Update the 1997 Exercise Testing guidelines) J Am Coll Cardiol 401531ndash 1540
Greenland et al [2007] ACCFAHA 2007 Clinical Expert Consensus Document on Coronary Artery Calcium Scoring By Computed Tomography in Global Cardiovascular Risk Assessment and in Evaluation of Patients With Chest Pain A Report of the American College of Cardiology Foundation Clinical Expert Consensus Task Force (ACCFAHA Writing Committee to Update the 2000 Expert Consensus Document on Electron Beam Computed Tomography) J Am Coll Cardiol 49378-402
Kales SN Tsismenakis AJ Zhang C Soteriades ES [2009] Blood pressure in fire fighters police officers and other emergency responders Am J Hypertens 2211-20
Schlant RC Adolph RJ DiMarco JP Dreifus LS Dunn MI Fisch C Garson A Jr Haywood LJ Levine HJ Murray JA Noble RJ Ronan JA Jr [1992] Guidelines for electrocardiography A report of the American College of CardiologyAmerican Heart Association Task Force on Assessment of Diagnostic and Therapeutic Cardiovascular Procedures (Committee on Electrocardiography) Circulation 85(3)1221-1228
Soteriades ES Kales SN Liarokapis D Christiani DC [2003] Prospective surveillance of hypertension in firefighters J Clin Hypertens 5315-320
Formatted Font Italic
Formatted Line spacing single
Formatted Font Italic
Formatted Font Italic
44
NFPA 1582‐ Draft Revisions for CVDHTN
EKG and stress tests
Reason for Revision
1) Change requirement for annual resting EKG to periodically to be more consistent with ACCAHA
recommendation (Schlant et al 1992)
2) Add language to clarify what constitutes a positive ST
3) Make criteria for conducting diagnostic ST in asymptomatic patients consistent with the
ACCAHA
Language in 2007 Edition with draft revisions in Red (Track changes)
776 Electrocardiograms (EKG) and Stress Tests 7761 A resting EKG shall be performed as part of the baseline medical evaluation and shall be obtained periodically (every 1 to 5 years) thereafter
A7761 A baseline resting EKGs shall be conducted Follow-up resting EKGs should be conducted as clinically indicated but at a minimum of every 1 to 5 years The frequency of these follow-up resting EKGs should increase as a members age increases or with increasing number andor severity of coronary heart disease risk factors Members above the age of 40 should have annual resting EKGs (Schlant et al 1992)
7762 The fire department physician or other qualified medical evaluator shall compare baseline and subsequent EKGs
7763 Stress testing with or without echocardiography or radionuclide scanning shall be performed as clinically indicated by history or symptoms
A7763 No firm guidelines for stress testing in asymptomatic individuals have been developed Stress testing as a screening tool is used as part of an evaluation of aerobic capacity during the annual occupational fitness evaluation Submaximal stress testing testing to 85 percent is commonly used as part of this screening
Submaximal stress testing should not be used for diagnostic purposes Cardiology evaluation with maximal stress testing together with imaging techniques (eg echocardiography technetium Tc99m sestamibi study) is necessary for diagnosticprognostic purposes for the following
(1) Fire fighters with positive or questionably positive changes on screening submaximal stress tests
(2) Fire fighters with new onset chest pain or other symptoms suggestive of coronary artery disease (CAD)
45
(3) Fire fighters with diabetes mellitus who
(a) are gt35 years old or
(b) have type I diabetes for more than 15 years or
(c) have type II diabetes for more than 10 years or
(d) have any other CHD risk factor (see below) or
(e) have the presence of microvascular disease (proliferative retinopathy)
(4) Fire fighters over the age of 45 (for men) and 55 (for women) with one or more risk factors for CAD Risk factors for CAD include hypercholesterolemia (total cholesterol greater than 240 mgdL) hypertension (systolic gt140 mmHg or diastolic gt90 mmHg) smoking or family history of premature CAD (heart attack or sudden cardiac death in a first degree relative less than 60 years of age)
(5) Fire fighters with a Framingham Risk Score gt10 Risk calculator is available at [httphp2010nhlbihinnetatpiiicalculatorasp]
(6) Fire fighters identified in 9431
Negative stress tests should be repeated as clinically indicated or at least every 2 to 5 years
Interpreting stress tests as ldquopositiverdquo or ldquonegativerdquo is beyond the scope of this document However factors that should be taken into consideration should include the individualrsquos exercise capacity symptoms blood pressure response heart rate response EKG changes and the presence of arrhythmias (Gibbon et al 2002)
There are other non-invasive tests to screen for coronary artery disease One of the most promising appears to be coronary artery calcium (CAD) scoring by computed tomography In 2007 an expert committee published an update to their original guidance document The committeersquos consensus was that ldquoit may be reasonable to consider use of CAC measurement in such patients [between 10 and 20 10-year risk of estimated coronary event]helliprdquo The committee did not recommend CAC measurement in low risk patients [lt10 10-year risk of estimated coronary event] or in high risk patients [gt20 10-year risk of estimate coronary event] (Greenland et al 2007]
D22 Cardiology
Resting EKG and Stress Tests
46
Chobanian AV Bakris GL Black HR Cushman WC Green LA Izzo JL Jr Jones DW Materson BJ Oparil S Wright JT Jr Roccella EJ the National High Blood Pressure Education Program Coordinating Committee [2003] The seventh report of the Joint National Committee [JNC-7] on Prevention Detection Evaluation and Treatment of High Blood Pressure JAMA 2892560ndash2571
Gibbons RJ Balady GJ Bricker JT Chaitman BR Fletcher GF Froelicher VF Mark DB McCallister BD Mooss AN OrsquoReilly MG Winters WL Jr [2002] ACCAHA 2002 guideline update for exercise testing summary article a report of the ACCAHA Task Force on Practice Guidelines (Committee to Update the 1997 Exercise Testing guidelines) J Am Coll Cardiol 401531ndash 1540
Greenland et al [2007] ACCFAHA 2007 Clinical Expert Consensus Document on Coronary Artery Calcium Scoring By Computed Tomography in Global Cardiovascular Risk Assessment and in Evaluation of Patients With Chest Pain A Report of the American College of Cardiology Foundation Clinical Expert Consensus Task Force (ACCFAHA Writing Committee to Update the 2000 Expert Consensus Document on Electron Beam Computed Tomography) J Am Coll Cardiol 49378-402
Kales SN Tsismenakis AJ Zhang C Soteriades ES [2009] Blood pressure in fire fighters police officers and other emergency responders Am J Hypertens 2211-20
Schlant RC Adolph RJ DiMarco JP Dreifus LS Dunn MI Fisch C Garson A Jr Haywood LJ Levine HJ Murray JA Noble RJ Ronan JA Jr [1992] Guidelines for electrocardiography A report of the American College of CardiologyAmerican Heart Association Task Force on Assessment of Diagnostic and Therapeutic Cardiovascular Procedures (Committee on Electrocardiography) Circulation 85(3)1221-1228
Soteriades ES Kales SN Liarokapis D Christiani DC [2003] Prospective surveillance of hypertension in firefighters J Clin Hypertens 5315-320
47
ATTACHMENT F
48
1
Current 1582 (2007) language in reference to pregnancy 43 (4) Report to the fire department physician any medical condition that could interfere with the ability of the individual to safely perform essential job tasks such as illness or injury use of prescription or nonprescription drugs and pregnancy 6112 Category B medical conditions shall include the following (1) Pregnancy for its duration A7792 (e) If HIV prophylaxis is to be given the following tests should be done i CBC ii Glucose renal and hepatic chemical function iii Pregnancy test for females B121 Pregnancy and Reproduction Federal regulations as well as many court decisions including the US Supreme Courtrsquos decision in International Union et al v Johnson Controls Inc [499 US 187 111 S Ct 1196 (1991)] have interpreted the requirements of Title VII with respect to pregnancy and reproduction The AHJ should seek the advice of counsel in resolving specific questions concerning these requirements as well as other requirements that can be imposed by state or local laws C211 (4) Review health status with the individual being evaluated Contraindications for evaluations shall be reviewed addressing any changes in the individualrsquos health status since their last medical evaluation that would warrant deferring the evaluation including (g) Pregnancy Recommendations to language enhancement
A female employee who is assigned to regular fire line duty shall report a pregnancy immediately to their respective Supervisor and the fire department physician The employee will then be given the option of a non-hazardous alternative duty position for the duration of her pregnancy (can we say this or is it even appropriate) Any pregnant employee wishing to remain on regular line duty shall be informed of the possible risks and consequences to herself and her fetus that are associated with continued line fire fighting duty Among those risk factors are exposure to teratogens known to have negative effects on the developing fetus such as smoke diesel fumes hazardous chemicals and extreme heat
49
Page 2
appendix It is recommended that the pregnant employee complete a release of liability form signed by herself and her health care provider utilizing NFPArsquos 13 critical tasks as a reference This will inform the health care provider of specific job-related tasks that will need to be performed in order to continue regular line duty These tasks are basic physical standards that any entry level firefighter would have to be able to complete competently The employeersquos health condition will be kept confidential by the department in accordance with HIPAA standards Employees are allowed to remain on active regular duty until they are no longer able to perform their duties in a reasonable manner andor their protective gear no longer fits correctly It is the responsibility of the health care provider to evaluate the pregnant employee If at any time the health care provider feels the pregnant employee can no longer perform the job related tasks this should be reported to the employer by the employee immediately
50
ATTACHMENT G
51
From GLENN BENARICKTo Sawyer SteveSubject RE RE 7743Date Monday August 30 2010 21633 PM
Yes thats my understanding
Glenn P Benarick 211 Winged Elm CircleAiken SC 29803803-644-7093gbenarprodigynet
--- On Mon 83010 Sawyer Steve ltssawyerNFPAorggt wrote
From Sawyer Steve ltssawyerNFPAorggtSubject RE RE 7743To GLENN BENARICK ltgbenarprodigynetgtDate Monday August 30 2010 212 PM
So it should be ldquoorrdquo instead of ldquoandrdquo for now
Steven F Sawyer
Senior Fire Service Specialist
Executive Secretary IFMAFire Service Section
NFPA
1 Batterymarch Park
Quincy MA 02169
6179847423
Fax 6179847056
ssawyernfpaorg
From GLENN BENARICK [mailtogbenarprodigynet] Sent Monday August 30 2010 1202 PMTo Sawyer SteveSubject Fw RE 7743
52
Steve a couple of our docs agree with April Boyer
Glenn P Benarick 211 Winged Elm Circle
Aiken SC 29803
803-644-7093
gbenarprodigynet
--- On Mon 83010 David Prezant ltprezandfdnynycgovgt wrote
From David Prezant ltprezandfdnynycgovgtSubject RE 7743To Thomas R (CDCNIOSHDSHEFS) Hales lttrh1cdcgovgt GLENNBENARICK ltgbenarprodigynetgtCc Sandy Bogucki ltsandyboguckiyaleedugtDate Monday August 30 2010 1004 AM
agree
we should change this to NHANES III rather than Knudson we should alsomodify this to allow not only for predicted cutoffs but all for use of thelower limit of normal cutoff This is important to prevent false-classificationof spirometry as abnormal in older groups and in taller grps The latter ofparticular import to firefighter occupational health surveillance
thanks
David Prezant MDChief Medical Officer Office of Medical AffairsCo-Director WTC Medical Monitoring amp Treatment ProgramsNew York City Fire Department9 Metrotech Center - Rm 4W-1Brooklyn NY 11201Phone 718-999-2696Fax 718-999-0665
Life is full of twists and turns
53
This email may contain confidential information If you are the unintendedrecipient of this email please send it back and delete from your directory
gtgtgt Hales Thomas R (CDCNIOSHDSHEFS) lttrh1cdcgovgt 8302010955 AM gtgtgt
Glen
This seems like a very reasonable comment and illustrates the importance of having clinicians providefeedback on the std Im not familiar with the software program of the various spirometers (NHANES IIIvs KnudsonATS vs both) Given the large role both Dave Prezant and Sandy Bogucki had for thepulmonary section let me forward to them for clarification
Tom
From GLENN BENARICK [mailtogbenarprodigynet] Sent Sunday August 29 2010 456 PMTo Hales Thomas R (CDCNIOSHDSHEFS)Subject FW 7743
Tom is April Boyer correct
Glenn P Benarick 211 Winged Elm Circle
Aiken SC 29803
803-644-7093
gbenarprodigynet
--- On Thu 82610 Sawyer Steve ltssawyerNFPAorggt wrote
From Sawyer Steve ltssawyerNFPAorggtSubject FW 7743To GLENN BENARICK ltgbenarprodigynetgtDate Thursday August 26 2010 925 PM
FYI Do you have any answer She is write
Steven
54
Steven F Sawyer
Senior Fire Service Specialist
Executive Secretary IFMAFire Service Section
NFPA
1 Batterymarch Park
Quincy MA 02169
6179847423
Fax 6179847056
ssawyernfpaorg
From April Boyer [mailtoaboyerbicclinicorg] Sent Thursday August 26 2010 232 PMTo Sawyer SteveCc RobinMWebbmilstateorusSubject 7743
Steven
The spirometry tests cannot be corrected according to both references as the NFPA states because thereferences are contradictory The first part of 7743 states to follow the ATS guidelines and use theKnudsen (we at Basin Immediate Care use the Nhanes III) The second part states to follow the ACOEMguidelines and use the Nhanes III in the occupational setting if available with your unit (which is availableon ours) 7743 does not use the word OR regarding both requirements it uses the word AND whenreferring to the first and second parts thence making 7743 contradictory I realize the NFPA 1582 hasnot been updated since 2007 unless I have just not received an updated version
Our question to you is which part of 7743 do you want us to follow the first or the second part Anyfacility that has an updated computerized spirometry system (as we do) will not be able to follow bothrequired parts for obvious reasons We can either follow the first part of 7743 and use an oldercorrected version of the Knudson by going into our system and changing out of the Nhanes III conversionOR we can follow the second part of 7743 and use the newer corrected version of Nhanes III which ourunit offers too
If you have any questions you may contact me at anytime and I also have many references in regards toboth parts of 7743 if you would like to see them
55
Thank you~
April
Confidentiality NoticeThis message may contain information that isconfidential or privileged
If you are not the intended recipientPlease advise the sender immediately and delete this message
56
ATTACHMENT H
57
NFPA 1582 771(7) Proposed revisions
Why
Preliminary results of two prospective randomized trials on the PSA test were published in 2009 These studies resulted in medical organizations that previously providing guidance to modify their recommendations
Current language
771 Blood Tests Blood tests shall be performed annually and shall include the following
(7) Prostate specific antigen (PSA) after age 40 for positive family history if African American or if otherwise clinically indicated after age 50 for all other male member
Suggested Revision
771 Blood Tests Blood tests shall be performed annually and shall include the following
(7) Prostate specific antigen (PSA) after age 40 for positive family history if African American or if otherwise clinically indicated after age 50 for all other male member
772 Prostate-Specific Antigen (PSA) test At age 50 fire fighters shall have an opportunity to make an informed decision with either the Fire Department physician or their health care provider concerning the PSA test For fire fighters at increased risk of prostate cancer (African-Americans or those with a first degree relative diagnosed with prostate cancer before age 65) shall have the opportunity for this informed decision at age 40
A772 The PSA as a screening test for prostate cancer in asymptomatic men is controversial controversial for two reasons First there is no consensus that PSA screening actually saves lives For example the PSA test may detect small cancers that would never become life threatening Second it is unclear that the benefits of PSA screening outweigh the risks of follow-up diagnostic tests and cancer treatments For example the prostate biopsy used to diagnose prostate cancer may cause bleeding and infection And prostate cancer treatments such as surgery and radiation therapy may cause incontinence (inability to control urine flow) erectile dysfunction (erections inadequate for intercourse) and other complications For these reasons it is important that the benefits and risks of prostate diagnostic procedures and treatment be taken into account when considering the PSA screening test These considerations can be taken account during discussions with the fire department physician or onersquos health care provider
D211 Cancer Screening
Smith R A C J Mettlin K J Davis and H Eyre 2000 ldquoAmerican Cancer Society guidelines for the early detection of cancerrdquo CA J Clin 50(1)34ndash49
Added references
58
Carroll P Albertsen PC Greene K et al [2010] Prostate-specific antigen best practice statement 2009 update Am Urological Assoc Available at httpwwwauanetorgcontentguidelines-and-quality-careclinical-guidelinesmain-reportspsa09pdf Date accessed September 2010
Ferrini R Woolf SH [2009] Screening for prostate cancer in American men American College of Preventive Medicine Practice Policy Statement Available at httpwwwacpmorgprostatehtm Date accessed September 2010
National Cancer Institute [2009] Prostate-specific antigen test National Cancer Institute Fact Sheet Available at httpwwwcancergovcancertopicsfactsheetDetectionPSA Date accessed September 2010
Wolf AMD Wender RC Etzioni RB et al [2010] American Cancer Society guideline for the early detection of prostate cancer Update 2010 Available at httpcaonlineamcancersocorgcgicontentfullcaac20066v1 Date accessed September 2010
59
will be in contact with Mr Grant for future work between the TC and the Foundation Also on Day 2 Ken Willette (Division Manager ndash NFPA Public Fire Protection Division) delivered a presentation on the initiative developed by Kelvin Cochran (US Fire Administrator) to reduce fire fighter injuries and deaths NFPA 1500 is an integral part of this initiative See ecommittee page for presentation The Chair will be coordinating a committee conference call in the coming weeks The purpose will be to review the work which needs to be completed for the October meeting The primary focus of the call will be on 1582 issues NOTE Subsequent to the meeting I have had some discussions with a fire chief in Kentucky on the use of hearing aids The TC especially the doctors need to review the current language in 1582 and decide if revisions are needed Also most of you know that Kelvin Cochran has left the USFA unexpectedly to return to Atlanta as their fire chief I have been in contact with the Acting Administrator Glenn Gaines to inform him that our committee remains focused on the work to reduce fire fighter injuries and deaths I told him that I would keep him informed of our work He indicated that one of his primary goals is to bring fire service organizations together in order to create a safe working environment Of particular interest to him is reducing heart related injuries and deaths Submitted by Glenn Benarick
12
Technical Committee on Fire Service Occupational Safety and Health
Conference Call Meeting Minutes August 30th 2010
Members participating
Glenn Benarick TC Chair
Murrey Loflin Secretary Dr Sandy Bogucki
Thomas Cuff Stephen Foley
Scott Kerwood Tammy Lopes
David Love Dr David Prezant
Joe Rivera David Ross
Mario Rueda Phil Stittleburg
Phil Vorlander Dominic Colletti
Thomas Hillenbrand
Denise Smith Brett Bowman Alternate
Andrew Schwartz Alternate Mike Young Alternate
Dr Thomas Hales Non-Voting Member Ken Holland NFPA Staff Liaison
Casey Grant NFPAResearch Foundation Staff Katie Hathway Guest from ADA
Dr Jim Fleming Guest from Phoenix Fire Dept
The chair welcomed everyone to the conference call in which he hoped
would last only an hour The purpose was to discuss any task groups that had reports for proposed changes to NFPA 1582 for the
committee This is in hopes to ensure the committee is ready for their
pre-ROP meeting in October The following topics were discussed and are in no specific order
Comments from ADA Katie Hathaway and the group went into deep
discussion regarding ones medical history and diagnosis of diabetes
13
and some proposed changesremoval of text based on research
findings The specific proposed changes will be available for the committee at their next meeting Some members on the call felt that
this issue was covered in another law enforcement document which might better serve this issue
Research topics for FSOSH projects Casey Grant offered his time to
answer any questions regarding his presentation from the May meeting in Baltimore There was also discussion about further
involvement of the Research Foundation with this committee and some of the medical requirements within the documents Glenn and Casey
are going to be in contact offline to discuss this further
Prosthetics amp Amputees report Nothing new to report
Heart amp Hypertension report There was discussion about the need for
periodic EKGrsquos that were done both in resting and non-resting states as well as discussion about stress test requirements and frequency of
such tests The hopes were to develop text that would point to annual versus periodic evaluations of EKGrsquos and stress tests
Epilepsy report Nothing new to report
Pregnancy report The initial textlanguage has been provided to the
group through email and e-committee page posting
Coagulation amp Meds report Nothing new to report
Hearing Aid discussion Nothing new to report
The committee also discussed the evaluation and documentation of
PSA results and test requirements for the purposes of consistency The proposed text and changes have been posted on the e-committee
page as well
All of the proposed text changes from the May meeting in Baltimore have been emailed out and posted on the e-committee page If there
are any questions or concerns that something was missed please contact Glenn Steven Sawyer or Ken Holland to ensure they are
resolved
The conference call lasted approximately an hour and was adjourned at 1400 hours
14
ATTACHMENT C
15
2012 ANNUAL REVISION CYCLE
PROCESS STAGE PROCESS STEP DATES
FOR TC DATES
FOR TCC 1 PRELIMINARY 10 Notification of intent to enter cycle 7910 7910
2 REPORT ON
PROPOSALS (ROP)
21 Proposal closing date 112310 112310 22 Final date for ROP meeting 22511 2411 23 Final date for mailing TC ballots 31811 21811 24 Receipt of (TC) ballots by staff liaison 42211 31111 25 Receipt of TC recirculation ballots 5611 31811 26 Final date for TCC meeting 41511 27 Final date for mailing TCC ballots 42211 28 Receipt of TCC ballots 51311 29 Receipt of TCC recirculation ballots 52011 210 Final copy (w ballot statements) to Secretary Standards Council 51311 52711 211 Completion of Reports 52011 6311 212 ROP Published and Posted 62411 62411
3 REPORT ON
COMMENTS
(ROC)
31 Comment closing date 83011 83011 32 Final date for ROC meeting 11411 10711 33 Final date for mailing TC ballots 111811 102111 34 Receipt of (TC) ballots by staff liaison 12211 111111 35 Receipt of TC recirculation ballots 12911 111811 36 Final date for TCC meeting 121611 37 Final date for mailing TCC ballots 122311 38 Receipt of TCC ballots 11312 39 Receipt of TCC recirculation ballots 12012 310 Final copy (w ballot statements) to Secretary Standards Council 122311 12712 311 Completion of Reports 11312 2312 312 ROC Published and Posted 22412 22412
4 TECH SESSION
PREPARATION amp
ISSUANCE OF
CONSENT
DOCUMENTS
41 Notice of Intent to Make a Motion (NITMAM) Closing Date 4612 4612 42 Posting of Filed NITMAM 5412 5412
43 Council Issuance Date for Consent Documents 52912 52912
44 Appeal Closing Date for Consent Documents 61312 61312
5 TECHNICAL
SESSION 50 Association Meeting for Documents with Certified Amending Motions
64-712 64-712
6
APPEALS amp
ISSUANCE OF
DOCUMENTS
WCAMS
61 Appeal closing date for Documents with Certified Amending Motions
62712 62712
62 Council issuance for Documents with Certified Amending Motions 8912 8912
Proposal Closing Dates may vary according to documents and schedules for Revision Cycles may change Please check the NFPA website (wwwnfpaorg) for the most up-to-date information on proposal closing dates and schedules
16
ATTACHMENT D
17
This weekrsquos conference call mentioned the Diabetes chapter written for the ACOEM document Guidance for the Medical Evaluation of the Law Enforcement Officer The task group working on this chapter (led Richard Miller of the Secret Service and our very own Dan Samo) worked with the ADA or over 2-3 years to come up with a consensus document
Please find the Chapter attached ltltDiabetes Guidance Sept 2010pdfgtgt
Regarding Dan Loeberrsquos points
1) Physical Evaluation Form - We could modify the LEO form (see end of the attached Chapter)
2) Duration required for stable regiment
1582 for IDDM Type 1 1 yr
Type 2 6 m
Oral Agents None specifically
ACOEM Police for IDDM Type 1 6m
Type 2 3m
Oral Agents 1m
The police document is much clearer about the decision regarding medical fitness for duty is the responsibility of the police physician with the treating diabetes-expert physician providing the data to the police physician to make an informed decision In this regard the police officer must provide the police physician with downloaded self monitoring glucose data for the 1 3 and 6 month time periods (see section 433)
3) HA1C ndash NFPA lt 8 over 3 month period
ACOEM Police ndash (Section 4333) Specifies the frequency on measurement and if gt8 requires further evaluation
Some other discrepancies End organ complications
NFPA ndash end organ complications (eye kidney heart neuro) ndash restriction
ACOEM Police ndash end organ complication -- requires further evaluation
18
Hypoglycemia (incapacitating ndash defined differently between the two documents (434)
NFPA ndash 0 episodes in past year le1 in past 5 yrs
ACOEM Police ndash 0 episodes in past year le2 in past 3 yrs
Given Dan Samorsquos and Richard Millerrsquos work with the ADALoeber it would be helpful to get their opinions on whether any of the changes requested by Loeber are appropriate for FF with DM
Tom
Thomas Hales MD MPH
Senior Medical Epidemiologist
NIOSH CDC
4676 Columbia Pkwy R-9
Cincinnati OH 45241
(513) 841-4583
trh1cdcgov
19
43 ndash DIABETES MELLITUS
431 ndash INTRODUCTION
The educated and motivated law enforcement officer (LEO) with well-managed diabetes mellitus can be capable of
safe and effective job performance1 However diabetes mellitus may place LEOs at risk for sudden incapacitation
thus jeopardizing their ability to perform critical job functions (These job functions include those listed in Sections
32 333 351 352 36 and 37 and discussed in Appendix A)
Therefore an individualized assessment of the LEOrsquos diabetes should be performed using the following evaluative
criteria to determine whether the individuals condition permits safe and effective job performance Such evaluation
must include the following key elements which are discussed in detail below
history of blood glucose control
knowledge of diabetes and its management
current stability of blood glucose
risk for significant hypoglycemia or hyperglycemia and
presence of diabetic complications
432 ndash OVERVIEW OF MEDICAL EVALUATION
The treating endocrinologist or other physician knowledgeable regarding diabetes management should provide
a narrative report certifying whether the LEO has or has not met the criteria set out in Sections 4321 through
4354 below In addition the physician should include supporting data (see Appendix B for the Physician Evalu-
ation Form)
4321 The LEO is under the care of an endocrinologist or other physician knowledgeable regarding diabetes
management Outpatient and in-patient medical record(s) for the last 3 years or since date of diagnosis
(whichever is shorter) should be reviewed by the treating physician and provided to the police physician
4322 If the LEO has type 1 diabetes the individual has been on a basalbolus regimena or an insulin pump
using analogue insulins for the 6 months prior to evaluation2
4323 If the LEO has type 2 diabetes on insulin the individual has been on a stable medication regimenb
for the 3 months prior to evaluation3 If on oral agents alone the LEO has been on a stable medication regimen
for the month prior to evaluationc
ACOEM Guidance for the Medical Evaluation of Law Enforcement Officers 1
43 ndash DIABETES MELLITUS
aA basalbolus insulin regimen consists of the use of a basal insulin (Glargine NPH) in a once or twice daily regimen to provide between-
meal insulin combined with the use of a short acting insulin (Regular Lispro Aspart or Glulisine) at mealtimes Insulin pumps are small
(beeper sized) battery powered devices that deliver small amounts of short-acting insulin in a constant infusion to meet basal insulin
requirements The wearer selects an additional mealtime bolus to be infused at the time of meals For more information on pumps visit
the manufacturerrsquos web sites ndash wwwMinimedcom wwwcozmorecom wwwanimascorpcom wwwdisetroniccom
bA stable insulin regimen is defined as maintaining the same types of insulin (long acting intermediate acting short or rapid acting)
Changes in insulin dose are part of the appropriate self-management of diabetes and do not disqualify an applicant or incumbent under
this section
cChanges in dose within the evaluation period will be allowed but addition of a new class of medications or insulin should result in a new
period of observation
one month for addition of a sulfonylurea or metformin
two months for the addition of a thiazolidinedione to insulin or a sulfonylurea or
three months for the addition of insulin
20
4324 If the LEO uses an insulin pump documentation is needed as follows
proper understanding and education in the use of the insulin pump
start date for the use of the pump
history of insulin site infectionsd
history of pump cessation and pump malfunction
backup plan for pump malfunction including use of injectable insulin and
frequency of infusion set changes
4325 The LEO has been educated in diabetes and its management and thoroughly informed of and under-
stands the procedures that must be followed to monitor and manage hisher diabetes and what procedures
should be followed if complications arise3
433 ndash QUANTITATIVE GLUCOSE MONITORING
4331 The LEO has documentation of ongoing self-monitoring of blood glucose
4332 This must be done with a glucose meter that stores every reading records date and time of reading
and from which data can be downloaded (Most meters now have this capability)
4333 Monitoring logs must be available covering the time period (1 3 or 6 months) as described in
Sections 4322 and 4323 The frequency of glucose monitoring must follow a schedule acceptable to the
police physician in consultation with the treating physician
Testing schedules are individual What follows is a common pattern but individual patterns may differ
2 ACOEM Guidance for the Medical Evaluation of Law Enforcement Officers
43 ndash DIABETES MELLITUS
dIndividual has not had more than one pump-site infection that caused him or her to miss work or usual daily activities in the preceding 6
months
THERAPEUTIC REGIMEN GLUCOSE TESTING SCHEDULE
Diet alone Once or twice a week
Metformin Thiazolidinediones or Alpha
Glucosidase inhibitors alone or in
combination
Once or twice a week
Sulfonylureas meglitanides nateglinide ndash
alone or in combination with the above group
Twice a day ndash AM and at supper with any
suspected hypoglycemic episodes
Insulin ndash one shot in combination with orals Twice a day ndash AM and at supper with any
suspected hypoglycemic episodes
2 to 3 times AM once a week
Insulin ndash two or more shots Insulin pump 3 to 4 times a day ndash at meals and bedtime
2 to 3 times AM once a week with any
suspected hypoglycemic episodes
21
4334 The LEO has had hemoglobin A1C measured at least 4 times a year (intervals of 2 to 3 months) over
the last 12 months prior to evaluation if diagnosis has been present for more than a year4 If hemoglobin A1C is
gt8 this may signal a problem with the LEOrsquos diabetes management that warrants further assessment5
434 ndash INCAPACITATING EVENTS
4341 The LEO has not had any incapacitating episodes within the past 1 year and no more than 2 episodes
in the past 3 years or since diagnosis of diabetes (whichever is shorter) of
43411 Severe hypoglycemia (loss of consciousness seizures or coma requiring assistance of others or
needing urgent treatment [glucagon injectionIV glucose]) or
43412 Blood sugar lt60 mgdl with unawareness demonstrated in current glucose logs6
435 ndash CHRONIC COMPLICATION SCREENING
4351 Chronic complications of diabetes are associated with increased risk for severe hypoglycemic
episodes and warrant further assessmente
4352 The components of screening for chronic complications are
43521 A complete eye exam by a qualified ophthalmologist or optometrist including a dilated retinal
exam demonstrating no more than mild background diabetic retinopathyf7
43522 Normal vibratory testing with a 128 Hz tuning forkg normal testing with 10 gram Semmes-
Weinstein monofilamentg and normal orthostatic blood pressureh and pulse testing89
ACOEM Guidance for the Medical Evaluation of Law Enforcement Officers 3
43 ndash DIABETES MELLITUS
ePresence of chronic complications of diabetes in and of themselves may not require the implementation of work restrictions
fNo more than one dot blot or flame-shaped hemorrhages or microaneurysm in all four fundus quadrants
gThe Michigan Diabetes Research and Training Center of the University of Michigan Health System recommends the following guidance
(see wwwmedumichedumdrtcprofsdocumentssviMNSI_howtopdf) for conducting vibratory and monofilament testing8
Vibration Sensation Vibration sensation should be performed with the great toe unsupported Vibration sensation will be tested bi-
laterally using a 128 Hz tuning fork placed over the dorsum of the great toe on the boney prominence of the DIP joint Patients whose
eyes are closed will be asked to indicate when they can no longer sense the vibration from the vibrating tuning fork In general the
examiner should be able to feel vibration from the hand-held tuning fork for 5 seconds longer on his distal forefinger than a normal subject
can at the great toe (eg examiners DIP joint of the first finger versus patients toe) If the examiner feels vibration for 10 or more seconds
on his or her finger then vibration is considered decreased A trial should be given when the tuning fork is not vibrating to be certain that
the patient is responding to vibration and not pressure or some other clue Vibration is scored as 1) present if the examiner senses the
vibration on his or her finger for lt10 seconds 2) reduced if sensed for 10 seconds or 3) absent (no vibration detection)
Monofilament Testing For this examination it is important that the patients foot be supported (ie allow the sole of the foot to rest on
a flat warm surface) The filament should initially be pre-stressed (4-6 perpendicular applications to the dorsum of the examiner s first
finger) The filament is then applied to the dorsum of the great toe midway between the nail fold and the DIP joint Do not hold the toe
directly The filament is applied perpendicularly and briefly (lt1 second) with an even pressure When the filament bends the force of
10 grams has been applied The patient whose eyes are closed is asked to respond yes if heshe feels the filament Eight correct responses
out of 10 applications is considered normal 1 to 7 correct responses indicates reduced sensation and no correct answers translates into
absent sensation
hOrthostatic hypotension is a physical finding defined by the American Autonomic Society and the American Academy of Neurology as a
systolic blood pressure decrease of at least 20 mm Hg or a diastolic blood pressure decrease of at least 10 mm Hg within 3 minutes of
standing
22
43523 Normal cardiac physical exam Cardiac stress testing to at least 12 METS is recommended and
should begin based on either the criteria of the American Heart AssociationAmerican College of
Cardiologyi10 or those of the American Diabetes Associationj11
Diabetics who have a normal cardiac stress test will be retested every one to three years based on
individual clinical assessment This assessment should consider
the age of the individual
the number and persistence of coronary artery disease (CAD) risk factors
the severity of CAD risk factors
43524 Microalbumincreatinine ratio 301 measured or calculatedk creatinine clearance
gt60 mlmin12
436 ndash ONGOING EVALUATION AND REQUIREMENTS
4361 Should have medical records and glucose meter logs reviewed periodically Because of the nature of
diabetes it is important that regular medical follow up be provided to the LEO The frequency and content of
the evaluation should be determined on an individual basis by the police physician in consultation with the
treating physicianl
4362 Must advise police physician of any change in type of medication
4363 Must advise police physician of any episodes of significant hypoglycemia or hyperglycemia
Urine microalbumincreatinine ratio _________________
III Treating Physician Statement
The above named individual meets all of the criteria provided on this form
Yes No ndash not recommended for position
No but IS recommended for position (letter of explanation attached)
It is my opinion that the above named individual is well-educated and well-motivated in diabetes self-management and has
achieved a level of diabetes management to be capable of safe and effective job performance as a law enforcement officer
I have reached this opinion after careful review of the above criteria
___________________________________________________________ ___________________________Signature of Physician Date
______________________________________________________________ ___________________________Printed or Typed Name of Physician Telephone Number
10 ACOEM Guidance for the Medical Evaluation of Law Enforcement Officers
43 ndash DIABETES MELLITUS
29
439 ndash REFERENCES
1 American Diabetes Association Diagnosis and classification of diabetes mellitus Diabetes Care 200427 Suppl
1S5-S10 See httpcarediabetesjournalsorgcgicontentfull27suppl_1s5
2 American Diabetes Association Continuous subcutaneous insulin infusion Diabetes Care 200427 Suppl 1S110
See httpcarediabetesjournalsorgcgicontentfull27suppl_1s110
3 Mensing C Boucher J Cypress M et al National standards for diabetes self-management education Diabetes
Care 200528 Suppl 1S72-9 See httpcarediabetesjournalsorgcgicontentfull28suppl_1s72
4 Goldstein DE Little RR Lorenz RA Malone JI Nathan DM Peterson CM American Diabetes Association Tests
of glycemia in diabetes Diabetes Care 200427 Suppl 1S91-3
See httpcarediabetesjournalsorgcgicontentfull27suppl_1s91
5 The Diabetes Control and Complications Trial Research Group Hypoglycemia in the Diabetes Control and
Complications Trial Diabetes 199746(2)271-86 See wwwncbinlmnihgovpubmed9000705 for abstract
6 American Diabetes Association Hypoglycemia and employmentlicensure Diabetes Care 200528 Suppl 1S61
See httpcarediabetesjournalsorgcgicontentfull28suppl_1s61
7 Viswanath K McGavin DD Diabetic Retinopathy Clinical Findings and Management J Comm Eye Health
200316(46)21-4 See wwwcehjournalorg0953-683316jceh_16_46_021html
8 Michigan Diabetes Research and Training Center University of Michigan Health System How to use the Michigan
Neuropathy Screening Instrument See wwwmedumichedumdrtcprofsdocumentssviMNSI_howtopdf
9 Bradley JG Davis KA Orthostatic hypotension Am Fam Physician 200368(12)2393-8
See wwwaafporgafp200312152393html
10 Gibbons RJ Balady GJ Bricker JT et al ACCAHA 2002 guideline update for exercise testing a report of the
American College of CardiologyAmerican Heart Association Task Force on Practice Guidelines (Committee on
Exercise Testing) J Am Coll Cardiol 200240(8)1531-40
See wwwaccorgqualityandscienceclinicalguidelinesexerciseexercise_cleanpdf
11 American Diabetes Association Standards of medical care in diabetes Diabetes Care 200528 Suppl 1S4-S36
Erratum in Diabetes Care 200528(4)990 See httpcarediabetesjournalsorgcgicontentfull28suppl_1s4
12 Molitch ME DeFronzo RA Franz MJ et al American Diabetes Association Nephropathy in diabetes Diabetes
Care 200427 Suppl 1S79-83 See httpcarediabetesjournalsorgcgicontentfull27suppl_1s79
13 Kitabchi AE Umpierrez GE Murphy MB et al American Diabetes Association Hyperglycemic crises in diabetes
Diabetes Care 200427 Suppl 1S94-102 See httpcarediabetesjournalsorgcgicontentfull27suppl_1s94
14 US Centers for Disease Control and Prevention National Diabetes Fact Sheet 2007
See wwwcdcgovdiabetespubspdfndfs_2007pdf
ACOEM Guidance for the Medical Evaluation of Law Enforcement Officers 11
43 ndash DIABETES MELLITUS
30
ATTACHMENT E
31
Typos A6921(2) 7th line down test should be plural 94201 Paragraph 2 target organ damage is used though end organ damage was defined earlier and in the appendix for that paragraph
A94201 Para A (1) d Id suggest deleting the phrases in brackets Im not sure either are predictably true or politically wise
a) tests for left ventricular hypertrophy Unfortunately use of the EKG to detect left ventricular hypertrophy is very insensitive (eg 5 sensitivity) The echocardiogram is the best test for diagnosing left ventricular hypertrophy but [it is relatively expensive and not readily available in small rural communities ] conducting echocardiograms on asymptomatic fire fighters with Stage 1 hypertension should be reserved only for those with long-standing hypertension
In addition
7761 A resting EKG shall be performed as part of the baseline medical evaluation and shall be obtained periodically thereafter
Changing from annually to periodically is noted has the language in the wellness-fitness initiative been changed as well Our previous decision was that we would support the W-F language since there was no compelling evidence to either support or refute it
Thanks
Sandy
32
NFPA 1582‐ HTN Draft 1
Reason for Revision
1) New classification of BP by the Joint National Commission [Chobanian et al 2002]
2) A high prevalence of FF have either HTN (~20) and Pre‐HTN (~20) [Soteriades et al 2003]
3) Among FF studies have shown a strong association between HTN and a number of adverse
cardiovascular events [Kales et al 2009]
4) A large percentage of on‐duty FF fatalities were found to have left ventricular hypertrophy a
complication of HTN at autopsy
Language in 2007 Edition with draft revisions in Red (Track changes)
611 The medical evaluation of a candidate shall include a medical history examination and any laboratory tests required to detect physical or medical condition(s) that could adversely affect hisher ability to safely perform the essential job tasks outlined in 511 A611 The medical history should include the candidates known health problems such as major illnesses surgeries medication use and allergies Symptom review is also important for detecting early signs of illness A medical history should also include a personal health history a family health history a health habit history an immunization history and a reproductive history
An occupational history should also be obtained to collect information about the persons past occupational and environmental exposures
(a) BP should be measured according to the Joint National Commission (JNC) -7 recommendations BP should be measured with a properly calibrated and validated instrument Patients should be seated quietly for at least 5 minutes in a chair with feet on the floor and arm supported at heart level An appropriate-sized cuff (cuff bladder encircling at least 80 of the arm) should be used to ensure accuracy At least 2 measurements should be made Systolic BP is the point at which the first of 2 or more sounds is heard (phase 1) and diastolic BP is the point before the disappearance of sounds (phase 5) [Chobanian et al 2003]
(2) Head eyes ears nose and throat (HEENT)
Formatted Font (Default) Times New RomanFont color Black
33
692 Vascular System 6921 Category A medical conditions shall include the following
(1) Uncontrolled or poorly controlled hypertension
(2) Hypertension with evidence of end organ damage
or not controlled by approved medications
A6921(1) Uncontrolled or poorly controlled hHypertension increases the risk of a sudden cardiac event This sudden cardiac event would cause sudden incapacitation which that is uncontrolled poorly controlled or requires medication likely to interferes with the safe performance of essential job tasks Uncontrolled or poorly controlled hypertension can be defined as the presence of end organ damage (see below) or stage 2 hypertension (BP systolic gt160 mmHg or BP diastolic gt100 mmHg) is an illness that can lead to functional impairment and potential for sudden incapacitation Individuals with pre- stage 1 or stage 2 hypertension should be referred to their primary care physician for evaluation lifestyle modification and treatment [QUESTION FOR GROUP _- WHAT ABOUT HAVING CANDIDATE RETURN IN ONE MONTH UNDER TREATMENT WITH NORMAL BP]
A6921(2)
Chronic hypertension can damage the eye (retinopathy) the kidneys (nephropathy) the vascular system (stroke transient ischemic attack or peripheral artery disease) or the heart (left ventricular hypertrophy and heart failure) These hypertension complications are known as end organ damage The cardiac and vascular complications are associated with an increased risk of sudden incapacitation and sudden cardiac death (Koren et al 1991) Unfortunately the cardiac complications are frequently asymptomatic and valid screening tests are not fast and are not inexpensive Therefore determining who to screen for cardiac complications (such as echocardiogram for LVH or a measurement of left ventricular ejection fraction for heart failure) should be based on the severity and the duration of HTN
76 Physical Examination The annual physical examination shall include each of the following components
(a) BP shall be measured according to the Joint National Commission (JNC)-7 recommendations
A76(1)(a) BP should be measured with a properly calibrated and validated instrument Patients should be seated quietly for at least 5 minutes in a chair with feet on the floor and arm supported at heart level An appropriate-sized cuff (cuff bladder encircling at least 80 of the arm) should be used to ensure accuracy At least 2 measurements should be made Systolic BP is the point at which the first of 2 or more sounds is heard (phase 1) and diastolic BP is the point before the disappearance of sounds (phase 5) [Chobanian et al 2003]
(2) Head eyes ears nose and throat (HEENT)
34
9420 Uncontrolled Hypertension 94201 Physician Evaluation Severe uncontrolled hypertension [defined as systolic pressure greater than 180 mm Hg diastolic pressure greater than 100 mm Hg or mean systolic blood
pressure ( systolic + diastolic) greater than 120 mm Hg] or malignant hypertension (defined as hypertension with the presence of target organ damage) compromises the members ability to safely perform essential job tasks 1 5 7 9 and 13 and the physician shall report the applicable job limitations to the fire department
Members with Pre-hypertention (systolic 120-139 mmHg or diastolic 80-89 mmHg) Stage 1 hypertension (systolic 140-159 mmHg or diastolic 90-99 mmHg) or Stage 2 hypertension (systolic ge160 mmHg or diastolic ge100 mmHg) should be referred to their primary care physician for evaluation lifestyle modification and treatment
(1) Members with Stage I hypertension should be followed-up not only by their primary care physician but also by the FD physician every 3 to 6 months to ensure their blood pressure is under control and to determine whether screening tests for asymptomatic end organ damage are appropriate
(2) Members with Stage 2 hypertension or with end organ damage (retinopathy nephropathy vascular or cardiac complications) compromises the members ability to safely perform essential job tasks 1 5 7 9 and 130 and the physician shall report the applicable job limitations to the fire department
A94201 Severe uncontrolled hypertension is a significant risk factor for the development of coronary artery disease congestive heart failure and stroke Blood pressure increases as a normal response to exercise This response is further exaggerated by the emotional and physical stress of performing these critical tasks while operating in personal protective clothing at extremes of temperature This normal elevation of blood pressure under these response conditions can lead to life-threatening hypertensive emergencies if a members daily blood pressure is already elevated to high levels In addition hypertension is a progressive illness that when uncontrolled ultimately and inevitably leads to target organ damage Target organs that are sensitive to the effects of elevated blood pressure are the central nervous system vision heart major blood vessels and kidneys
Chronic hypertension can damage the eye (retinopathy) the kidneys (nephropathy) the vascular system (stroke transient ischemic attack or peripheral artery disease) or the heart (left ventricular hypertrophy and heart failure) These hypertension complications are known as end organ damage The cardiac and vascular complications are associated with an increased risk of sudden incapacitation and sudden cardiac death (Koren et al 1991) Fortunately with proper evaluation life style modification and treatment these complications can be avoided Life style modification includes weight reduction DASH eating plan reduction in dietary sodium an increase in aerobic physical activity and moderation in alcohol consumption [Chobanian 2003]
Formatted Font (Default) Times New Roman12 pt Font color Black
Formatted Font (Default) Times New Roman12 pt Font color Black
35
A94201 (1) Members with Stage I hypertension whose BP returns to either pre-hypertenion or normal with lifestyle modification andor treatment can return to an annual medical evaluation For members with long-standing Stage I hypertension whose BP has not been reduced additional evaluation for possible end organ damage should be considered This evaluation could include any or all of the following
a) a compete patient history for symptoms of heart failure (eg shortness of breath upon exertion) or transient ischemic attacks (TIAs)
b) dilated eye examination for retinopathy
c) blood creatinine measurement for nephropathy
d) tests for left ventricular hypertrophy Unfortunately use of the resting EKG to detect left ventricular hypertrophy is very insensitive (eg 5 sensitivity) The echocardiogram is the best test for diagnosing left ventricular hypertrophy
A 94201 (2) Due to the high risk of a sudden cardiovascular event members with Stage 2 hypertension should be restricted until their BP can be brought under control Once the BP is brought under control they should be followed in the same manner as a member with Stage I hypertension
Formatted Font (Default) Times New Roman12 pt
36
D22 Cardiology Gibbons R J GJ Balady J W Beasley et al 1997 ACCAHA guidelines for exercise testing a report of American College of CardiologyAmerican Heart Association Task Force on Practice Guidelines (Committee on Exercise Testing) J Am Coll Cardiol 30260ndash311
Gibbons RJ Balady GJ Bricker JT Chaitman BR Fletcher GF Froelicher VF Mark DB McCallister BD Mooss AN OrsquoReilly MG Winters WL Jr [2002] ACCAHA 2002 guideline update for exercise testing summary article a report of the ACCAHA Task Force on Practice Guidelines (Committee to Update the 1997 Exercise Testing guidelines) J Am Coll Cardiol 401531ndash 40
Chobanian AV Bakris GL Black HR Cushman WC Green LA Izzo JL Jr Jones DW Materson BJ Oparil S Wright JT Jr Roccella EJ the National High Blood Pressure Education Program Coordinating Committee [2003] The seventh report of the Joint National Committee [JNC-7] on Prevention Detection Evaluation and Treatment of High Blood Pressure JAMA 2892560ndash2571
Soteriades ES Kales SN Liarokapis D Christiani DC [2003] Prospective surveillance of hypertension in firefighters J Clin Hypertens 5315-320
Kales SN Tsismenakis AJ Zhang C Soteriades ES [2009] Blood pressure in fire fighters police officers and other emergency responders Am J Hypertens 2211-20
37
NFPA 1582‐ HTN Draft 1
Reason for Revision
1) New classification of BP by the Joint National Commission [Chobanian et al 2002]
2) A high prevalence of FF have either HTN (~20) and Pre‐HTN (~20) [Soteriades et al 2003]
3) Among FF studies have shown a strong association between HTN and a number of adverse
cardiovascular events [Kales et al 2009]
4) A large percentage of on‐duty FF fatalities were found to have left ventricular hypertrophy a
complication of HTN at autopsy
Language in 2007 Edition with draft revisions in Red (Track changes)
611 The medical evaluation of a candidate shall include a medical history examination and any laboratory tests required to detect physical or medical condition(s) that could adversely affect hisher ability to safely perform the essential job tasks outlined in 511 A611 The medical history should include the candidates known health problems such as major illnesses surgeries medication use and allergies Symptom review is also important for detecting early signs of illness A medical history should also include a personal health history a family health history a health habit history an immunization history and a reproductive history
An occupational history should also be obtained to collect information about the persons past occupational and environmental exposures
(a) BP should be measured according to the Joint National Commission (JNC) -7 recommendations BP should be measured with a properly calibrated and validated instrument Patients should be seated quietly for at least 5 minutes in a chair with feet on the floor and arm supported at heart level An appropriate-sized cuff (cuff bladder encircling at least 80 of the arm) should be used to ensure accuracy At least 2 measurements should be made Systolic BP is the point at which the first of 2 or more sounds is heard (phase 1) and diastolic BP is the point before the disappearance of sounds (phase 5) [Chobanian et al 2003]
(2) Head eyes ears nose and throat
38
692 Vascular System 6921 Category A medical conditions shall include the following
(1) Uncontrolled or poorly controlled hypertension
(2) Hypertension with evidence of end organ damage
A6921(1) Uncontrolled or poorly controlled hypertension increases the risk of a sudden cardiac event This sudden cardiac event would cause sudden incapacitation which interferes with the safe performance of essential job tasks Uncontrolled or poorly controlled hypertension can be defined as the presence of end organ damage (see below) or stage 2 hypertension (BP systolic gt160 mmHg or BP diastolic gt100 mmHg) Individuals with pre- stage 1 or stage 2 hypertension should be referred to their primary care physician for evaluation lifestyle modification and treatment [QUESTION FOR GROUP _- WHAT ABOUT HAVING CANDIDATE RETURN IN ONE MONTH UNDER TREATMENT WITH NORMAL BP]
A6921(2)Chronic hypertension can damage the eye (retinopathy) the kidneys (nephropathy) the vascular system (stroke transient ischemic attack or peripheral artery disease) or the heart (left ventricular hypertrophy and heart failure) These hypertension complications are known as end organ damage The cardiac and vascular complications are associated with an increased risk of sudden incapacitation and sudden cardiac death (Koren et al 1991) Unfortunately the cardiac complications are frequently asymptomatic and valid screening tests are not fast and are not inexpensive Therefore determining who to screen for cardiac complications (such as echocardiogram for LVH or a measurement of left ventricular ejection fraction for heart failure) should be based on the severity and the duration of HTN
76 Physical Examination The annual physical examination shall include each of the following components
(a) BP shall be measured according to the Joint National Commission (JNC)-7 recommendations
A76(1)(a) BP should be measured with a properly calibrated and validated instrument Patients should be seated quietly for at least 5 minutes in a chair with feet on the floor and arm supported at heart level An appropriate-sized cuff (cuff bladder encircling at least 80 of the arm) should be used to ensure accuracy At least 2 measurements should be made Systolic BP is the point at which the first of 2 or more sounds is heard (phase 1) and diastolic BP is the point before the disappearance of sounds (phase 5) [Chobanian et al 2003]
(2) Head eyes ears nose and throat9420 Hypertension 94201 Physician Evaluation Members with Pre-hypertention (systolic 120-139 mmHg or diastolic 80-89 mmHg) Stage 1 hypertension (systolic 140-159 mmHg or diastolic 90-99 mmHg) or Stage 2 hypertension (systolic ge160 mmHg or diastolic ge100 mmHg) should be referred to their primary care physician for evaluation lifestyle modification and treatment
39
(1) Members with Stage I hypertension should be followed-up not only by their primary care physician but also by the FD physician every 3 to 6 months to ensure their blood pressure is under control and to determine whether screening tests for asymptomatic end organ damage are appropriate
(2) Members with Stage 2 hypertension or with end organ damage (retinopathy nephropathy vascular or cardiac complications) compromises the members ability to safely perform essential job tasks 1 5 7 9 and 130 and the physician shall report the applicable job limitations to the fire department
A94201 Chronic hypertension can damage the eye (retinopathy) the kidneys (nephropathy) the vascular system (stroke transient ischemic attack or peripheral artery disease) or the heart (left ventricular hypertrophy and heart failure) These hypertension complications are known as end organ damage The cardiac and vascular complications are associated with an increased risk of sudden incapacitation and sudden cardiac death (Koren et al 1991) Fortunately with proper evaluation life style modification and treatment these complications can be avoided Life style modification includes weight reduction DASH eating plan reduction in dietary sodium an increase in aerobic physical activity and moderation in alcohol consumption [Chobanian 2003]
A94201 (1) Members with Stage I hypertension whose BP returns to either pre-hypertenion or normal with lifestyle modification andor treatment can return to an annual medical evaluation For members with long-standing Stage I hypertension whose BP has not been reduced additional evaluation for possible end organ damage should be considered This evaluation could include any or all of the following
a) a compete patient history for symptoms of heart failure (eg shortness of breath upon exertion) or transient ischemic attacks (TIAs)
b) dilated eye examination for retinopathy
c) blood creatinine measurement for nephropathy
d) tests for left ventricular hypertrophy Unfortunately use of the resting EKG to detect left ventricular hypertrophy is very insensitive (eg 5 sensitivity) The echocardiogram is the best test for diagnosing left ventricular hypertrophy
A 94201 (2) Due to the high risk of a sudden cardiovascular event members with Stage 2 hypertension should be restricted until their BP can be brought under control Once the BP is brought under control they should be followed in the same manner as a member with Stage I hypertension
D22 Cardiology
40
Hypertension
Gibbons RJ Balady GJ Bricker JT Chaitman BR Fletcher GF Froelicher VF Mark DB McCallister BD Mooss AN OrsquoReilly MG Winters WL Jr [2002] ACCAHA 2002 guideline update for exercise testing summary article a report of the ACCAHA Task Force on Practice Guidelines (Committee to Update the 1997 Exercise Testing guidelines) J Am Coll Cardiol 401531ndash 40
Chobanian AV Bakris GL Black HR Cushman WC Green LA Izzo JL Jr Jones DW Materson BJ Oparil S Wright JT Jr Roccella EJ the National High Blood Pressure Education Program Coordinating Committee [2003] The seventh report of the Joint National Committee [JNC-7] on Prevention Detection Evaluation and Treatment of High Blood Pressure JAMA 2892560ndash2571
Soteriades ES Kales SN Liarokapis D Christiani DC [2003] Prospective surveillance of hypertension in firefighters J Clin Hypertens 5315-320
Kales SN Tsismenakis AJ Zhang C Soteriades ES [2009] Blood pressure in fire fighters police officers and other emergency responders Am J Hypertens 2211-20
41
NFPA 1582‐ Draft Revisions for CVDHTN
EKG and stress tests
Reason for Revision
1) Change requirement for annual resting EKG to periodically to be more consistent with ACCAHA
recommendation (Schlant et al 1992)
2) Add language to clarify what constitutes a positive ST
3) Make criteria for conducting diagnostic ST in asymptomatic patients consistent with the
ACCAHA
Language in 2007 Edition with draft revisions in Red (Track changes)
776 Electrocardiograms (EKG)) and Stress Tests 7761 A resting EKG shall be performed as part of the baseline medical evaluation and shall be obtained periodically (every 1 to 5 years) annually thereafter
A7761 A baseline resting EKGs shall be conducted Follow-up resting EKGs should be conducted as clinically indicated but at a minimum of every 1 to 5 years The frequency of these follow-up resting EKGs should increase as a members age increases or with increasing number andor severity of coronary heart disease risk factors Members above the age of 40 should have annual resting EKGs (Schlant et al 1992)
7762 The fire department physician or other qualified medical evaluator shall compare EKGs obtained during yearly evaluations with baseline and subsequent EKGs
7763 Stress testing EKG with or without echocardiography or radionuclide scanning shall be performed as clinically indicated by history or symptoms
A7761 Baseline electrocardiography should be conducted (Periodic resting electrocardiograms have not been shown to be useful but can be reasonable as a members agefactors increase)
A7763 No firm guidelines for stress testingelectrocardiography in asymptomatic individuals have been developed Stress testingelectrocardiography as a screening tool is used as part of an evaluation of aerobic capacity during the annual occupational fitness evaluation Submaximal stress testingelectrocardiography testing to 85 percent is commonly used as part of this screening
Submaximal stress electrocardiography testing should not be used for diagnostic purposes Cardiology evaluation with maximal stress testingelectrocardiography together with imaging techniques (eg echocardiography technetium Tc99m sestamibi study andor coronary angiography) is necessary for diagnosticprognostic purposes for the following
42
(1) Fire fighters with positive or questionably positive changes on screening submaximal stress tests
(2) Fire fighters with new onset chest pain or other symptoms suggestive of coronary artery disease (CAD)
(3) Fire fighters with diabetes mellitus who
(a) are gt35 years old or
(b) have type I diabetes for more than 15 years or
(c) have type II diabetes for more than 10 years or
(d) have any other CHD risk factor (see below) or
(e) have the presence of microvascular disease (proliferative retinopathy)
(4) Fire fighters over the age of 45 (for men) and 55 (for women) with onetwo or more risk factors for CAD Risk factors for CAD include hypercholesterolemia (total cholesterol greater than 240 mgdL) hypertension (systolic gt140 mmHg or diastolic gt90 mmHg) smoking or family history of premature CAD (heart attack or sudden cardiac death in a first degree relative less than 60 years of age)
as defined below if stress electrocardiography with imaging is negative then repeat as clinically indicated or at least every 5 years
(5) Fire fighters with a Framingham Risk Score gt10 Risk calculator is available at [httphp2010nhlbihinnetatpiiicalculatorasp]
(6) Fire fighters identified in 9431
Negative stress tests should be repeated as clinically indicated or at least every 2 to 5 years
Interpreting stress tests as ldquopositiverdquo or ldquonegativerdquo is beyond the scope of this document However factors that should be taken into consideration should include the individualrsquos exercise capacity symptoms blood pressure response heart rate response EKG changes and the presence of arrhythmias (Gibbon et al 2002)
Risk factors for CAD include hypercholesterolemia (total cholesterol greater than 240 mgdL) hypertension (systolic greater than 140 andor diastolic greater than 90) smoking diabetes mellitus or family history of premature CAD (heart attack or sudden cardiac death in a first degree relative less than 60 years of age)
There are other non-invasive tests to screen for coronary artery disease One of the most promising appears to be coronary artery calcium (CAD) scoring by computed tomography In 2007 an expert committee published an update to their original guidance document The committeersquos consensus was that ldquoit may be reasonable to consider use of CAC measurement in such patients [between 10 and 20 10-year risk of estimated coronary event]helliprdquo The committee did not recommend CAC measurement in low risk patients [lt10 10-year risk of estimated coronary event] or in high risk patients [gt20 10-year risk of estimate coronary event] (Greenland et al 2007]
43
D22 Cardiology
Chobanian AV Bakris GL Black HR Cushman WC Green LA Izzo JL Jr Jones DW Materson BJ Oparil S Wright JT Jr Roccella EJ the National High Blood Pressure Education Program Coordinating Committee [2003] The seventh report of the Joint National Committee [JNC-7] on Prevention Detection Evaluation and Treatment of High Blood Pressure JAMA 2892560ndash2571
Gibbons RJ Balady GJ Bricker JT Chaitman BR Fletcher GF Froelicher VF Mark DB McCallister BD Mooss AN OrsquoReilly MG Winters WL Jr [2002] ACCAHA 2002 guideline update for exercise testing summary article a report of the ACCAHA Task Force on Practice Guidelines (Committee to Update the 1997 Exercise Testing guidelines) J Am Coll Cardiol 401531ndash 1540
Greenland et al [2007] ACCFAHA 2007 Clinical Expert Consensus Document on Coronary Artery Calcium Scoring By Computed Tomography in Global Cardiovascular Risk Assessment and in Evaluation of Patients With Chest Pain A Report of the American College of Cardiology Foundation Clinical Expert Consensus Task Force (ACCFAHA Writing Committee to Update the 2000 Expert Consensus Document on Electron Beam Computed Tomography) J Am Coll Cardiol 49378-402
Kales SN Tsismenakis AJ Zhang C Soteriades ES [2009] Blood pressure in fire fighters police officers and other emergency responders Am J Hypertens 2211-20
Schlant RC Adolph RJ DiMarco JP Dreifus LS Dunn MI Fisch C Garson A Jr Haywood LJ Levine HJ Murray JA Noble RJ Ronan JA Jr [1992] Guidelines for electrocardiography A report of the American College of CardiologyAmerican Heart Association Task Force on Assessment of Diagnostic and Therapeutic Cardiovascular Procedures (Committee on Electrocardiography) Circulation 85(3)1221-1228
Soteriades ES Kales SN Liarokapis D Christiani DC [2003] Prospective surveillance of hypertension in firefighters J Clin Hypertens 5315-320
Formatted Font Italic
Formatted Line spacing single
Formatted Font Italic
Formatted Font Italic
44
NFPA 1582‐ Draft Revisions for CVDHTN
EKG and stress tests
Reason for Revision
1) Change requirement for annual resting EKG to periodically to be more consistent with ACCAHA
recommendation (Schlant et al 1992)
2) Add language to clarify what constitutes a positive ST
3) Make criteria for conducting diagnostic ST in asymptomatic patients consistent with the
ACCAHA
Language in 2007 Edition with draft revisions in Red (Track changes)
776 Electrocardiograms (EKG) and Stress Tests 7761 A resting EKG shall be performed as part of the baseline medical evaluation and shall be obtained periodically (every 1 to 5 years) thereafter
A7761 A baseline resting EKGs shall be conducted Follow-up resting EKGs should be conducted as clinically indicated but at a minimum of every 1 to 5 years The frequency of these follow-up resting EKGs should increase as a members age increases or with increasing number andor severity of coronary heart disease risk factors Members above the age of 40 should have annual resting EKGs (Schlant et al 1992)
7762 The fire department physician or other qualified medical evaluator shall compare baseline and subsequent EKGs
7763 Stress testing with or without echocardiography or radionuclide scanning shall be performed as clinically indicated by history or symptoms
A7763 No firm guidelines for stress testing in asymptomatic individuals have been developed Stress testing as a screening tool is used as part of an evaluation of aerobic capacity during the annual occupational fitness evaluation Submaximal stress testing testing to 85 percent is commonly used as part of this screening
Submaximal stress testing should not be used for diagnostic purposes Cardiology evaluation with maximal stress testing together with imaging techniques (eg echocardiography technetium Tc99m sestamibi study) is necessary for diagnosticprognostic purposes for the following
(1) Fire fighters with positive or questionably positive changes on screening submaximal stress tests
(2) Fire fighters with new onset chest pain or other symptoms suggestive of coronary artery disease (CAD)
45
(3) Fire fighters with diabetes mellitus who
(a) are gt35 years old or
(b) have type I diabetes for more than 15 years or
(c) have type II diabetes for more than 10 years or
(d) have any other CHD risk factor (see below) or
(e) have the presence of microvascular disease (proliferative retinopathy)
(4) Fire fighters over the age of 45 (for men) and 55 (for women) with one or more risk factors for CAD Risk factors for CAD include hypercholesterolemia (total cholesterol greater than 240 mgdL) hypertension (systolic gt140 mmHg or diastolic gt90 mmHg) smoking or family history of premature CAD (heart attack or sudden cardiac death in a first degree relative less than 60 years of age)
(5) Fire fighters with a Framingham Risk Score gt10 Risk calculator is available at [httphp2010nhlbihinnetatpiiicalculatorasp]
(6) Fire fighters identified in 9431
Negative stress tests should be repeated as clinically indicated or at least every 2 to 5 years
Interpreting stress tests as ldquopositiverdquo or ldquonegativerdquo is beyond the scope of this document However factors that should be taken into consideration should include the individualrsquos exercise capacity symptoms blood pressure response heart rate response EKG changes and the presence of arrhythmias (Gibbon et al 2002)
There are other non-invasive tests to screen for coronary artery disease One of the most promising appears to be coronary artery calcium (CAD) scoring by computed tomography In 2007 an expert committee published an update to their original guidance document The committeersquos consensus was that ldquoit may be reasonable to consider use of CAC measurement in such patients [between 10 and 20 10-year risk of estimated coronary event]helliprdquo The committee did not recommend CAC measurement in low risk patients [lt10 10-year risk of estimated coronary event] or in high risk patients [gt20 10-year risk of estimate coronary event] (Greenland et al 2007]
D22 Cardiology
Resting EKG and Stress Tests
46
Chobanian AV Bakris GL Black HR Cushman WC Green LA Izzo JL Jr Jones DW Materson BJ Oparil S Wright JT Jr Roccella EJ the National High Blood Pressure Education Program Coordinating Committee [2003] The seventh report of the Joint National Committee [JNC-7] on Prevention Detection Evaluation and Treatment of High Blood Pressure JAMA 2892560ndash2571
Gibbons RJ Balady GJ Bricker JT Chaitman BR Fletcher GF Froelicher VF Mark DB McCallister BD Mooss AN OrsquoReilly MG Winters WL Jr [2002] ACCAHA 2002 guideline update for exercise testing summary article a report of the ACCAHA Task Force on Practice Guidelines (Committee to Update the 1997 Exercise Testing guidelines) J Am Coll Cardiol 401531ndash 1540
Greenland et al [2007] ACCFAHA 2007 Clinical Expert Consensus Document on Coronary Artery Calcium Scoring By Computed Tomography in Global Cardiovascular Risk Assessment and in Evaluation of Patients With Chest Pain A Report of the American College of Cardiology Foundation Clinical Expert Consensus Task Force (ACCFAHA Writing Committee to Update the 2000 Expert Consensus Document on Electron Beam Computed Tomography) J Am Coll Cardiol 49378-402
Kales SN Tsismenakis AJ Zhang C Soteriades ES [2009] Blood pressure in fire fighters police officers and other emergency responders Am J Hypertens 2211-20
Schlant RC Adolph RJ DiMarco JP Dreifus LS Dunn MI Fisch C Garson A Jr Haywood LJ Levine HJ Murray JA Noble RJ Ronan JA Jr [1992] Guidelines for electrocardiography A report of the American College of CardiologyAmerican Heart Association Task Force on Assessment of Diagnostic and Therapeutic Cardiovascular Procedures (Committee on Electrocardiography) Circulation 85(3)1221-1228
Soteriades ES Kales SN Liarokapis D Christiani DC [2003] Prospective surveillance of hypertension in firefighters J Clin Hypertens 5315-320
47
ATTACHMENT F
48
1
Current 1582 (2007) language in reference to pregnancy 43 (4) Report to the fire department physician any medical condition that could interfere with the ability of the individual to safely perform essential job tasks such as illness or injury use of prescription or nonprescription drugs and pregnancy 6112 Category B medical conditions shall include the following (1) Pregnancy for its duration A7792 (e) If HIV prophylaxis is to be given the following tests should be done i CBC ii Glucose renal and hepatic chemical function iii Pregnancy test for females B121 Pregnancy and Reproduction Federal regulations as well as many court decisions including the US Supreme Courtrsquos decision in International Union et al v Johnson Controls Inc [499 US 187 111 S Ct 1196 (1991)] have interpreted the requirements of Title VII with respect to pregnancy and reproduction The AHJ should seek the advice of counsel in resolving specific questions concerning these requirements as well as other requirements that can be imposed by state or local laws C211 (4) Review health status with the individual being evaluated Contraindications for evaluations shall be reviewed addressing any changes in the individualrsquos health status since their last medical evaluation that would warrant deferring the evaluation including (g) Pregnancy Recommendations to language enhancement
A female employee who is assigned to regular fire line duty shall report a pregnancy immediately to their respective Supervisor and the fire department physician The employee will then be given the option of a non-hazardous alternative duty position for the duration of her pregnancy (can we say this or is it even appropriate) Any pregnant employee wishing to remain on regular line duty shall be informed of the possible risks and consequences to herself and her fetus that are associated with continued line fire fighting duty Among those risk factors are exposure to teratogens known to have negative effects on the developing fetus such as smoke diesel fumes hazardous chemicals and extreme heat
49
Page 2
appendix It is recommended that the pregnant employee complete a release of liability form signed by herself and her health care provider utilizing NFPArsquos 13 critical tasks as a reference This will inform the health care provider of specific job-related tasks that will need to be performed in order to continue regular line duty These tasks are basic physical standards that any entry level firefighter would have to be able to complete competently The employeersquos health condition will be kept confidential by the department in accordance with HIPAA standards Employees are allowed to remain on active regular duty until they are no longer able to perform their duties in a reasonable manner andor their protective gear no longer fits correctly It is the responsibility of the health care provider to evaluate the pregnant employee If at any time the health care provider feels the pregnant employee can no longer perform the job related tasks this should be reported to the employer by the employee immediately
50
ATTACHMENT G
51
From GLENN BENARICKTo Sawyer SteveSubject RE RE 7743Date Monday August 30 2010 21633 PM
Yes thats my understanding
Glenn P Benarick 211 Winged Elm CircleAiken SC 29803803-644-7093gbenarprodigynet
--- On Mon 83010 Sawyer Steve ltssawyerNFPAorggt wrote
From Sawyer Steve ltssawyerNFPAorggtSubject RE RE 7743To GLENN BENARICK ltgbenarprodigynetgtDate Monday August 30 2010 212 PM
So it should be ldquoorrdquo instead of ldquoandrdquo for now
Steven F Sawyer
Senior Fire Service Specialist
Executive Secretary IFMAFire Service Section
NFPA
1 Batterymarch Park
Quincy MA 02169
6179847423
Fax 6179847056
ssawyernfpaorg
From GLENN BENARICK [mailtogbenarprodigynet] Sent Monday August 30 2010 1202 PMTo Sawyer SteveSubject Fw RE 7743
52
Steve a couple of our docs agree with April Boyer
Glenn P Benarick 211 Winged Elm Circle
Aiken SC 29803
803-644-7093
gbenarprodigynet
--- On Mon 83010 David Prezant ltprezandfdnynycgovgt wrote
From David Prezant ltprezandfdnynycgovgtSubject RE 7743To Thomas R (CDCNIOSHDSHEFS) Hales lttrh1cdcgovgt GLENNBENARICK ltgbenarprodigynetgtCc Sandy Bogucki ltsandyboguckiyaleedugtDate Monday August 30 2010 1004 AM
agree
we should change this to NHANES III rather than Knudson we should alsomodify this to allow not only for predicted cutoffs but all for use of thelower limit of normal cutoff This is important to prevent false-classificationof spirometry as abnormal in older groups and in taller grps The latter ofparticular import to firefighter occupational health surveillance
thanks
David Prezant MDChief Medical Officer Office of Medical AffairsCo-Director WTC Medical Monitoring amp Treatment ProgramsNew York City Fire Department9 Metrotech Center - Rm 4W-1Brooklyn NY 11201Phone 718-999-2696Fax 718-999-0665
Life is full of twists and turns
53
This email may contain confidential information If you are the unintendedrecipient of this email please send it back and delete from your directory
gtgtgt Hales Thomas R (CDCNIOSHDSHEFS) lttrh1cdcgovgt 8302010955 AM gtgtgt
Glen
This seems like a very reasonable comment and illustrates the importance of having clinicians providefeedback on the std Im not familiar with the software program of the various spirometers (NHANES IIIvs KnudsonATS vs both) Given the large role both Dave Prezant and Sandy Bogucki had for thepulmonary section let me forward to them for clarification
Tom
From GLENN BENARICK [mailtogbenarprodigynet] Sent Sunday August 29 2010 456 PMTo Hales Thomas R (CDCNIOSHDSHEFS)Subject FW 7743
Tom is April Boyer correct
Glenn P Benarick 211 Winged Elm Circle
Aiken SC 29803
803-644-7093
gbenarprodigynet
--- On Thu 82610 Sawyer Steve ltssawyerNFPAorggt wrote
From Sawyer Steve ltssawyerNFPAorggtSubject FW 7743To GLENN BENARICK ltgbenarprodigynetgtDate Thursday August 26 2010 925 PM
FYI Do you have any answer She is write
Steven
54
Steven F Sawyer
Senior Fire Service Specialist
Executive Secretary IFMAFire Service Section
NFPA
1 Batterymarch Park
Quincy MA 02169
6179847423
Fax 6179847056
ssawyernfpaorg
From April Boyer [mailtoaboyerbicclinicorg] Sent Thursday August 26 2010 232 PMTo Sawyer SteveCc RobinMWebbmilstateorusSubject 7743
Steven
The spirometry tests cannot be corrected according to both references as the NFPA states because thereferences are contradictory The first part of 7743 states to follow the ATS guidelines and use theKnudsen (we at Basin Immediate Care use the Nhanes III) The second part states to follow the ACOEMguidelines and use the Nhanes III in the occupational setting if available with your unit (which is availableon ours) 7743 does not use the word OR regarding both requirements it uses the word AND whenreferring to the first and second parts thence making 7743 contradictory I realize the NFPA 1582 hasnot been updated since 2007 unless I have just not received an updated version
Our question to you is which part of 7743 do you want us to follow the first or the second part Anyfacility that has an updated computerized spirometry system (as we do) will not be able to follow bothrequired parts for obvious reasons We can either follow the first part of 7743 and use an oldercorrected version of the Knudson by going into our system and changing out of the Nhanes III conversionOR we can follow the second part of 7743 and use the newer corrected version of Nhanes III which ourunit offers too
If you have any questions you may contact me at anytime and I also have many references in regards toboth parts of 7743 if you would like to see them
55
Thank you~
April
Confidentiality NoticeThis message may contain information that isconfidential or privileged
If you are not the intended recipientPlease advise the sender immediately and delete this message
56
ATTACHMENT H
57
NFPA 1582 771(7) Proposed revisions
Why
Preliminary results of two prospective randomized trials on the PSA test were published in 2009 These studies resulted in medical organizations that previously providing guidance to modify their recommendations
Current language
771 Blood Tests Blood tests shall be performed annually and shall include the following
(7) Prostate specific antigen (PSA) after age 40 for positive family history if African American or if otherwise clinically indicated after age 50 for all other male member
Suggested Revision
771 Blood Tests Blood tests shall be performed annually and shall include the following
(7) Prostate specific antigen (PSA) after age 40 for positive family history if African American or if otherwise clinically indicated after age 50 for all other male member
772 Prostate-Specific Antigen (PSA) test At age 50 fire fighters shall have an opportunity to make an informed decision with either the Fire Department physician or their health care provider concerning the PSA test For fire fighters at increased risk of prostate cancer (African-Americans or those with a first degree relative diagnosed with prostate cancer before age 65) shall have the opportunity for this informed decision at age 40
A772 The PSA as a screening test for prostate cancer in asymptomatic men is controversial controversial for two reasons First there is no consensus that PSA screening actually saves lives For example the PSA test may detect small cancers that would never become life threatening Second it is unclear that the benefits of PSA screening outweigh the risks of follow-up diagnostic tests and cancer treatments For example the prostate biopsy used to diagnose prostate cancer may cause bleeding and infection And prostate cancer treatments such as surgery and radiation therapy may cause incontinence (inability to control urine flow) erectile dysfunction (erections inadequate for intercourse) and other complications For these reasons it is important that the benefits and risks of prostate diagnostic procedures and treatment be taken into account when considering the PSA screening test These considerations can be taken account during discussions with the fire department physician or onersquos health care provider
D211 Cancer Screening
Smith R A C J Mettlin K J Davis and H Eyre 2000 ldquoAmerican Cancer Society guidelines for the early detection of cancerrdquo CA J Clin 50(1)34ndash49
Added references
58
Carroll P Albertsen PC Greene K et al [2010] Prostate-specific antigen best practice statement 2009 update Am Urological Assoc Available at httpwwwauanetorgcontentguidelines-and-quality-careclinical-guidelinesmain-reportspsa09pdf Date accessed September 2010
Ferrini R Woolf SH [2009] Screening for prostate cancer in American men American College of Preventive Medicine Practice Policy Statement Available at httpwwwacpmorgprostatehtm Date accessed September 2010
National Cancer Institute [2009] Prostate-specific antigen test National Cancer Institute Fact Sheet Available at httpwwwcancergovcancertopicsfactsheetDetectionPSA Date accessed September 2010
Wolf AMD Wender RC Etzioni RB et al [2010] American Cancer Society guideline for the early detection of prostate cancer Update 2010 Available at httpcaonlineamcancersocorgcgicontentfullcaac20066v1 Date accessed September 2010
59
Technical Committee on Fire Service Occupational Safety and Health
Conference Call Meeting Minutes August 30th 2010
Members participating
Glenn Benarick TC Chair
Murrey Loflin Secretary Dr Sandy Bogucki
Thomas Cuff Stephen Foley
Scott Kerwood Tammy Lopes
David Love Dr David Prezant
Joe Rivera David Ross
Mario Rueda Phil Stittleburg
Phil Vorlander Dominic Colletti
Thomas Hillenbrand
Denise Smith Brett Bowman Alternate
Andrew Schwartz Alternate Mike Young Alternate
Dr Thomas Hales Non-Voting Member Ken Holland NFPA Staff Liaison
Casey Grant NFPAResearch Foundation Staff Katie Hathway Guest from ADA
Dr Jim Fleming Guest from Phoenix Fire Dept
The chair welcomed everyone to the conference call in which he hoped
would last only an hour The purpose was to discuss any task groups that had reports for proposed changes to NFPA 1582 for the
committee This is in hopes to ensure the committee is ready for their
pre-ROP meeting in October The following topics were discussed and are in no specific order
Comments from ADA Katie Hathaway and the group went into deep
discussion regarding ones medical history and diagnosis of diabetes
13
and some proposed changesremoval of text based on research
findings The specific proposed changes will be available for the committee at their next meeting Some members on the call felt that
this issue was covered in another law enforcement document which might better serve this issue
Research topics for FSOSH projects Casey Grant offered his time to
answer any questions regarding his presentation from the May meeting in Baltimore There was also discussion about further
involvement of the Research Foundation with this committee and some of the medical requirements within the documents Glenn and Casey
are going to be in contact offline to discuss this further
Prosthetics amp Amputees report Nothing new to report
Heart amp Hypertension report There was discussion about the need for
periodic EKGrsquos that were done both in resting and non-resting states as well as discussion about stress test requirements and frequency of
such tests The hopes were to develop text that would point to annual versus periodic evaluations of EKGrsquos and stress tests
Epilepsy report Nothing new to report
Pregnancy report The initial textlanguage has been provided to the
group through email and e-committee page posting
Coagulation amp Meds report Nothing new to report
Hearing Aid discussion Nothing new to report
The committee also discussed the evaluation and documentation of
PSA results and test requirements for the purposes of consistency The proposed text and changes have been posted on the e-committee
page as well
All of the proposed text changes from the May meeting in Baltimore have been emailed out and posted on the e-committee page If there
are any questions or concerns that something was missed please contact Glenn Steven Sawyer or Ken Holland to ensure they are
resolved
The conference call lasted approximately an hour and was adjourned at 1400 hours
14
ATTACHMENT C
15
2012 ANNUAL REVISION CYCLE
PROCESS STAGE PROCESS STEP DATES
FOR TC DATES
FOR TCC 1 PRELIMINARY 10 Notification of intent to enter cycle 7910 7910
2 REPORT ON
PROPOSALS (ROP)
21 Proposal closing date 112310 112310 22 Final date for ROP meeting 22511 2411 23 Final date for mailing TC ballots 31811 21811 24 Receipt of (TC) ballots by staff liaison 42211 31111 25 Receipt of TC recirculation ballots 5611 31811 26 Final date for TCC meeting 41511 27 Final date for mailing TCC ballots 42211 28 Receipt of TCC ballots 51311 29 Receipt of TCC recirculation ballots 52011 210 Final copy (w ballot statements) to Secretary Standards Council 51311 52711 211 Completion of Reports 52011 6311 212 ROP Published and Posted 62411 62411
3 REPORT ON
COMMENTS
(ROC)
31 Comment closing date 83011 83011 32 Final date for ROC meeting 11411 10711 33 Final date for mailing TC ballots 111811 102111 34 Receipt of (TC) ballots by staff liaison 12211 111111 35 Receipt of TC recirculation ballots 12911 111811 36 Final date for TCC meeting 121611 37 Final date for mailing TCC ballots 122311 38 Receipt of TCC ballots 11312 39 Receipt of TCC recirculation ballots 12012 310 Final copy (w ballot statements) to Secretary Standards Council 122311 12712 311 Completion of Reports 11312 2312 312 ROC Published and Posted 22412 22412
4 TECH SESSION
PREPARATION amp
ISSUANCE OF
CONSENT
DOCUMENTS
41 Notice of Intent to Make a Motion (NITMAM) Closing Date 4612 4612 42 Posting of Filed NITMAM 5412 5412
43 Council Issuance Date for Consent Documents 52912 52912
44 Appeal Closing Date for Consent Documents 61312 61312
5 TECHNICAL
SESSION 50 Association Meeting for Documents with Certified Amending Motions
64-712 64-712
6
APPEALS amp
ISSUANCE OF
DOCUMENTS
WCAMS
61 Appeal closing date for Documents with Certified Amending Motions
62712 62712
62 Council issuance for Documents with Certified Amending Motions 8912 8912
Proposal Closing Dates may vary according to documents and schedules for Revision Cycles may change Please check the NFPA website (wwwnfpaorg) for the most up-to-date information on proposal closing dates and schedules
16
ATTACHMENT D
17
This weekrsquos conference call mentioned the Diabetes chapter written for the ACOEM document Guidance for the Medical Evaluation of the Law Enforcement Officer The task group working on this chapter (led Richard Miller of the Secret Service and our very own Dan Samo) worked with the ADA or over 2-3 years to come up with a consensus document
Please find the Chapter attached ltltDiabetes Guidance Sept 2010pdfgtgt
Regarding Dan Loeberrsquos points
1) Physical Evaluation Form - We could modify the LEO form (see end of the attached Chapter)
2) Duration required for stable regiment
1582 for IDDM Type 1 1 yr
Type 2 6 m
Oral Agents None specifically
ACOEM Police for IDDM Type 1 6m
Type 2 3m
Oral Agents 1m
The police document is much clearer about the decision regarding medical fitness for duty is the responsibility of the police physician with the treating diabetes-expert physician providing the data to the police physician to make an informed decision In this regard the police officer must provide the police physician with downloaded self monitoring glucose data for the 1 3 and 6 month time periods (see section 433)
3) HA1C ndash NFPA lt 8 over 3 month period
ACOEM Police ndash (Section 4333) Specifies the frequency on measurement and if gt8 requires further evaluation
Some other discrepancies End organ complications
NFPA ndash end organ complications (eye kidney heart neuro) ndash restriction
ACOEM Police ndash end organ complication -- requires further evaluation
18
Hypoglycemia (incapacitating ndash defined differently between the two documents (434)
NFPA ndash 0 episodes in past year le1 in past 5 yrs
ACOEM Police ndash 0 episodes in past year le2 in past 3 yrs
Given Dan Samorsquos and Richard Millerrsquos work with the ADALoeber it would be helpful to get their opinions on whether any of the changes requested by Loeber are appropriate for FF with DM
Tom
Thomas Hales MD MPH
Senior Medical Epidemiologist
NIOSH CDC
4676 Columbia Pkwy R-9
Cincinnati OH 45241
(513) 841-4583
trh1cdcgov
19
43 ndash DIABETES MELLITUS
431 ndash INTRODUCTION
The educated and motivated law enforcement officer (LEO) with well-managed diabetes mellitus can be capable of
safe and effective job performance1 However diabetes mellitus may place LEOs at risk for sudden incapacitation
thus jeopardizing their ability to perform critical job functions (These job functions include those listed in Sections
32 333 351 352 36 and 37 and discussed in Appendix A)
Therefore an individualized assessment of the LEOrsquos diabetes should be performed using the following evaluative
criteria to determine whether the individuals condition permits safe and effective job performance Such evaluation
must include the following key elements which are discussed in detail below
history of blood glucose control
knowledge of diabetes and its management
current stability of blood glucose
risk for significant hypoglycemia or hyperglycemia and
presence of diabetic complications
432 ndash OVERVIEW OF MEDICAL EVALUATION
The treating endocrinologist or other physician knowledgeable regarding diabetes management should provide
a narrative report certifying whether the LEO has or has not met the criteria set out in Sections 4321 through
4354 below In addition the physician should include supporting data (see Appendix B for the Physician Evalu-
ation Form)
4321 The LEO is under the care of an endocrinologist or other physician knowledgeable regarding diabetes
management Outpatient and in-patient medical record(s) for the last 3 years or since date of diagnosis
(whichever is shorter) should be reviewed by the treating physician and provided to the police physician
4322 If the LEO has type 1 diabetes the individual has been on a basalbolus regimena or an insulin pump
using analogue insulins for the 6 months prior to evaluation2
4323 If the LEO has type 2 diabetes on insulin the individual has been on a stable medication regimenb
for the 3 months prior to evaluation3 If on oral agents alone the LEO has been on a stable medication regimen
for the month prior to evaluationc
ACOEM Guidance for the Medical Evaluation of Law Enforcement Officers 1
43 ndash DIABETES MELLITUS
aA basalbolus insulin regimen consists of the use of a basal insulin (Glargine NPH) in a once or twice daily regimen to provide between-
meal insulin combined with the use of a short acting insulin (Regular Lispro Aspart or Glulisine) at mealtimes Insulin pumps are small
(beeper sized) battery powered devices that deliver small amounts of short-acting insulin in a constant infusion to meet basal insulin
requirements The wearer selects an additional mealtime bolus to be infused at the time of meals For more information on pumps visit
the manufacturerrsquos web sites ndash wwwMinimedcom wwwcozmorecom wwwanimascorpcom wwwdisetroniccom
bA stable insulin regimen is defined as maintaining the same types of insulin (long acting intermediate acting short or rapid acting)
Changes in insulin dose are part of the appropriate self-management of diabetes and do not disqualify an applicant or incumbent under
this section
cChanges in dose within the evaluation period will be allowed but addition of a new class of medications or insulin should result in a new
period of observation
one month for addition of a sulfonylurea or metformin
two months for the addition of a thiazolidinedione to insulin or a sulfonylurea or
three months for the addition of insulin
20
4324 If the LEO uses an insulin pump documentation is needed as follows
proper understanding and education in the use of the insulin pump
start date for the use of the pump
history of insulin site infectionsd
history of pump cessation and pump malfunction
backup plan for pump malfunction including use of injectable insulin and
frequency of infusion set changes
4325 The LEO has been educated in diabetes and its management and thoroughly informed of and under-
stands the procedures that must be followed to monitor and manage hisher diabetes and what procedures
should be followed if complications arise3
433 ndash QUANTITATIVE GLUCOSE MONITORING
4331 The LEO has documentation of ongoing self-monitoring of blood glucose
4332 This must be done with a glucose meter that stores every reading records date and time of reading
and from which data can be downloaded (Most meters now have this capability)
4333 Monitoring logs must be available covering the time period (1 3 or 6 months) as described in
Sections 4322 and 4323 The frequency of glucose monitoring must follow a schedule acceptable to the
police physician in consultation with the treating physician
Testing schedules are individual What follows is a common pattern but individual patterns may differ
2 ACOEM Guidance for the Medical Evaluation of Law Enforcement Officers
43 ndash DIABETES MELLITUS
dIndividual has not had more than one pump-site infection that caused him or her to miss work or usual daily activities in the preceding 6
months
THERAPEUTIC REGIMEN GLUCOSE TESTING SCHEDULE
Diet alone Once or twice a week
Metformin Thiazolidinediones or Alpha
Glucosidase inhibitors alone or in
combination
Once or twice a week
Sulfonylureas meglitanides nateglinide ndash
alone or in combination with the above group
Twice a day ndash AM and at supper with any
suspected hypoglycemic episodes
Insulin ndash one shot in combination with orals Twice a day ndash AM and at supper with any
suspected hypoglycemic episodes
2 to 3 times AM once a week
Insulin ndash two or more shots Insulin pump 3 to 4 times a day ndash at meals and bedtime
2 to 3 times AM once a week with any
suspected hypoglycemic episodes
21
4334 The LEO has had hemoglobin A1C measured at least 4 times a year (intervals of 2 to 3 months) over
the last 12 months prior to evaluation if diagnosis has been present for more than a year4 If hemoglobin A1C is
gt8 this may signal a problem with the LEOrsquos diabetes management that warrants further assessment5
434 ndash INCAPACITATING EVENTS
4341 The LEO has not had any incapacitating episodes within the past 1 year and no more than 2 episodes
in the past 3 years or since diagnosis of diabetes (whichever is shorter) of
43411 Severe hypoglycemia (loss of consciousness seizures or coma requiring assistance of others or
needing urgent treatment [glucagon injectionIV glucose]) or
43412 Blood sugar lt60 mgdl with unawareness demonstrated in current glucose logs6
435 ndash CHRONIC COMPLICATION SCREENING
4351 Chronic complications of diabetes are associated with increased risk for severe hypoglycemic
episodes and warrant further assessmente
4352 The components of screening for chronic complications are
43521 A complete eye exam by a qualified ophthalmologist or optometrist including a dilated retinal
exam demonstrating no more than mild background diabetic retinopathyf7
43522 Normal vibratory testing with a 128 Hz tuning forkg normal testing with 10 gram Semmes-
Weinstein monofilamentg and normal orthostatic blood pressureh and pulse testing89
ACOEM Guidance for the Medical Evaluation of Law Enforcement Officers 3
43 ndash DIABETES MELLITUS
ePresence of chronic complications of diabetes in and of themselves may not require the implementation of work restrictions
fNo more than one dot blot or flame-shaped hemorrhages or microaneurysm in all four fundus quadrants
gThe Michigan Diabetes Research and Training Center of the University of Michigan Health System recommends the following guidance
(see wwwmedumichedumdrtcprofsdocumentssviMNSI_howtopdf) for conducting vibratory and monofilament testing8
Vibration Sensation Vibration sensation should be performed with the great toe unsupported Vibration sensation will be tested bi-
laterally using a 128 Hz tuning fork placed over the dorsum of the great toe on the boney prominence of the DIP joint Patients whose
eyes are closed will be asked to indicate when they can no longer sense the vibration from the vibrating tuning fork In general the
examiner should be able to feel vibration from the hand-held tuning fork for 5 seconds longer on his distal forefinger than a normal subject
can at the great toe (eg examiners DIP joint of the first finger versus patients toe) If the examiner feels vibration for 10 or more seconds
on his or her finger then vibration is considered decreased A trial should be given when the tuning fork is not vibrating to be certain that
the patient is responding to vibration and not pressure or some other clue Vibration is scored as 1) present if the examiner senses the
vibration on his or her finger for lt10 seconds 2) reduced if sensed for 10 seconds or 3) absent (no vibration detection)
Monofilament Testing For this examination it is important that the patients foot be supported (ie allow the sole of the foot to rest on
a flat warm surface) The filament should initially be pre-stressed (4-6 perpendicular applications to the dorsum of the examiner s first
finger) The filament is then applied to the dorsum of the great toe midway between the nail fold and the DIP joint Do not hold the toe
directly The filament is applied perpendicularly and briefly (lt1 second) with an even pressure When the filament bends the force of
10 grams has been applied The patient whose eyes are closed is asked to respond yes if heshe feels the filament Eight correct responses
out of 10 applications is considered normal 1 to 7 correct responses indicates reduced sensation and no correct answers translates into
absent sensation
hOrthostatic hypotension is a physical finding defined by the American Autonomic Society and the American Academy of Neurology as a
systolic blood pressure decrease of at least 20 mm Hg or a diastolic blood pressure decrease of at least 10 mm Hg within 3 minutes of
standing
22
43523 Normal cardiac physical exam Cardiac stress testing to at least 12 METS is recommended and
should begin based on either the criteria of the American Heart AssociationAmerican College of
Cardiologyi10 or those of the American Diabetes Associationj11
Diabetics who have a normal cardiac stress test will be retested every one to three years based on
individual clinical assessment This assessment should consider
the age of the individual
the number and persistence of coronary artery disease (CAD) risk factors
the severity of CAD risk factors
43524 Microalbumincreatinine ratio 301 measured or calculatedk creatinine clearance
gt60 mlmin12
436 ndash ONGOING EVALUATION AND REQUIREMENTS
4361 Should have medical records and glucose meter logs reviewed periodically Because of the nature of
diabetes it is important that regular medical follow up be provided to the LEO The frequency and content of
the evaluation should be determined on an individual basis by the police physician in consultation with the
treating physicianl
4362 Must advise police physician of any change in type of medication
4363 Must advise police physician of any episodes of significant hypoglycemia or hyperglycemia
Urine microalbumincreatinine ratio _________________
III Treating Physician Statement
The above named individual meets all of the criteria provided on this form
Yes No ndash not recommended for position
No but IS recommended for position (letter of explanation attached)
It is my opinion that the above named individual is well-educated and well-motivated in diabetes self-management and has
achieved a level of diabetes management to be capable of safe and effective job performance as a law enforcement officer
I have reached this opinion after careful review of the above criteria
___________________________________________________________ ___________________________Signature of Physician Date
______________________________________________________________ ___________________________Printed or Typed Name of Physician Telephone Number
10 ACOEM Guidance for the Medical Evaluation of Law Enforcement Officers
43 ndash DIABETES MELLITUS
29
439 ndash REFERENCES
1 American Diabetes Association Diagnosis and classification of diabetes mellitus Diabetes Care 200427 Suppl
1S5-S10 See httpcarediabetesjournalsorgcgicontentfull27suppl_1s5
2 American Diabetes Association Continuous subcutaneous insulin infusion Diabetes Care 200427 Suppl 1S110
See httpcarediabetesjournalsorgcgicontentfull27suppl_1s110
3 Mensing C Boucher J Cypress M et al National standards for diabetes self-management education Diabetes
Care 200528 Suppl 1S72-9 See httpcarediabetesjournalsorgcgicontentfull28suppl_1s72
4 Goldstein DE Little RR Lorenz RA Malone JI Nathan DM Peterson CM American Diabetes Association Tests
of glycemia in diabetes Diabetes Care 200427 Suppl 1S91-3
See httpcarediabetesjournalsorgcgicontentfull27suppl_1s91
5 The Diabetes Control and Complications Trial Research Group Hypoglycemia in the Diabetes Control and
Complications Trial Diabetes 199746(2)271-86 See wwwncbinlmnihgovpubmed9000705 for abstract
6 American Diabetes Association Hypoglycemia and employmentlicensure Diabetes Care 200528 Suppl 1S61
See httpcarediabetesjournalsorgcgicontentfull28suppl_1s61
7 Viswanath K McGavin DD Diabetic Retinopathy Clinical Findings and Management J Comm Eye Health
200316(46)21-4 See wwwcehjournalorg0953-683316jceh_16_46_021html
8 Michigan Diabetes Research and Training Center University of Michigan Health System How to use the Michigan
Neuropathy Screening Instrument See wwwmedumichedumdrtcprofsdocumentssviMNSI_howtopdf
9 Bradley JG Davis KA Orthostatic hypotension Am Fam Physician 200368(12)2393-8
See wwwaafporgafp200312152393html
10 Gibbons RJ Balady GJ Bricker JT et al ACCAHA 2002 guideline update for exercise testing a report of the
American College of CardiologyAmerican Heart Association Task Force on Practice Guidelines (Committee on
Exercise Testing) J Am Coll Cardiol 200240(8)1531-40
See wwwaccorgqualityandscienceclinicalguidelinesexerciseexercise_cleanpdf
11 American Diabetes Association Standards of medical care in diabetes Diabetes Care 200528 Suppl 1S4-S36
Erratum in Diabetes Care 200528(4)990 See httpcarediabetesjournalsorgcgicontentfull28suppl_1s4
12 Molitch ME DeFronzo RA Franz MJ et al American Diabetes Association Nephropathy in diabetes Diabetes
Care 200427 Suppl 1S79-83 See httpcarediabetesjournalsorgcgicontentfull27suppl_1s79
13 Kitabchi AE Umpierrez GE Murphy MB et al American Diabetes Association Hyperglycemic crises in diabetes
Diabetes Care 200427 Suppl 1S94-102 See httpcarediabetesjournalsorgcgicontentfull27suppl_1s94
14 US Centers for Disease Control and Prevention National Diabetes Fact Sheet 2007
See wwwcdcgovdiabetespubspdfndfs_2007pdf
ACOEM Guidance for the Medical Evaluation of Law Enforcement Officers 11
43 ndash DIABETES MELLITUS
30
ATTACHMENT E
31
Typos A6921(2) 7th line down test should be plural 94201 Paragraph 2 target organ damage is used though end organ damage was defined earlier and in the appendix for that paragraph
A94201 Para A (1) d Id suggest deleting the phrases in brackets Im not sure either are predictably true or politically wise
a) tests for left ventricular hypertrophy Unfortunately use of the EKG to detect left ventricular hypertrophy is very insensitive (eg 5 sensitivity) The echocardiogram is the best test for diagnosing left ventricular hypertrophy but [it is relatively expensive and not readily available in small rural communities ] conducting echocardiograms on asymptomatic fire fighters with Stage 1 hypertension should be reserved only for those with long-standing hypertension
In addition
7761 A resting EKG shall be performed as part of the baseline medical evaluation and shall be obtained periodically thereafter
Changing from annually to periodically is noted has the language in the wellness-fitness initiative been changed as well Our previous decision was that we would support the W-F language since there was no compelling evidence to either support or refute it
Thanks
Sandy
32
NFPA 1582‐ HTN Draft 1
Reason for Revision
1) New classification of BP by the Joint National Commission [Chobanian et al 2002]
2) A high prevalence of FF have either HTN (~20) and Pre‐HTN (~20) [Soteriades et al 2003]
3) Among FF studies have shown a strong association between HTN and a number of adverse
cardiovascular events [Kales et al 2009]
4) A large percentage of on‐duty FF fatalities were found to have left ventricular hypertrophy a
complication of HTN at autopsy
Language in 2007 Edition with draft revisions in Red (Track changes)
611 The medical evaluation of a candidate shall include a medical history examination and any laboratory tests required to detect physical or medical condition(s) that could adversely affect hisher ability to safely perform the essential job tasks outlined in 511 A611 The medical history should include the candidates known health problems such as major illnesses surgeries medication use and allergies Symptom review is also important for detecting early signs of illness A medical history should also include a personal health history a family health history a health habit history an immunization history and a reproductive history
An occupational history should also be obtained to collect information about the persons past occupational and environmental exposures
(a) BP should be measured according to the Joint National Commission (JNC) -7 recommendations BP should be measured with a properly calibrated and validated instrument Patients should be seated quietly for at least 5 minutes in a chair with feet on the floor and arm supported at heart level An appropriate-sized cuff (cuff bladder encircling at least 80 of the arm) should be used to ensure accuracy At least 2 measurements should be made Systolic BP is the point at which the first of 2 or more sounds is heard (phase 1) and diastolic BP is the point before the disappearance of sounds (phase 5) [Chobanian et al 2003]
(2) Head eyes ears nose and throat (HEENT)
Formatted Font (Default) Times New RomanFont color Black
33
692 Vascular System 6921 Category A medical conditions shall include the following
(1) Uncontrolled or poorly controlled hypertension
(2) Hypertension with evidence of end organ damage
or not controlled by approved medications
A6921(1) Uncontrolled or poorly controlled hHypertension increases the risk of a sudden cardiac event This sudden cardiac event would cause sudden incapacitation which that is uncontrolled poorly controlled or requires medication likely to interferes with the safe performance of essential job tasks Uncontrolled or poorly controlled hypertension can be defined as the presence of end organ damage (see below) or stage 2 hypertension (BP systolic gt160 mmHg or BP diastolic gt100 mmHg) is an illness that can lead to functional impairment and potential for sudden incapacitation Individuals with pre- stage 1 or stage 2 hypertension should be referred to their primary care physician for evaluation lifestyle modification and treatment [QUESTION FOR GROUP _- WHAT ABOUT HAVING CANDIDATE RETURN IN ONE MONTH UNDER TREATMENT WITH NORMAL BP]
A6921(2)
Chronic hypertension can damage the eye (retinopathy) the kidneys (nephropathy) the vascular system (stroke transient ischemic attack or peripheral artery disease) or the heart (left ventricular hypertrophy and heart failure) These hypertension complications are known as end organ damage The cardiac and vascular complications are associated with an increased risk of sudden incapacitation and sudden cardiac death (Koren et al 1991) Unfortunately the cardiac complications are frequently asymptomatic and valid screening tests are not fast and are not inexpensive Therefore determining who to screen for cardiac complications (such as echocardiogram for LVH or a measurement of left ventricular ejection fraction for heart failure) should be based on the severity and the duration of HTN
76 Physical Examination The annual physical examination shall include each of the following components
(a) BP shall be measured according to the Joint National Commission (JNC)-7 recommendations
A76(1)(a) BP should be measured with a properly calibrated and validated instrument Patients should be seated quietly for at least 5 minutes in a chair with feet on the floor and arm supported at heart level An appropriate-sized cuff (cuff bladder encircling at least 80 of the arm) should be used to ensure accuracy At least 2 measurements should be made Systolic BP is the point at which the first of 2 or more sounds is heard (phase 1) and diastolic BP is the point before the disappearance of sounds (phase 5) [Chobanian et al 2003]
(2) Head eyes ears nose and throat (HEENT)
34
9420 Uncontrolled Hypertension 94201 Physician Evaluation Severe uncontrolled hypertension [defined as systolic pressure greater than 180 mm Hg diastolic pressure greater than 100 mm Hg or mean systolic blood
pressure ( systolic + diastolic) greater than 120 mm Hg] or malignant hypertension (defined as hypertension with the presence of target organ damage) compromises the members ability to safely perform essential job tasks 1 5 7 9 and 13 and the physician shall report the applicable job limitations to the fire department
Members with Pre-hypertention (systolic 120-139 mmHg or diastolic 80-89 mmHg) Stage 1 hypertension (systolic 140-159 mmHg or diastolic 90-99 mmHg) or Stage 2 hypertension (systolic ge160 mmHg or diastolic ge100 mmHg) should be referred to their primary care physician for evaluation lifestyle modification and treatment
(1) Members with Stage I hypertension should be followed-up not only by their primary care physician but also by the FD physician every 3 to 6 months to ensure their blood pressure is under control and to determine whether screening tests for asymptomatic end organ damage are appropriate
(2) Members with Stage 2 hypertension or with end organ damage (retinopathy nephropathy vascular or cardiac complications) compromises the members ability to safely perform essential job tasks 1 5 7 9 and 130 and the physician shall report the applicable job limitations to the fire department
A94201 Severe uncontrolled hypertension is a significant risk factor for the development of coronary artery disease congestive heart failure and stroke Blood pressure increases as a normal response to exercise This response is further exaggerated by the emotional and physical stress of performing these critical tasks while operating in personal protective clothing at extremes of temperature This normal elevation of blood pressure under these response conditions can lead to life-threatening hypertensive emergencies if a members daily blood pressure is already elevated to high levels In addition hypertension is a progressive illness that when uncontrolled ultimately and inevitably leads to target organ damage Target organs that are sensitive to the effects of elevated blood pressure are the central nervous system vision heart major blood vessels and kidneys
Chronic hypertension can damage the eye (retinopathy) the kidneys (nephropathy) the vascular system (stroke transient ischemic attack or peripheral artery disease) or the heart (left ventricular hypertrophy and heart failure) These hypertension complications are known as end organ damage The cardiac and vascular complications are associated with an increased risk of sudden incapacitation and sudden cardiac death (Koren et al 1991) Fortunately with proper evaluation life style modification and treatment these complications can be avoided Life style modification includes weight reduction DASH eating plan reduction in dietary sodium an increase in aerobic physical activity and moderation in alcohol consumption [Chobanian 2003]
Formatted Font (Default) Times New Roman12 pt Font color Black
Formatted Font (Default) Times New Roman12 pt Font color Black
35
A94201 (1) Members with Stage I hypertension whose BP returns to either pre-hypertenion or normal with lifestyle modification andor treatment can return to an annual medical evaluation For members with long-standing Stage I hypertension whose BP has not been reduced additional evaluation for possible end organ damage should be considered This evaluation could include any or all of the following
a) a compete patient history for symptoms of heart failure (eg shortness of breath upon exertion) or transient ischemic attacks (TIAs)
b) dilated eye examination for retinopathy
c) blood creatinine measurement for nephropathy
d) tests for left ventricular hypertrophy Unfortunately use of the resting EKG to detect left ventricular hypertrophy is very insensitive (eg 5 sensitivity) The echocardiogram is the best test for diagnosing left ventricular hypertrophy
A 94201 (2) Due to the high risk of a sudden cardiovascular event members with Stage 2 hypertension should be restricted until their BP can be brought under control Once the BP is brought under control they should be followed in the same manner as a member with Stage I hypertension
Formatted Font (Default) Times New Roman12 pt
36
D22 Cardiology Gibbons R J GJ Balady J W Beasley et al 1997 ACCAHA guidelines for exercise testing a report of American College of CardiologyAmerican Heart Association Task Force on Practice Guidelines (Committee on Exercise Testing) J Am Coll Cardiol 30260ndash311
Gibbons RJ Balady GJ Bricker JT Chaitman BR Fletcher GF Froelicher VF Mark DB McCallister BD Mooss AN OrsquoReilly MG Winters WL Jr [2002] ACCAHA 2002 guideline update for exercise testing summary article a report of the ACCAHA Task Force on Practice Guidelines (Committee to Update the 1997 Exercise Testing guidelines) J Am Coll Cardiol 401531ndash 40
Chobanian AV Bakris GL Black HR Cushman WC Green LA Izzo JL Jr Jones DW Materson BJ Oparil S Wright JT Jr Roccella EJ the National High Blood Pressure Education Program Coordinating Committee [2003] The seventh report of the Joint National Committee [JNC-7] on Prevention Detection Evaluation and Treatment of High Blood Pressure JAMA 2892560ndash2571
Soteriades ES Kales SN Liarokapis D Christiani DC [2003] Prospective surveillance of hypertension in firefighters J Clin Hypertens 5315-320
Kales SN Tsismenakis AJ Zhang C Soteriades ES [2009] Blood pressure in fire fighters police officers and other emergency responders Am J Hypertens 2211-20
37
NFPA 1582‐ HTN Draft 1
Reason for Revision
1) New classification of BP by the Joint National Commission [Chobanian et al 2002]
2) A high prevalence of FF have either HTN (~20) and Pre‐HTN (~20) [Soteriades et al 2003]
3) Among FF studies have shown a strong association between HTN and a number of adverse
cardiovascular events [Kales et al 2009]
4) A large percentage of on‐duty FF fatalities were found to have left ventricular hypertrophy a
complication of HTN at autopsy
Language in 2007 Edition with draft revisions in Red (Track changes)
611 The medical evaluation of a candidate shall include a medical history examination and any laboratory tests required to detect physical or medical condition(s) that could adversely affect hisher ability to safely perform the essential job tasks outlined in 511 A611 The medical history should include the candidates known health problems such as major illnesses surgeries medication use and allergies Symptom review is also important for detecting early signs of illness A medical history should also include a personal health history a family health history a health habit history an immunization history and a reproductive history
An occupational history should also be obtained to collect information about the persons past occupational and environmental exposures
(a) BP should be measured according to the Joint National Commission (JNC) -7 recommendations BP should be measured with a properly calibrated and validated instrument Patients should be seated quietly for at least 5 minutes in a chair with feet on the floor and arm supported at heart level An appropriate-sized cuff (cuff bladder encircling at least 80 of the arm) should be used to ensure accuracy At least 2 measurements should be made Systolic BP is the point at which the first of 2 or more sounds is heard (phase 1) and diastolic BP is the point before the disappearance of sounds (phase 5) [Chobanian et al 2003]
(2) Head eyes ears nose and throat
38
692 Vascular System 6921 Category A medical conditions shall include the following
(1) Uncontrolled or poorly controlled hypertension
(2) Hypertension with evidence of end organ damage
A6921(1) Uncontrolled or poorly controlled hypertension increases the risk of a sudden cardiac event This sudden cardiac event would cause sudden incapacitation which interferes with the safe performance of essential job tasks Uncontrolled or poorly controlled hypertension can be defined as the presence of end organ damage (see below) or stage 2 hypertension (BP systolic gt160 mmHg or BP diastolic gt100 mmHg) Individuals with pre- stage 1 or stage 2 hypertension should be referred to their primary care physician for evaluation lifestyle modification and treatment [QUESTION FOR GROUP _- WHAT ABOUT HAVING CANDIDATE RETURN IN ONE MONTH UNDER TREATMENT WITH NORMAL BP]
A6921(2)Chronic hypertension can damage the eye (retinopathy) the kidneys (nephropathy) the vascular system (stroke transient ischemic attack or peripheral artery disease) or the heart (left ventricular hypertrophy and heart failure) These hypertension complications are known as end organ damage The cardiac and vascular complications are associated with an increased risk of sudden incapacitation and sudden cardiac death (Koren et al 1991) Unfortunately the cardiac complications are frequently asymptomatic and valid screening tests are not fast and are not inexpensive Therefore determining who to screen for cardiac complications (such as echocardiogram for LVH or a measurement of left ventricular ejection fraction for heart failure) should be based on the severity and the duration of HTN
76 Physical Examination The annual physical examination shall include each of the following components
(a) BP shall be measured according to the Joint National Commission (JNC)-7 recommendations
A76(1)(a) BP should be measured with a properly calibrated and validated instrument Patients should be seated quietly for at least 5 minutes in a chair with feet on the floor and arm supported at heart level An appropriate-sized cuff (cuff bladder encircling at least 80 of the arm) should be used to ensure accuracy At least 2 measurements should be made Systolic BP is the point at which the first of 2 or more sounds is heard (phase 1) and diastolic BP is the point before the disappearance of sounds (phase 5) [Chobanian et al 2003]
(2) Head eyes ears nose and throat9420 Hypertension 94201 Physician Evaluation Members with Pre-hypertention (systolic 120-139 mmHg or diastolic 80-89 mmHg) Stage 1 hypertension (systolic 140-159 mmHg or diastolic 90-99 mmHg) or Stage 2 hypertension (systolic ge160 mmHg or diastolic ge100 mmHg) should be referred to their primary care physician for evaluation lifestyle modification and treatment
39
(1) Members with Stage I hypertension should be followed-up not only by their primary care physician but also by the FD physician every 3 to 6 months to ensure their blood pressure is under control and to determine whether screening tests for asymptomatic end organ damage are appropriate
(2) Members with Stage 2 hypertension or with end organ damage (retinopathy nephropathy vascular or cardiac complications) compromises the members ability to safely perform essential job tasks 1 5 7 9 and 130 and the physician shall report the applicable job limitations to the fire department
A94201 Chronic hypertension can damage the eye (retinopathy) the kidneys (nephropathy) the vascular system (stroke transient ischemic attack or peripheral artery disease) or the heart (left ventricular hypertrophy and heart failure) These hypertension complications are known as end organ damage The cardiac and vascular complications are associated with an increased risk of sudden incapacitation and sudden cardiac death (Koren et al 1991) Fortunately with proper evaluation life style modification and treatment these complications can be avoided Life style modification includes weight reduction DASH eating plan reduction in dietary sodium an increase in aerobic physical activity and moderation in alcohol consumption [Chobanian 2003]
A94201 (1) Members with Stage I hypertension whose BP returns to either pre-hypertenion or normal with lifestyle modification andor treatment can return to an annual medical evaluation For members with long-standing Stage I hypertension whose BP has not been reduced additional evaluation for possible end organ damage should be considered This evaluation could include any or all of the following
a) a compete patient history for symptoms of heart failure (eg shortness of breath upon exertion) or transient ischemic attacks (TIAs)
b) dilated eye examination for retinopathy
c) blood creatinine measurement for nephropathy
d) tests for left ventricular hypertrophy Unfortunately use of the resting EKG to detect left ventricular hypertrophy is very insensitive (eg 5 sensitivity) The echocardiogram is the best test for diagnosing left ventricular hypertrophy
A 94201 (2) Due to the high risk of a sudden cardiovascular event members with Stage 2 hypertension should be restricted until their BP can be brought under control Once the BP is brought under control they should be followed in the same manner as a member with Stage I hypertension
D22 Cardiology
40
Hypertension
Gibbons RJ Balady GJ Bricker JT Chaitman BR Fletcher GF Froelicher VF Mark DB McCallister BD Mooss AN OrsquoReilly MG Winters WL Jr [2002] ACCAHA 2002 guideline update for exercise testing summary article a report of the ACCAHA Task Force on Practice Guidelines (Committee to Update the 1997 Exercise Testing guidelines) J Am Coll Cardiol 401531ndash 40
Chobanian AV Bakris GL Black HR Cushman WC Green LA Izzo JL Jr Jones DW Materson BJ Oparil S Wright JT Jr Roccella EJ the National High Blood Pressure Education Program Coordinating Committee [2003] The seventh report of the Joint National Committee [JNC-7] on Prevention Detection Evaluation and Treatment of High Blood Pressure JAMA 2892560ndash2571
Soteriades ES Kales SN Liarokapis D Christiani DC [2003] Prospective surveillance of hypertension in firefighters J Clin Hypertens 5315-320
Kales SN Tsismenakis AJ Zhang C Soteriades ES [2009] Blood pressure in fire fighters police officers and other emergency responders Am J Hypertens 2211-20
41
NFPA 1582‐ Draft Revisions for CVDHTN
EKG and stress tests
Reason for Revision
1) Change requirement for annual resting EKG to periodically to be more consistent with ACCAHA
recommendation (Schlant et al 1992)
2) Add language to clarify what constitutes a positive ST
3) Make criteria for conducting diagnostic ST in asymptomatic patients consistent with the
ACCAHA
Language in 2007 Edition with draft revisions in Red (Track changes)
776 Electrocardiograms (EKG)) and Stress Tests 7761 A resting EKG shall be performed as part of the baseline medical evaluation and shall be obtained periodically (every 1 to 5 years) annually thereafter
A7761 A baseline resting EKGs shall be conducted Follow-up resting EKGs should be conducted as clinically indicated but at a minimum of every 1 to 5 years The frequency of these follow-up resting EKGs should increase as a members age increases or with increasing number andor severity of coronary heart disease risk factors Members above the age of 40 should have annual resting EKGs (Schlant et al 1992)
7762 The fire department physician or other qualified medical evaluator shall compare EKGs obtained during yearly evaluations with baseline and subsequent EKGs
7763 Stress testing EKG with or without echocardiography or radionuclide scanning shall be performed as clinically indicated by history or symptoms
A7761 Baseline electrocardiography should be conducted (Periodic resting electrocardiograms have not been shown to be useful but can be reasonable as a members agefactors increase)
A7763 No firm guidelines for stress testingelectrocardiography in asymptomatic individuals have been developed Stress testingelectrocardiography as a screening tool is used as part of an evaluation of aerobic capacity during the annual occupational fitness evaluation Submaximal stress testingelectrocardiography testing to 85 percent is commonly used as part of this screening
Submaximal stress electrocardiography testing should not be used for diagnostic purposes Cardiology evaluation with maximal stress testingelectrocardiography together with imaging techniques (eg echocardiography technetium Tc99m sestamibi study andor coronary angiography) is necessary for diagnosticprognostic purposes for the following
42
(1) Fire fighters with positive or questionably positive changes on screening submaximal stress tests
(2) Fire fighters with new onset chest pain or other symptoms suggestive of coronary artery disease (CAD)
(3) Fire fighters with diabetes mellitus who
(a) are gt35 years old or
(b) have type I diabetes for more than 15 years or
(c) have type II diabetes for more than 10 years or
(d) have any other CHD risk factor (see below) or
(e) have the presence of microvascular disease (proliferative retinopathy)
(4) Fire fighters over the age of 45 (for men) and 55 (for women) with onetwo or more risk factors for CAD Risk factors for CAD include hypercholesterolemia (total cholesterol greater than 240 mgdL) hypertension (systolic gt140 mmHg or diastolic gt90 mmHg) smoking or family history of premature CAD (heart attack or sudden cardiac death in a first degree relative less than 60 years of age)
as defined below if stress electrocardiography with imaging is negative then repeat as clinically indicated or at least every 5 years
(5) Fire fighters with a Framingham Risk Score gt10 Risk calculator is available at [httphp2010nhlbihinnetatpiiicalculatorasp]
(6) Fire fighters identified in 9431
Negative stress tests should be repeated as clinically indicated or at least every 2 to 5 years
Interpreting stress tests as ldquopositiverdquo or ldquonegativerdquo is beyond the scope of this document However factors that should be taken into consideration should include the individualrsquos exercise capacity symptoms blood pressure response heart rate response EKG changes and the presence of arrhythmias (Gibbon et al 2002)
Risk factors for CAD include hypercholesterolemia (total cholesterol greater than 240 mgdL) hypertension (systolic greater than 140 andor diastolic greater than 90) smoking diabetes mellitus or family history of premature CAD (heart attack or sudden cardiac death in a first degree relative less than 60 years of age)
There are other non-invasive tests to screen for coronary artery disease One of the most promising appears to be coronary artery calcium (CAD) scoring by computed tomography In 2007 an expert committee published an update to their original guidance document The committeersquos consensus was that ldquoit may be reasonable to consider use of CAC measurement in such patients [between 10 and 20 10-year risk of estimated coronary event]helliprdquo The committee did not recommend CAC measurement in low risk patients [lt10 10-year risk of estimated coronary event] or in high risk patients [gt20 10-year risk of estimate coronary event] (Greenland et al 2007]
43
D22 Cardiology
Chobanian AV Bakris GL Black HR Cushman WC Green LA Izzo JL Jr Jones DW Materson BJ Oparil S Wright JT Jr Roccella EJ the National High Blood Pressure Education Program Coordinating Committee [2003] The seventh report of the Joint National Committee [JNC-7] on Prevention Detection Evaluation and Treatment of High Blood Pressure JAMA 2892560ndash2571
Gibbons RJ Balady GJ Bricker JT Chaitman BR Fletcher GF Froelicher VF Mark DB McCallister BD Mooss AN OrsquoReilly MG Winters WL Jr [2002] ACCAHA 2002 guideline update for exercise testing summary article a report of the ACCAHA Task Force on Practice Guidelines (Committee to Update the 1997 Exercise Testing guidelines) J Am Coll Cardiol 401531ndash 1540
Greenland et al [2007] ACCFAHA 2007 Clinical Expert Consensus Document on Coronary Artery Calcium Scoring By Computed Tomography in Global Cardiovascular Risk Assessment and in Evaluation of Patients With Chest Pain A Report of the American College of Cardiology Foundation Clinical Expert Consensus Task Force (ACCFAHA Writing Committee to Update the 2000 Expert Consensus Document on Electron Beam Computed Tomography) J Am Coll Cardiol 49378-402
Kales SN Tsismenakis AJ Zhang C Soteriades ES [2009] Blood pressure in fire fighters police officers and other emergency responders Am J Hypertens 2211-20
Schlant RC Adolph RJ DiMarco JP Dreifus LS Dunn MI Fisch C Garson A Jr Haywood LJ Levine HJ Murray JA Noble RJ Ronan JA Jr [1992] Guidelines for electrocardiography A report of the American College of CardiologyAmerican Heart Association Task Force on Assessment of Diagnostic and Therapeutic Cardiovascular Procedures (Committee on Electrocardiography) Circulation 85(3)1221-1228
Soteriades ES Kales SN Liarokapis D Christiani DC [2003] Prospective surveillance of hypertension in firefighters J Clin Hypertens 5315-320
Formatted Font Italic
Formatted Line spacing single
Formatted Font Italic
Formatted Font Italic
44
NFPA 1582‐ Draft Revisions for CVDHTN
EKG and stress tests
Reason for Revision
1) Change requirement for annual resting EKG to periodically to be more consistent with ACCAHA
recommendation (Schlant et al 1992)
2) Add language to clarify what constitutes a positive ST
3) Make criteria for conducting diagnostic ST in asymptomatic patients consistent with the
ACCAHA
Language in 2007 Edition with draft revisions in Red (Track changes)
776 Electrocardiograms (EKG) and Stress Tests 7761 A resting EKG shall be performed as part of the baseline medical evaluation and shall be obtained periodically (every 1 to 5 years) thereafter
A7761 A baseline resting EKGs shall be conducted Follow-up resting EKGs should be conducted as clinically indicated but at a minimum of every 1 to 5 years The frequency of these follow-up resting EKGs should increase as a members age increases or with increasing number andor severity of coronary heart disease risk factors Members above the age of 40 should have annual resting EKGs (Schlant et al 1992)
7762 The fire department physician or other qualified medical evaluator shall compare baseline and subsequent EKGs
7763 Stress testing with or without echocardiography or radionuclide scanning shall be performed as clinically indicated by history or symptoms
A7763 No firm guidelines for stress testing in asymptomatic individuals have been developed Stress testing as a screening tool is used as part of an evaluation of aerobic capacity during the annual occupational fitness evaluation Submaximal stress testing testing to 85 percent is commonly used as part of this screening
Submaximal stress testing should not be used for diagnostic purposes Cardiology evaluation with maximal stress testing together with imaging techniques (eg echocardiography technetium Tc99m sestamibi study) is necessary for diagnosticprognostic purposes for the following
(1) Fire fighters with positive or questionably positive changes on screening submaximal stress tests
(2) Fire fighters with new onset chest pain or other symptoms suggestive of coronary artery disease (CAD)
45
(3) Fire fighters with diabetes mellitus who
(a) are gt35 years old or
(b) have type I diabetes for more than 15 years or
(c) have type II diabetes for more than 10 years or
(d) have any other CHD risk factor (see below) or
(e) have the presence of microvascular disease (proliferative retinopathy)
(4) Fire fighters over the age of 45 (for men) and 55 (for women) with one or more risk factors for CAD Risk factors for CAD include hypercholesterolemia (total cholesterol greater than 240 mgdL) hypertension (systolic gt140 mmHg or diastolic gt90 mmHg) smoking or family history of premature CAD (heart attack or sudden cardiac death in a first degree relative less than 60 years of age)
(5) Fire fighters with a Framingham Risk Score gt10 Risk calculator is available at [httphp2010nhlbihinnetatpiiicalculatorasp]
(6) Fire fighters identified in 9431
Negative stress tests should be repeated as clinically indicated or at least every 2 to 5 years
Interpreting stress tests as ldquopositiverdquo or ldquonegativerdquo is beyond the scope of this document However factors that should be taken into consideration should include the individualrsquos exercise capacity symptoms blood pressure response heart rate response EKG changes and the presence of arrhythmias (Gibbon et al 2002)
There are other non-invasive tests to screen for coronary artery disease One of the most promising appears to be coronary artery calcium (CAD) scoring by computed tomography In 2007 an expert committee published an update to their original guidance document The committeersquos consensus was that ldquoit may be reasonable to consider use of CAC measurement in such patients [between 10 and 20 10-year risk of estimated coronary event]helliprdquo The committee did not recommend CAC measurement in low risk patients [lt10 10-year risk of estimated coronary event] or in high risk patients [gt20 10-year risk of estimate coronary event] (Greenland et al 2007]
D22 Cardiology
Resting EKG and Stress Tests
46
Chobanian AV Bakris GL Black HR Cushman WC Green LA Izzo JL Jr Jones DW Materson BJ Oparil S Wright JT Jr Roccella EJ the National High Blood Pressure Education Program Coordinating Committee [2003] The seventh report of the Joint National Committee [JNC-7] on Prevention Detection Evaluation and Treatment of High Blood Pressure JAMA 2892560ndash2571
Gibbons RJ Balady GJ Bricker JT Chaitman BR Fletcher GF Froelicher VF Mark DB McCallister BD Mooss AN OrsquoReilly MG Winters WL Jr [2002] ACCAHA 2002 guideline update for exercise testing summary article a report of the ACCAHA Task Force on Practice Guidelines (Committee to Update the 1997 Exercise Testing guidelines) J Am Coll Cardiol 401531ndash 1540
Greenland et al [2007] ACCFAHA 2007 Clinical Expert Consensus Document on Coronary Artery Calcium Scoring By Computed Tomography in Global Cardiovascular Risk Assessment and in Evaluation of Patients With Chest Pain A Report of the American College of Cardiology Foundation Clinical Expert Consensus Task Force (ACCFAHA Writing Committee to Update the 2000 Expert Consensus Document on Electron Beam Computed Tomography) J Am Coll Cardiol 49378-402
Kales SN Tsismenakis AJ Zhang C Soteriades ES [2009] Blood pressure in fire fighters police officers and other emergency responders Am J Hypertens 2211-20
Schlant RC Adolph RJ DiMarco JP Dreifus LS Dunn MI Fisch C Garson A Jr Haywood LJ Levine HJ Murray JA Noble RJ Ronan JA Jr [1992] Guidelines for electrocardiography A report of the American College of CardiologyAmerican Heart Association Task Force on Assessment of Diagnostic and Therapeutic Cardiovascular Procedures (Committee on Electrocardiography) Circulation 85(3)1221-1228
Soteriades ES Kales SN Liarokapis D Christiani DC [2003] Prospective surveillance of hypertension in firefighters J Clin Hypertens 5315-320
47
ATTACHMENT F
48
1
Current 1582 (2007) language in reference to pregnancy 43 (4) Report to the fire department physician any medical condition that could interfere with the ability of the individual to safely perform essential job tasks such as illness or injury use of prescription or nonprescription drugs and pregnancy 6112 Category B medical conditions shall include the following (1) Pregnancy for its duration A7792 (e) If HIV prophylaxis is to be given the following tests should be done i CBC ii Glucose renal and hepatic chemical function iii Pregnancy test for females B121 Pregnancy and Reproduction Federal regulations as well as many court decisions including the US Supreme Courtrsquos decision in International Union et al v Johnson Controls Inc [499 US 187 111 S Ct 1196 (1991)] have interpreted the requirements of Title VII with respect to pregnancy and reproduction The AHJ should seek the advice of counsel in resolving specific questions concerning these requirements as well as other requirements that can be imposed by state or local laws C211 (4) Review health status with the individual being evaluated Contraindications for evaluations shall be reviewed addressing any changes in the individualrsquos health status since their last medical evaluation that would warrant deferring the evaluation including (g) Pregnancy Recommendations to language enhancement
A female employee who is assigned to regular fire line duty shall report a pregnancy immediately to their respective Supervisor and the fire department physician The employee will then be given the option of a non-hazardous alternative duty position for the duration of her pregnancy (can we say this or is it even appropriate) Any pregnant employee wishing to remain on regular line duty shall be informed of the possible risks and consequences to herself and her fetus that are associated with continued line fire fighting duty Among those risk factors are exposure to teratogens known to have negative effects on the developing fetus such as smoke diesel fumes hazardous chemicals and extreme heat
49
Page 2
appendix It is recommended that the pregnant employee complete a release of liability form signed by herself and her health care provider utilizing NFPArsquos 13 critical tasks as a reference This will inform the health care provider of specific job-related tasks that will need to be performed in order to continue regular line duty These tasks are basic physical standards that any entry level firefighter would have to be able to complete competently The employeersquos health condition will be kept confidential by the department in accordance with HIPAA standards Employees are allowed to remain on active regular duty until they are no longer able to perform their duties in a reasonable manner andor their protective gear no longer fits correctly It is the responsibility of the health care provider to evaluate the pregnant employee If at any time the health care provider feels the pregnant employee can no longer perform the job related tasks this should be reported to the employer by the employee immediately
50
ATTACHMENT G
51
From GLENN BENARICKTo Sawyer SteveSubject RE RE 7743Date Monday August 30 2010 21633 PM
Yes thats my understanding
Glenn P Benarick 211 Winged Elm CircleAiken SC 29803803-644-7093gbenarprodigynet
--- On Mon 83010 Sawyer Steve ltssawyerNFPAorggt wrote
From Sawyer Steve ltssawyerNFPAorggtSubject RE RE 7743To GLENN BENARICK ltgbenarprodigynetgtDate Monday August 30 2010 212 PM
So it should be ldquoorrdquo instead of ldquoandrdquo for now
Steven F Sawyer
Senior Fire Service Specialist
Executive Secretary IFMAFire Service Section
NFPA
1 Batterymarch Park
Quincy MA 02169
6179847423
Fax 6179847056
ssawyernfpaorg
From GLENN BENARICK [mailtogbenarprodigynet] Sent Monday August 30 2010 1202 PMTo Sawyer SteveSubject Fw RE 7743
52
Steve a couple of our docs agree with April Boyer
Glenn P Benarick 211 Winged Elm Circle
Aiken SC 29803
803-644-7093
gbenarprodigynet
--- On Mon 83010 David Prezant ltprezandfdnynycgovgt wrote
From David Prezant ltprezandfdnynycgovgtSubject RE 7743To Thomas R (CDCNIOSHDSHEFS) Hales lttrh1cdcgovgt GLENNBENARICK ltgbenarprodigynetgtCc Sandy Bogucki ltsandyboguckiyaleedugtDate Monday August 30 2010 1004 AM
agree
we should change this to NHANES III rather than Knudson we should alsomodify this to allow not only for predicted cutoffs but all for use of thelower limit of normal cutoff This is important to prevent false-classificationof spirometry as abnormal in older groups and in taller grps The latter ofparticular import to firefighter occupational health surveillance
thanks
David Prezant MDChief Medical Officer Office of Medical AffairsCo-Director WTC Medical Monitoring amp Treatment ProgramsNew York City Fire Department9 Metrotech Center - Rm 4W-1Brooklyn NY 11201Phone 718-999-2696Fax 718-999-0665
Life is full of twists and turns
53
This email may contain confidential information If you are the unintendedrecipient of this email please send it back and delete from your directory
gtgtgt Hales Thomas R (CDCNIOSHDSHEFS) lttrh1cdcgovgt 8302010955 AM gtgtgt
Glen
This seems like a very reasonable comment and illustrates the importance of having clinicians providefeedback on the std Im not familiar with the software program of the various spirometers (NHANES IIIvs KnudsonATS vs both) Given the large role both Dave Prezant and Sandy Bogucki had for thepulmonary section let me forward to them for clarification
Tom
From GLENN BENARICK [mailtogbenarprodigynet] Sent Sunday August 29 2010 456 PMTo Hales Thomas R (CDCNIOSHDSHEFS)Subject FW 7743
Tom is April Boyer correct
Glenn P Benarick 211 Winged Elm Circle
Aiken SC 29803
803-644-7093
gbenarprodigynet
--- On Thu 82610 Sawyer Steve ltssawyerNFPAorggt wrote
From Sawyer Steve ltssawyerNFPAorggtSubject FW 7743To GLENN BENARICK ltgbenarprodigynetgtDate Thursday August 26 2010 925 PM
FYI Do you have any answer She is write
Steven
54
Steven F Sawyer
Senior Fire Service Specialist
Executive Secretary IFMAFire Service Section
NFPA
1 Batterymarch Park
Quincy MA 02169
6179847423
Fax 6179847056
ssawyernfpaorg
From April Boyer [mailtoaboyerbicclinicorg] Sent Thursday August 26 2010 232 PMTo Sawyer SteveCc RobinMWebbmilstateorusSubject 7743
Steven
The spirometry tests cannot be corrected according to both references as the NFPA states because thereferences are contradictory The first part of 7743 states to follow the ATS guidelines and use theKnudsen (we at Basin Immediate Care use the Nhanes III) The second part states to follow the ACOEMguidelines and use the Nhanes III in the occupational setting if available with your unit (which is availableon ours) 7743 does not use the word OR regarding both requirements it uses the word AND whenreferring to the first and second parts thence making 7743 contradictory I realize the NFPA 1582 hasnot been updated since 2007 unless I have just not received an updated version
Our question to you is which part of 7743 do you want us to follow the first or the second part Anyfacility that has an updated computerized spirometry system (as we do) will not be able to follow bothrequired parts for obvious reasons We can either follow the first part of 7743 and use an oldercorrected version of the Knudson by going into our system and changing out of the Nhanes III conversionOR we can follow the second part of 7743 and use the newer corrected version of Nhanes III which ourunit offers too
If you have any questions you may contact me at anytime and I also have many references in regards toboth parts of 7743 if you would like to see them
55
Thank you~
April
Confidentiality NoticeThis message may contain information that isconfidential or privileged
If you are not the intended recipientPlease advise the sender immediately and delete this message
56
ATTACHMENT H
57
NFPA 1582 771(7) Proposed revisions
Why
Preliminary results of two prospective randomized trials on the PSA test were published in 2009 These studies resulted in medical organizations that previously providing guidance to modify their recommendations
Current language
771 Blood Tests Blood tests shall be performed annually and shall include the following
(7) Prostate specific antigen (PSA) after age 40 for positive family history if African American or if otherwise clinically indicated after age 50 for all other male member
Suggested Revision
771 Blood Tests Blood tests shall be performed annually and shall include the following
(7) Prostate specific antigen (PSA) after age 40 for positive family history if African American or if otherwise clinically indicated after age 50 for all other male member
772 Prostate-Specific Antigen (PSA) test At age 50 fire fighters shall have an opportunity to make an informed decision with either the Fire Department physician or their health care provider concerning the PSA test For fire fighters at increased risk of prostate cancer (African-Americans or those with a first degree relative diagnosed with prostate cancer before age 65) shall have the opportunity for this informed decision at age 40
A772 The PSA as a screening test for prostate cancer in asymptomatic men is controversial controversial for two reasons First there is no consensus that PSA screening actually saves lives For example the PSA test may detect small cancers that would never become life threatening Second it is unclear that the benefits of PSA screening outweigh the risks of follow-up diagnostic tests and cancer treatments For example the prostate biopsy used to diagnose prostate cancer may cause bleeding and infection And prostate cancer treatments such as surgery and radiation therapy may cause incontinence (inability to control urine flow) erectile dysfunction (erections inadequate for intercourse) and other complications For these reasons it is important that the benefits and risks of prostate diagnostic procedures and treatment be taken into account when considering the PSA screening test These considerations can be taken account during discussions with the fire department physician or onersquos health care provider
D211 Cancer Screening
Smith R A C J Mettlin K J Davis and H Eyre 2000 ldquoAmerican Cancer Society guidelines for the early detection of cancerrdquo CA J Clin 50(1)34ndash49
Added references
58
Carroll P Albertsen PC Greene K et al [2010] Prostate-specific antigen best practice statement 2009 update Am Urological Assoc Available at httpwwwauanetorgcontentguidelines-and-quality-careclinical-guidelinesmain-reportspsa09pdf Date accessed September 2010
Ferrini R Woolf SH [2009] Screening for prostate cancer in American men American College of Preventive Medicine Practice Policy Statement Available at httpwwwacpmorgprostatehtm Date accessed September 2010
National Cancer Institute [2009] Prostate-specific antigen test National Cancer Institute Fact Sheet Available at httpwwwcancergovcancertopicsfactsheetDetectionPSA Date accessed September 2010
Wolf AMD Wender RC Etzioni RB et al [2010] American Cancer Society guideline for the early detection of prostate cancer Update 2010 Available at httpcaonlineamcancersocorgcgicontentfullcaac20066v1 Date accessed September 2010
59
and some proposed changesremoval of text based on research
findings The specific proposed changes will be available for the committee at their next meeting Some members on the call felt that
this issue was covered in another law enforcement document which might better serve this issue
Research topics for FSOSH projects Casey Grant offered his time to
answer any questions regarding his presentation from the May meeting in Baltimore There was also discussion about further
involvement of the Research Foundation with this committee and some of the medical requirements within the documents Glenn and Casey
are going to be in contact offline to discuss this further
Prosthetics amp Amputees report Nothing new to report
Heart amp Hypertension report There was discussion about the need for
periodic EKGrsquos that were done both in resting and non-resting states as well as discussion about stress test requirements and frequency of
such tests The hopes were to develop text that would point to annual versus periodic evaluations of EKGrsquos and stress tests
Epilepsy report Nothing new to report
Pregnancy report The initial textlanguage has been provided to the
group through email and e-committee page posting
Coagulation amp Meds report Nothing new to report
Hearing Aid discussion Nothing new to report
The committee also discussed the evaluation and documentation of
PSA results and test requirements for the purposes of consistency The proposed text and changes have been posted on the e-committee
page as well
All of the proposed text changes from the May meeting in Baltimore have been emailed out and posted on the e-committee page If there
are any questions or concerns that something was missed please contact Glenn Steven Sawyer or Ken Holland to ensure they are
resolved
The conference call lasted approximately an hour and was adjourned at 1400 hours
14
ATTACHMENT C
15
2012 ANNUAL REVISION CYCLE
PROCESS STAGE PROCESS STEP DATES
FOR TC DATES
FOR TCC 1 PRELIMINARY 10 Notification of intent to enter cycle 7910 7910
2 REPORT ON
PROPOSALS (ROP)
21 Proposal closing date 112310 112310 22 Final date for ROP meeting 22511 2411 23 Final date for mailing TC ballots 31811 21811 24 Receipt of (TC) ballots by staff liaison 42211 31111 25 Receipt of TC recirculation ballots 5611 31811 26 Final date for TCC meeting 41511 27 Final date for mailing TCC ballots 42211 28 Receipt of TCC ballots 51311 29 Receipt of TCC recirculation ballots 52011 210 Final copy (w ballot statements) to Secretary Standards Council 51311 52711 211 Completion of Reports 52011 6311 212 ROP Published and Posted 62411 62411
3 REPORT ON
COMMENTS
(ROC)
31 Comment closing date 83011 83011 32 Final date for ROC meeting 11411 10711 33 Final date for mailing TC ballots 111811 102111 34 Receipt of (TC) ballots by staff liaison 12211 111111 35 Receipt of TC recirculation ballots 12911 111811 36 Final date for TCC meeting 121611 37 Final date for mailing TCC ballots 122311 38 Receipt of TCC ballots 11312 39 Receipt of TCC recirculation ballots 12012 310 Final copy (w ballot statements) to Secretary Standards Council 122311 12712 311 Completion of Reports 11312 2312 312 ROC Published and Posted 22412 22412
4 TECH SESSION
PREPARATION amp
ISSUANCE OF
CONSENT
DOCUMENTS
41 Notice of Intent to Make a Motion (NITMAM) Closing Date 4612 4612 42 Posting of Filed NITMAM 5412 5412
43 Council Issuance Date for Consent Documents 52912 52912
44 Appeal Closing Date for Consent Documents 61312 61312
5 TECHNICAL
SESSION 50 Association Meeting for Documents with Certified Amending Motions
64-712 64-712
6
APPEALS amp
ISSUANCE OF
DOCUMENTS
WCAMS
61 Appeal closing date for Documents with Certified Amending Motions
62712 62712
62 Council issuance for Documents with Certified Amending Motions 8912 8912
Proposal Closing Dates may vary according to documents and schedules for Revision Cycles may change Please check the NFPA website (wwwnfpaorg) for the most up-to-date information on proposal closing dates and schedules
16
ATTACHMENT D
17
This weekrsquos conference call mentioned the Diabetes chapter written for the ACOEM document Guidance for the Medical Evaluation of the Law Enforcement Officer The task group working on this chapter (led Richard Miller of the Secret Service and our very own Dan Samo) worked with the ADA or over 2-3 years to come up with a consensus document
Please find the Chapter attached ltltDiabetes Guidance Sept 2010pdfgtgt
Regarding Dan Loeberrsquos points
1) Physical Evaluation Form - We could modify the LEO form (see end of the attached Chapter)
2) Duration required for stable regiment
1582 for IDDM Type 1 1 yr
Type 2 6 m
Oral Agents None specifically
ACOEM Police for IDDM Type 1 6m
Type 2 3m
Oral Agents 1m
The police document is much clearer about the decision regarding medical fitness for duty is the responsibility of the police physician with the treating diabetes-expert physician providing the data to the police physician to make an informed decision In this regard the police officer must provide the police physician with downloaded self monitoring glucose data for the 1 3 and 6 month time periods (see section 433)
3) HA1C ndash NFPA lt 8 over 3 month period
ACOEM Police ndash (Section 4333) Specifies the frequency on measurement and if gt8 requires further evaluation
Some other discrepancies End organ complications
NFPA ndash end organ complications (eye kidney heart neuro) ndash restriction
ACOEM Police ndash end organ complication -- requires further evaluation
18
Hypoglycemia (incapacitating ndash defined differently between the two documents (434)
NFPA ndash 0 episodes in past year le1 in past 5 yrs
ACOEM Police ndash 0 episodes in past year le2 in past 3 yrs
Given Dan Samorsquos and Richard Millerrsquos work with the ADALoeber it would be helpful to get their opinions on whether any of the changes requested by Loeber are appropriate for FF with DM
Tom
Thomas Hales MD MPH
Senior Medical Epidemiologist
NIOSH CDC
4676 Columbia Pkwy R-9
Cincinnati OH 45241
(513) 841-4583
trh1cdcgov
19
43 ndash DIABETES MELLITUS
431 ndash INTRODUCTION
The educated and motivated law enforcement officer (LEO) with well-managed diabetes mellitus can be capable of
safe and effective job performance1 However diabetes mellitus may place LEOs at risk for sudden incapacitation
thus jeopardizing their ability to perform critical job functions (These job functions include those listed in Sections
32 333 351 352 36 and 37 and discussed in Appendix A)
Therefore an individualized assessment of the LEOrsquos diabetes should be performed using the following evaluative
criteria to determine whether the individuals condition permits safe and effective job performance Such evaluation
must include the following key elements which are discussed in detail below
history of blood glucose control
knowledge of diabetes and its management
current stability of blood glucose
risk for significant hypoglycemia or hyperglycemia and
presence of diabetic complications
432 ndash OVERVIEW OF MEDICAL EVALUATION
The treating endocrinologist or other physician knowledgeable regarding diabetes management should provide
a narrative report certifying whether the LEO has or has not met the criteria set out in Sections 4321 through
4354 below In addition the physician should include supporting data (see Appendix B for the Physician Evalu-
ation Form)
4321 The LEO is under the care of an endocrinologist or other physician knowledgeable regarding diabetes
management Outpatient and in-patient medical record(s) for the last 3 years or since date of diagnosis
(whichever is shorter) should be reviewed by the treating physician and provided to the police physician
4322 If the LEO has type 1 diabetes the individual has been on a basalbolus regimena or an insulin pump
using analogue insulins for the 6 months prior to evaluation2
4323 If the LEO has type 2 diabetes on insulin the individual has been on a stable medication regimenb
for the 3 months prior to evaluation3 If on oral agents alone the LEO has been on a stable medication regimen
for the month prior to evaluationc
ACOEM Guidance for the Medical Evaluation of Law Enforcement Officers 1
43 ndash DIABETES MELLITUS
aA basalbolus insulin regimen consists of the use of a basal insulin (Glargine NPH) in a once or twice daily regimen to provide between-
meal insulin combined with the use of a short acting insulin (Regular Lispro Aspart or Glulisine) at mealtimes Insulin pumps are small
(beeper sized) battery powered devices that deliver small amounts of short-acting insulin in a constant infusion to meet basal insulin
requirements The wearer selects an additional mealtime bolus to be infused at the time of meals For more information on pumps visit
the manufacturerrsquos web sites ndash wwwMinimedcom wwwcozmorecom wwwanimascorpcom wwwdisetroniccom
bA stable insulin regimen is defined as maintaining the same types of insulin (long acting intermediate acting short or rapid acting)
Changes in insulin dose are part of the appropriate self-management of diabetes and do not disqualify an applicant or incumbent under
this section
cChanges in dose within the evaluation period will be allowed but addition of a new class of medications or insulin should result in a new
period of observation
one month for addition of a sulfonylurea or metformin
two months for the addition of a thiazolidinedione to insulin or a sulfonylurea or
three months for the addition of insulin
20
4324 If the LEO uses an insulin pump documentation is needed as follows
proper understanding and education in the use of the insulin pump
start date for the use of the pump
history of insulin site infectionsd
history of pump cessation and pump malfunction
backup plan for pump malfunction including use of injectable insulin and
frequency of infusion set changes
4325 The LEO has been educated in diabetes and its management and thoroughly informed of and under-
stands the procedures that must be followed to monitor and manage hisher diabetes and what procedures
should be followed if complications arise3
433 ndash QUANTITATIVE GLUCOSE MONITORING
4331 The LEO has documentation of ongoing self-monitoring of blood glucose
4332 This must be done with a glucose meter that stores every reading records date and time of reading
and from which data can be downloaded (Most meters now have this capability)
4333 Monitoring logs must be available covering the time period (1 3 or 6 months) as described in
Sections 4322 and 4323 The frequency of glucose monitoring must follow a schedule acceptable to the
police physician in consultation with the treating physician
Testing schedules are individual What follows is a common pattern but individual patterns may differ
2 ACOEM Guidance for the Medical Evaluation of Law Enforcement Officers
43 ndash DIABETES MELLITUS
dIndividual has not had more than one pump-site infection that caused him or her to miss work or usual daily activities in the preceding 6
months
THERAPEUTIC REGIMEN GLUCOSE TESTING SCHEDULE
Diet alone Once or twice a week
Metformin Thiazolidinediones or Alpha
Glucosidase inhibitors alone or in
combination
Once or twice a week
Sulfonylureas meglitanides nateglinide ndash
alone or in combination with the above group
Twice a day ndash AM and at supper with any
suspected hypoglycemic episodes
Insulin ndash one shot in combination with orals Twice a day ndash AM and at supper with any
suspected hypoglycemic episodes
2 to 3 times AM once a week
Insulin ndash two or more shots Insulin pump 3 to 4 times a day ndash at meals and bedtime
2 to 3 times AM once a week with any
suspected hypoglycemic episodes
21
4334 The LEO has had hemoglobin A1C measured at least 4 times a year (intervals of 2 to 3 months) over
the last 12 months prior to evaluation if diagnosis has been present for more than a year4 If hemoglobin A1C is
gt8 this may signal a problem with the LEOrsquos diabetes management that warrants further assessment5
434 ndash INCAPACITATING EVENTS
4341 The LEO has not had any incapacitating episodes within the past 1 year and no more than 2 episodes
in the past 3 years or since diagnosis of diabetes (whichever is shorter) of
43411 Severe hypoglycemia (loss of consciousness seizures or coma requiring assistance of others or
needing urgent treatment [glucagon injectionIV glucose]) or
43412 Blood sugar lt60 mgdl with unawareness demonstrated in current glucose logs6
435 ndash CHRONIC COMPLICATION SCREENING
4351 Chronic complications of diabetes are associated with increased risk for severe hypoglycemic
episodes and warrant further assessmente
4352 The components of screening for chronic complications are
43521 A complete eye exam by a qualified ophthalmologist or optometrist including a dilated retinal
exam demonstrating no more than mild background diabetic retinopathyf7
43522 Normal vibratory testing with a 128 Hz tuning forkg normal testing with 10 gram Semmes-
Weinstein monofilamentg and normal orthostatic blood pressureh and pulse testing89
ACOEM Guidance for the Medical Evaluation of Law Enforcement Officers 3
43 ndash DIABETES MELLITUS
ePresence of chronic complications of diabetes in and of themselves may not require the implementation of work restrictions
fNo more than one dot blot or flame-shaped hemorrhages or microaneurysm in all four fundus quadrants
gThe Michigan Diabetes Research and Training Center of the University of Michigan Health System recommends the following guidance
(see wwwmedumichedumdrtcprofsdocumentssviMNSI_howtopdf) for conducting vibratory and monofilament testing8
Vibration Sensation Vibration sensation should be performed with the great toe unsupported Vibration sensation will be tested bi-
laterally using a 128 Hz tuning fork placed over the dorsum of the great toe on the boney prominence of the DIP joint Patients whose
eyes are closed will be asked to indicate when they can no longer sense the vibration from the vibrating tuning fork In general the
examiner should be able to feel vibration from the hand-held tuning fork for 5 seconds longer on his distal forefinger than a normal subject
can at the great toe (eg examiners DIP joint of the first finger versus patients toe) If the examiner feels vibration for 10 or more seconds
on his or her finger then vibration is considered decreased A trial should be given when the tuning fork is not vibrating to be certain that
the patient is responding to vibration and not pressure or some other clue Vibration is scored as 1) present if the examiner senses the
vibration on his or her finger for lt10 seconds 2) reduced if sensed for 10 seconds or 3) absent (no vibration detection)
Monofilament Testing For this examination it is important that the patients foot be supported (ie allow the sole of the foot to rest on
a flat warm surface) The filament should initially be pre-stressed (4-6 perpendicular applications to the dorsum of the examiner s first
finger) The filament is then applied to the dorsum of the great toe midway between the nail fold and the DIP joint Do not hold the toe
directly The filament is applied perpendicularly and briefly (lt1 second) with an even pressure When the filament bends the force of
10 grams has been applied The patient whose eyes are closed is asked to respond yes if heshe feels the filament Eight correct responses
out of 10 applications is considered normal 1 to 7 correct responses indicates reduced sensation and no correct answers translates into
absent sensation
hOrthostatic hypotension is a physical finding defined by the American Autonomic Society and the American Academy of Neurology as a
systolic blood pressure decrease of at least 20 mm Hg or a diastolic blood pressure decrease of at least 10 mm Hg within 3 minutes of
standing
22
43523 Normal cardiac physical exam Cardiac stress testing to at least 12 METS is recommended and
should begin based on either the criteria of the American Heart AssociationAmerican College of
Cardiologyi10 or those of the American Diabetes Associationj11
Diabetics who have a normal cardiac stress test will be retested every one to three years based on
individual clinical assessment This assessment should consider
the age of the individual
the number and persistence of coronary artery disease (CAD) risk factors
the severity of CAD risk factors
43524 Microalbumincreatinine ratio 301 measured or calculatedk creatinine clearance
gt60 mlmin12
436 ndash ONGOING EVALUATION AND REQUIREMENTS
4361 Should have medical records and glucose meter logs reviewed periodically Because of the nature of
diabetes it is important that regular medical follow up be provided to the LEO The frequency and content of
the evaluation should be determined on an individual basis by the police physician in consultation with the
treating physicianl
4362 Must advise police physician of any change in type of medication
4363 Must advise police physician of any episodes of significant hypoglycemia or hyperglycemia
Urine microalbumincreatinine ratio _________________
III Treating Physician Statement
The above named individual meets all of the criteria provided on this form
Yes No ndash not recommended for position
No but IS recommended for position (letter of explanation attached)
It is my opinion that the above named individual is well-educated and well-motivated in diabetes self-management and has
achieved a level of diabetes management to be capable of safe and effective job performance as a law enforcement officer
I have reached this opinion after careful review of the above criteria
___________________________________________________________ ___________________________Signature of Physician Date
______________________________________________________________ ___________________________Printed or Typed Name of Physician Telephone Number
10 ACOEM Guidance for the Medical Evaluation of Law Enforcement Officers
43 ndash DIABETES MELLITUS
29
439 ndash REFERENCES
1 American Diabetes Association Diagnosis and classification of diabetes mellitus Diabetes Care 200427 Suppl
1S5-S10 See httpcarediabetesjournalsorgcgicontentfull27suppl_1s5
2 American Diabetes Association Continuous subcutaneous insulin infusion Diabetes Care 200427 Suppl 1S110
See httpcarediabetesjournalsorgcgicontentfull27suppl_1s110
3 Mensing C Boucher J Cypress M et al National standards for diabetes self-management education Diabetes
Care 200528 Suppl 1S72-9 See httpcarediabetesjournalsorgcgicontentfull28suppl_1s72
4 Goldstein DE Little RR Lorenz RA Malone JI Nathan DM Peterson CM American Diabetes Association Tests
of glycemia in diabetes Diabetes Care 200427 Suppl 1S91-3
See httpcarediabetesjournalsorgcgicontentfull27suppl_1s91
5 The Diabetes Control and Complications Trial Research Group Hypoglycemia in the Diabetes Control and
Complications Trial Diabetes 199746(2)271-86 See wwwncbinlmnihgovpubmed9000705 for abstract
6 American Diabetes Association Hypoglycemia and employmentlicensure Diabetes Care 200528 Suppl 1S61
See httpcarediabetesjournalsorgcgicontentfull28suppl_1s61
7 Viswanath K McGavin DD Diabetic Retinopathy Clinical Findings and Management J Comm Eye Health
200316(46)21-4 See wwwcehjournalorg0953-683316jceh_16_46_021html
8 Michigan Diabetes Research and Training Center University of Michigan Health System How to use the Michigan
Neuropathy Screening Instrument See wwwmedumichedumdrtcprofsdocumentssviMNSI_howtopdf
9 Bradley JG Davis KA Orthostatic hypotension Am Fam Physician 200368(12)2393-8
See wwwaafporgafp200312152393html
10 Gibbons RJ Balady GJ Bricker JT et al ACCAHA 2002 guideline update for exercise testing a report of the
American College of CardiologyAmerican Heart Association Task Force on Practice Guidelines (Committee on
Exercise Testing) J Am Coll Cardiol 200240(8)1531-40
See wwwaccorgqualityandscienceclinicalguidelinesexerciseexercise_cleanpdf
11 American Diabetes Association Standards of medical care in diabetes Diabetes Care 200528 Suppl 1S4-S36
Erratum in Diabetes Care 200528(4)990 See httpcarediabetesjournalsorgcgicontentfull28suppl_1s4
12 Molitch ME DeFronzo RA Franz MJ et al American Diabetes Association Nephropathy in diabetes Diabetes
Care 200427 Suppl 1S79-83 See httpcarediabetesjournalsorgcgicontentfull27suppl_1s79
13 Kitabchi AE Umpierrez GE Murphy MB et al American Diabetes Association Hyperglycemic crises in diabetes
Diabetes Care 200427 Suppl 1S94-102 See httpcarediabetesjournalsorgcgicontentfull27suppl_1s94
14 US Centers for Disease Control and Prevention National Diabetes Fact Sheet 2007
See wwwcdcgovdiabetespubspdfndfs_2007pdf
ACOEM Guidance for the Medical Evaluation of Law Enforcement Officers 11
43 ndash DIABETES MELLITUS
30
ATTACHMENT E
31
Typos A6921(2) 7th line down test should be plural 94201 Paragraph 2 target organ damage is used though end organ damage was defined earlier and in the appendix for that paragraph
A94201 Para A (1) d Id suggest deleting the phrases in brackets Im not sure either are predictably true or politically wise
a) tests for left ventricular hypertrophy Unfortunately use of the EKG to detect left ventricular hypertrophy is very insensitive (eg 5 sensitivity) The echocardiogram is the best test for diagnosing left ventricular hypertrophy but [it is relatively expensive and not readily available in small rural communities ] conducting echocardiograms on asymptomatic fire fighters with Stage 1 hypertension should be reserved only for those with long-standing hypertension
In addition
7761 A resting EKG shall be performed as part of the baseline medical evaluation and shall be obtained periodically thereafter
Changing from annually to periodically is noted has the language in the wellness-fitness initiative been changed as well Our previous decision was that we would support the W-F language since there was no compelling evidence to either support or refute it
Thanks
Sandy
32
NFPA 1582‐ HTN Draft 1
Reason for Revision
1) New classification of BP by the Joint National Commission [Chobanian et al 2002]
2) A high prevalence of FF have either HTN (~20) and Pre‐HTN (~20) [Soteriades et al 2003]
3) Among FF studies have shown a strong association between HTN and a number of adverse
cardiovascular events [Kales et al 2009]
4) A large percentage of on‐duty FF fatalities were found to have left ventricular hypertrophy a
complication of HTN at autopsy
Language in 2007 Edition with draft revisions in Red (Track changes)
611 The medical evaluation of a candidate shall include a medical history examination and any laboratory tests required to detect physical or medical condition(s) that could adversely affect hisher ability to safely perform the essential job tasks outlined in 511 A611 The medical history should include the candidates known health problems such as major illnesses surgeries medication use and allergies Symptom review is also important for detecting early signs of illness A medical history should also include a personal health history a family health history a health habit history an immunization history and a reproductive history
An occupational history should also be obtained to collect information about the persons past occupational and environmental exposures
(a) BP should be measured according to the Joint National Commission (JNC) -7 recommendations BP should be measured with a properly calibrated and validated instrument Patients should be seated quietly for at least 5 minutes in a chair with feet on the floor and arm supported at heart level An appropriate-sized cuff (cuff bladder encircling at least 80 of the arm) should be used to ensure accuracy At least 2 measurements should be made Systolic BP is the point at which the first of 2 or more sounds is heard (phase 1) and diastolic BP is the point before the disappearance of sounds (phase 5) [Chobanian et al 2003]
(2) Head eyes ears nose and throat (HEENT)
Formatted Font (Default) Times New RomanFont color Black
33
692 Vascular System 6921 Category A medical conditions shall include the following
(1) Uncontrolled or poorly controlled hypertension
(2) Hypertension with evidence of end organ damage
or not controlled by approved medications
A6921(1) Uncontrolled or poorly controlled hHypertension increases the risk of a sudden cardiac event This sudden cardiac event would cause sudden incapacitation which that is uncontrolled poorly controlled or requires medication likely to interferes with the safe performance of essential job tasks Uncontrolled or poorly controlled hypertension can be defined as the presence of end organ damage (see below) or stage 2 hypertension (BP systolic gt160 mmHg or BP diastolic gt100 mmHg) is an illness that can lead to functional impairment and potential for sudden incapacitation Individuals with pre- stage 1 or stage 2 hypertension should be referred to their primary care physician for evaluation lifestyle modification and treatment [QUESTION FOR GROUP _- WHAT ABOUT HAVING CANDIDATE RETURN IN ONE MONTH UNDER TREATMENT WITH NORMAL BP]
A6921(2)
Chronic hypertension can damage the eye (retinopathy) the kidneys (nephropathy) the vascular system (stroke transient ischemic attack or peripheral artery disease) or the heart (left ventricular hypertrophy and heart failure) These hypertension complications are known as end organ damage The cardiac and vascular complications are associated with an increased risk of sudden incapacitation and sudden cardiac death (Koren et al 1991) Unfortunately the cardiac complications are frequently asymptomatic and valid screening tests are not fast and are not inexpensive Therefore determining who to screen for cardiac complications (such as echocardiogram for LVH or a measurement of left ventricular ejection fraction for heart failure) should be based on the severity and the duration of HTN
76 Physical Examination The annual physical examination shall include each of the following components
(a) BP shall be measured according to the Joint National Commission (JNC)-7 recommendations
A76(1)(a) BP should be measured with a properly calibrated and validated instrument Patients should be seated quietly for at least 5 minutes in a chair with feet on the floor and arm supported at heart level An appropriate-sized cuff (cuff bladder encircling at least 80 of the arm) should be used to ensure accuracy At least 2 measurements should be made Systolic BP is the point at which the first of 2 or more sounds is heard (phase 1) and diastolic BP is the point before the disappearance of sounds (phase 5) [Chobanian et al 2003]
(2) Head eyes ears nose and throat (HEENT)
34
9420 Uncontrolled Hypertension 94201 Physician Evaluation Severe uncontrolled hypertension [defined as systolic pressure greater than 180 mm Hg diastolic pressure greater than 100 mm Hg or mean systolic blood
pressure ( systolic + diastolic) greater than 120 mm Hg] or malignant hypertension (defined as hypertension with the presence of target organ damage) compromises the members ability to safely perform essential job tasks 1 5 7 9 and 13 and the physician shall report the applicable job limitations to the fire department
Members with Pre-hypertention (systolic 120-139 mmHg or diastolic 80-89 mmHg) Stage 1 hypertension (systolic 140-159 mmHg or diastolic 90-99 mmHg) or Stage 2 hypertension (systolic ge160 mmHg or diastolic ge100 mmHg) should be referred to their primary care physician for evaluation lifestyle modification and treatment
(1) Members with Stage I hypertension should be followed-up not only by their primary care physician but also by the FD physician every 3 to 6 months to ensure their blood pressure is under control and to determine whether screening tests for asymptomatic end organ damage are appropriate
(2) Members with Stage 2 hypertension or with end organ damage (retinopathy nephropathy vascular or cardiac complications) compromises the members ability to safely perform essential job tasks 1 5 7 9 and 130 and the physician shall report the applicable job limitations to the fire department
A94201 Severe uncontrolled hypertension is a significant risk factor for the development of coronary artery disease congestive heart failure and stroke Blood pressure increases as a normal response to exercise This response is further exaggerated by the emotional and physical stress of performing these critical tasks while operating in personal protective clothing at extremes of temperature This normal elevation of blood pressure under these response conditions can lead to life-threatening hypertensive emergencies if a members daily blood pressure is already elevated to high levels In addition hypertension is a progressive illness that when uncontrolled ultimately and inevitably leads to target organ damage Target organs that are sensitive to the effects of elevated blood pressure are the central nervous system vision heart major blood vessels and kidneys
Chronic hypertension can damage the eye (retinopathy) the kidneys (nephropathy) the vascular system (stroke transient ischemic attack or peripheral artery disease) or the heart (left ventricular hypertrophy and heart failure) These hypertension complications are known as end organ damage The cardiac and vascular complications are associated with an increased risk of sudden incapacitation and sudden cardiac death (Koren et al 1991) Fortunately with proper evaluation life style modification and treatment these complications can be avoided Life style modification includes weight reduction DASH eating plan reduction in dietary sodium an increase in aerobic physical activity and moderation in alcohol consumption [Chobanian 2003]
Formatted Font (Default) Times New Roman12 pt Font color Black
Formatted Font (Default) Times New Roman12 pt Font color Black
35
A94201 (1) Members with Stage I hypertension whose BP returns to either pre-hypertenion or normal with lifestyle modification andor treatment can return to an annual medical evaluation For members with long-standing Stage I hypertension whose BP has not been reduced additional evaluation for possible end organ damage should be considered This evaluation could include any or all of the following
a) a compete patient history for symptoms of heart failure (eg shortness of breath upon exertion) or transient ischemic attacks (TIAs)
b) dilated eye examination for retinopathy
c) blood creatinine measurement for nephropathy
d) tests for left ventricular hypertrophy Unfortunately use of the resting EKG to detect left ventricular hypertrophy is very insensitive (eg 5 sensitivity) The echocardiogram is the best test for diagnosing left ventricular hypertrophy
A 94201 (2) Due to the high risk of a sudden cardiovascular event members with Stage 2 hypertension should be restricted until their BP can be brought under control Once the BP is brought under control they should be followed in the same manner as a member with Stage I hypertension
Formatted Font (Default) Times New Roman12 pt
36
D22 Cardiology Gibbons R J GJ Balady J W Beasley et al 1997 ACCAHA guidelines for exercise testing a report of American College of CardiologyAmerican Heart Association Task Force on Practice Guidelines (Committee on Exercise Testing) J Am Coll Cardiol 30260ndash311
Gibbons RJ Balady GJ Bricker JT Chaitman BR Fletcher GF Froelicher VF Mark DB McCallister BD Mooss AN OrsquoReilly MG Winters WL Jr [2002] ACCAHA 2002 guideline update for exercise testing summary article a report of the ACCAHA Task Force on Practice Guidelines (Committee to Update the 1997 Exercise Testing guidelines) J Am Coll Cardiol 401531ndash 40
Chobanian AV Bakris GL Black HR Cushman WC Green LA Izzo JL Jr Jones DW Materson BJ Oparil S Wright JT Jr Roccella EJ the National High Blood Pressure Education Program Coordinating Committee [2003] The seventh report of the Joint National Committee [JNC-7] on Prevention Detection Evaluation and Treatment of High Blood Pressure JAMA 2892560ndash2571
Soteriades ES Kales SN Liarokapis D Christiani DC [2003] Prospective surveillance of hypertension in firefighters J Clin Hypertens 5315-320
Kales SN Tsismenakis AJ Zhang C Soteriades ES [2009] Blood pressure in fire fighters police officers and other emergency responders Am J Hypertens 2211-20
37
NFPA 1582‐ HTN Draft 1
Reason for Revision
1) New classification of BP by the Joint National Commission [Chobanian et al 2002]
2) A high prevalence of FF have either HTN (~20) and Pre‐HTN (~20) [Soteriades et al 2003]
3) Among FF studies have shown a strong association between HTN and a number of adverse
cardiovascular events [Kales et al 2009]
4) A large percentage of on‐duty FF fatalities were found to have left ventricular hypertrophy a
complication of HTN at autopsy
Language in 2007 Edition with draft revisions in Red (Track changes)
611 The medical evaluation of a candidate shall include a medical history examination and any laboratory tests required to detect physical or medical condition(s) that could adversely affect hisher ability to safely perform the essential job tasks outlined in 511 A611 The medical history should include the candidates known health problems such as major illnesses surgeries medication use and allergies Symptom review is also important for detecting early signs of illness A medical history should also include a personal health history a family health history a health habit history an immunization history and a reproductive history
An occupational history should also be obtained to collect information about the persons past occupational and environmental exposures
(a) BP should be measured according to the Joint National Commission (JNC) -7 recommendations BP should be measured with a properly calibrated and validated instrument Patients should be seated quietly for at least 5 minutes in a chair with feet on the floor and arm supported at heart level An appropriate-sized cuff (cuff bladder encircling at least 80 of the arm) should be used to ensure accuracy At least 2 measurements should be made Systolic BP is the point at which the first of 2 or more sounds is heard (phase 1) and diastolic BP is the point before the disappearance of sounds (phase 5) [Chobanian et al 2003]
(2) Head eyes ears nose and throat
38
692 Vascular System 6921 Category A medical conditions shall include the following
(1) Uncontrolled or poorly controlled hypertension
(2) Hypertension with evidence of end organ damage
A6921(1) Uncontrolled or poorly controlled hypertension increases the risk of a sudden cardiac event This sudden cardiac event would cause sudden incapacitation which interferes with the safe performance of essential job tasks Uncontrolled or poorly controlled hypertension can be defined as the presence of end organ damage (see below) or stage 2 hypertension (BP systolic gt160 mmHg or BP diastolic gt100 mmHg) Individuals with pre- stage 1 or stage 2 hypertension should be referred to their primary care physician for evaluation lifestyle modification and treatment [QUESTION FOR GROUP _- WHAT ABOUT HAVING CANDIDATE RETURN IN ONE MONTH UNDER TREATMENT WITH NORMAL BP]
A6921(2)Chronic hypertension can damage the eye (retinopathy) the kidneys (nephropathy) the vascular system (stroke transient ischemic attack or peripheral artery disease) or the heart (left ventricular hypertrophy and heart failure) These hypertension complications are known as end organ damage The cardiac and vascular complications are associated with an increased risk of sudden incapacitation and sudden cardiac death (Koren et al 1991) Unfortunately the cardiac complications are frequently asymptomatic and valid screening tests are not fast and are not inexpensive Therefore determining who to screen for cardiac complications (such as echocardiogram for LVH or a measurement of left ventricular ejection fraction for heart failure) should be based on the severity and the duration of HTN
76 Physical Examination The annual physical examination shall include each of the following components
(a) BP shall be measured according to the Joint National Commission (JNC)-7 recommendations
A76(1)(a) BP should be measured with a properly calibrated and validated instrument Patients should be seated quietly for at least 5 minutes in a chair with feet on the floor and arm supported at heart level An appropriate-sized cuff (cuff bladder encircling at least 80 of the arm) should be used to ensure accuracy At least 2 measurements should be made Systolic BP is the point at which the first of 2 or more sounds is heard (phase 1) and diastolic BP is the point before the disappearance of sounds (phase 5) [Chobanian et al 2003]
(2) Head eyes ears nose and throat9420 Hypertension 94201 Physician Evaluation Members with Pre-hypertention (systolic 120-139 mmHg or diastolic 80-89 mmHg) Stage 1 hypertension (systolic 140-159 mmHg or diastolic 90-99 mmHg) or Stage 2 hypertension (systolic ge160 mmHg or diastolic ge100 mmHg) should be referred to their primary care physician for evaluation lifestyle modification and treatment
39
(1) Members with Stage I hypertension should be followed-up not only by their primary care physician but also by the FD physician every 3 to 6 months to ensure their blood pressure is under control and to determine whether screening tests for asymptomatic end organ damage are appropriate
(2) Members with Stage 2 hypertension or with end organ damage (retinopathy nephropathy vascular or cardiac complications) compromises the members ability to safely perform essential job tasks 1 5 7 9 and 130 and the physician shall report the applicable job limitations to the fire department
A94201 Chronic hypertension can damage the eye (retinopathy) the kidneys (nephropathy) the vascular system (stroke transient ischemic attack or peripheral artery disease) or the heart (left ventricular hypertrophy and heart failure) These hypertension complications are known as end organ damage The cardiac and vascular complications are associated with an increased risk of sudden incapacitation and sudden cardiac death (Koren et al 1991) Fortunately with proper evaluation life style modification and treatment these complications can be avoided Life style modification includes weight reduction DASH eating plan reduction in dietary sodium an increase in aerobic physical activity and moderation in alcohol consumption [Chobanian 2003]
A94201 (1) Members with Stage I hypertension whose BP returns to either pre-hypertenion or normal with lifestyle modification andor treatment can return to an annual medical evaluation For members with long-standing Stage I hypertension whose BP has not been reduced additional evaluation for possible end organ damage should be considered This evaluation could include any or all of the following
a) a compete patient history for symptoms of heart failure (eg shortness of breath upon exertion) or transient ischemic attacks (TIAs)
b) dilated eye examination for retinopathy
c) blood creatinine measurement for nephropathy
d) tests for left ventricular hypertrophy Unfortunately use of the resting EKG to detect left ventricular hypertrophy is very insensitive (eg 5 sensitivity) The echocardiogram is the best test for diagnosing left ventricular hypertrophy
A 94201 (2) Due to the high risk of a sudden cardiovascular event members with Stage 2 hypertension should be restricted until their BP can be brought under control Once the BP is brought under control they should be followed in the same manner as a member with Stage I hypertension
D22 Cardiology
40
Hypertension
Gibbons RJ Balady GJ Bricker JT Chaitman BR Fletcher GF Froelicher VF Mark DB McCallister BD Mooss AN OrsquoReilly MG Winters WL Jr [2002] ACCAHA 2002 guideline update for exercise testing summary article a report of the ACCAHA Task Force on Practice Guidelines (Committee to Update the 1997 Exercise Testing guidelines) J Am Coll Cardiol 401531ndash 40
Chobanian AV Bakris GL Black HR Cushman WC Green LA Izzo JL Jr Jones DW Materson BJ Oparil S Wright JT Jr Roccella EJ the National High Blood Pressure Education Program Coordinating Committee [2003] The seventh report of the Joint National Committee [JNC-7] on Prevention Detection Evaluation and Treatment of High Blood Pressure JAMA 2892560ndash2571
Soteriades ES Kales SN Liarokapis D Christiani DC [2003] Prospective surveillance of hypertension in firefighters J Clin Hypertens 5315-320
Kales SN Tsismenakis AJ Zhang C Soteriades ES [2009] Blood pressure in fire fighters police officers and other emergency responders Am J Hypertens 2211-20
41
NFPA 1582‐ Draft Revisions for CVDHTN
EKG and stress tests
Reason for Revision
1) Change requirement for annual resting EKG to periodically to be more consistent with ACCAHA
recommendation (Schlant et al 1992)
2) Add language to clarify what constitutes a positive ST
3) Make criteria for conducting diagnostic ST in asymptomatic patients consistent with the
ACCAHA
Language in 2007 Edition with draft revisions in Red (Track changes)
776 Electrocardiograms (EKG)) and Stress Tests 7761 A resting EKG shall be performed as part of the baseline medical evaluation and shall be obtained periodically (every 1 to 5 years) annually thereafter
A7761 A baseline resting EKGs shall be conducted Follow-up resting EKGs should be conducted as clinically indicated but at a minimum of every 1 to 5 years The frequency of these follow-up resting EKGs should increase as a members age increases or with increasing number andor severity of coronary heart disease risk factors Members above the age of 40 should have annual resting EKGs (Schlant et al 1992)
7762 The fire department physician or other qualified medical evaluator shall compare EKGs obtained during yearly evaluations with baseline and subsequent EKGs
7763 Stress testing EKG with or without echocardiography or radionuclide scanning shall be performed as clinically indicated by history or symptoms
A7761 Baseline electrocardiography should be conducted (Periodic resting electrocardiograms have not been shown to be useful but can be reasonable as a members agefactors increase)
A7763 No firm guidelines for stress testingelectrocardiography in asymptomatic individuals have been developed Stress testingelectrocardiography as a screening tool is used as part of an evaluation of aerobic capacity during the annual occupational fitness evaluation Submaximal stress testingelectrocardiography testing to 85 percent is commonly used as part of this screening
Submaximal stress electrocardiography testing should not be used for diagnostic purposes Cardiology evaluation with maximal stress testingelectrocardiography together with imaging techniques (eg echocardiography technetium Tc99m sestamibi study andor coronary angiography) is necessary for diagnosticprognostic purposes for the following
42
(1) Fire fighters with positive or questionably positive changes on screening submaximal stress tests
(2) Fire fighters with new onset chest pain or other symptoms suggestive of coronary artery disease (CAD)
(3) Fire fighters with diabetes mellitus who
(a) are gt35 years old or
(b) have type I diabetes for more than 15 years or
(c) have type II diabetes for more than 10 years or
(d) have any other CHD risk factor (see below) or
(e) have the presence of microvascular disease (proliferative retinopathy)
(4) Fire fighters over the age of 45 (for men) and 55 (for women) with onetwo or more risk factors for CAD Risk factors for CAD include hypercholesterolemia (total cholesterol greater than 240 mgdL) hypertension (systolic gt140 mmHg or diastolic gt90 mmHg) smoking or family history of premature CAD (heart attack or sudden cardiac death in a first degree relative less than 60 years of age)
as defined below if stress electrocardiography with imaging is negative then repeat as clinically indicated or at least every 5 years
(5) Fire fighters with a Framingham Risk Score gt10 Risk calculator is available at [httphp2010nhlbihinnetatpiiicalculatorasp]
(6) Fire fighters identified in 9431
Negative stress tests should be repeated as clinically indicated or at least every 2 to 5 years
Interpreting stress tests as ldquopositiverdquo or ldquonegativerdquo is beyond the scope of this document However factors that should be taken into consideration should include the individualrsquos exercise capacity symptoms blood pressure response heart rate response EKG changes and the presence of arrhythmias (Gibbon et al 2002)
Risk factors for CAD include hypercholesterolemia (total cholesterol greater than 240 mgdL) hypertension (systolic greater than 140 andor diastolic greater than 90) smoking diabetes mellitus or family history of premature CAD (heart attack or sudden cardiac death in a first degree relative less than 60 years of age)
There are other non-invasive tests to screen for coronary artery disease One of the most promising appears to be coronary artery calcium (CAD) scoring by computed tomography In 2007 an expert committee published an update to their original guidance document The committeersquos consensus was that ldquoit may be reasonable to consider use of CAC measurement in such patients [between 10 and 20 10-year risk of estimated coronary event]helliprdquo The committee did not recommend CAC measurement in low risk patients [lt10 10-year risk of estimated coronary event] or in high risk patients [gt20 10-year risk of estimate coronary event] (Greenland et al 2007]
43
D22 Cardiology
Chobanian AV Bakris GL Black HR Cushman WC Green LA Izzo JL Jr Jones DW Materson BJ Oparil S Wright JT Jr Roccella EJ the National High Blood Pressure Education Program Coordinating Committee [2003] The seventh report of the Joint National Committee [JNC-7] on Prevention Detection Evaluation and Treatment of High Blood Pressure JAMA 2892560ndash2571
Gibbons RJ Balady GJ Bricker JT Chaitman BR Fletcher GF Froelicher VF Mark DB McCallister BD Mooss AN OrsquoReilly MG Winters WL Jr [2002] ACCAHA 2002 guideline update for exercise testing summary article a report of the ACCAHA Task Force on Practice Guidelines (Committee to Update the 1997 Exercise Testing guidelines) J Am Coll Cardiol 401531ndash 1540
Greenland et al [2007] ACCFAHA 2007 Clinical Expert Consensus Document on Coronary Artery Calcium Scoring By Computed Tomography in Global Cardiovascular Risk Assessment and in Evaluation of Patients With Chest Pain A Report of the American College of Cardiology Foundation Clinical Expert Consensus Task Force (ACCFAHA Writing Committee to Update the 2000 Expert Consensus Document on Electron Beam Computed Tomography) J Am Coll Cardiol 49378-402
Kales SN Tsismenakis AJ Zhang C Soteriades ES [2009] Blood pressure in fire fighters police officers and other emergency responders Am J Hypertens 2211-20
Schlant RC Adolph RJ DiMarco JP Dreifus LS Dunn MI Fisch C Garson A Jr Haywood LJ Levine HJ Murray JA Noble RJ Ronan JA Jr [1992] Guidelines for electrocardiography A report of the American College of CardiologyAmerican Heart Association Task Force on Assessment of Diagnostic and Therapeutic Cardiovascular Procedures (Committee on Electrocardiography) Circulation 85(3)1221-1228
Soteriades ES Kales SN Liarokapis D Christiani DC [2003] Prospective surveillance of hypertension in firefighters J Clin Hypertens 5315-320
Formatted Font Italic
Formatted Line spacing single
Formatted Font Italic
Formatted Font Italic
44
NFPA 1582‐ Draft Revisions for CVDHTN
EKG and stress tests
Reason for Revision
1) Change requirement for annual resting EKG to periodically to be more consistent with ACCAHA
recommendation (Schlant et al 1992)
2) Add language to clarify what constitutes a positive ST
3) Make criteria for conducting diagnostic ST in asymptomatic patients consistent with the
ACCAHA
Language in 2007 Edition with draft revisions in Red (Track changes)
776 Electrocardiograms (EKG) and Stress Tests 7761 A resting EKG shall be performed as part of the baseline medical evaluation and shall be obtained periodically (every 1 to 5 years) thereafter
A7761 A baseline resting EKGs shall be conducted Follow-up resting EKGs should be conducted as clinically indicated but at a minimum of every 1 to 5 years The frequency of these follow-up resting EKGs should increase as a members age increases or with increasing number andor severity of coronary heart disease risk factors Members above the age of 40 should have annual resting EKGs (Schlant et al 1992)
7762 The fire department physician or other qualified medical evaluator shall compare baseline and subsequent EKGs
7763 Stress testing with or without echocardiography or radionuclide scanning shall be performed as clinically indicated by history or symptoms
A7763 No firm guidelines for stress testing in asymptomatic individuals have been developed Stress testing as a screening tool is used as part of an evaluation of aerobic capacity during the annual occupational fitness evaluation Submaximal stress testing testing to 85 percent is commonly used as part of this screening
Submaximal stress testing should not be used for diagnostic purposes Cardiology evaluation with maximal stress testing together with imaging techniques (eg echocardiography technetium Tc99m sestamibi study) is necessary for diagnosticprognostic purposes for the following
(1) Fire fighters with positive or questionably positive changes on screening submaximal stress tests
(2) Fire fighters with new onset chest pain or other symptoms suggestive of coronary artery disease (CAD)
45
(3) Fire fighters with diabetes mellitus who
(a) are gt35 years old or
(b) have type I diabetes for more than 15 years or
(c) have type II diabetes for more than 10 years or
(d) have any other CHD risk factor (see below) or
(e) have the presence of microvascular disease (proliferative retinopathy)
(4) Fire fighters over the age of 45 (for men) and 55 (for women) with one or more risk factors for CAD Risk factors for CAD include hypercholesterolemia (total cholesterol greater than 240 mgdL) hypertension (systolic gt140 mmHg or diastolic gt90 mmHg) smoking or family history of premature CAD (heart attack or sudden cardiac death in a first degree relative less than 60 years of age)
(5) Fire fighters with a Framingham Risk Score gt10 Risk calculator is available at [httphp2010nhlbihinnetatpiiicalculatorasp]
(6) Fire fighters identified in 9431
Negative stress tests should be repeated as clinically indicated or at least every 2 to 5 years
Interpreting stress tests as ldquopositiverdquo or ldquonegativerdquo is beyond the scope of this document However factors that should be taken into consideration should include the individualrsquos exercise capacity symptoms blood pressure response heart rate response EKG changes and the presence of arrhythmias (Gibbon et al 2002)
There are other non-invasive tests to screen for coronary artery disease One of the most promising appears to be coronary artery calcium (CAD) scoring by computed tomography In 2007 an expert committee published an update to their original guidance document The committeersquos consensus was that ldquoit may be reasonable to consider use of CAC measurement in such patients [between 10 and 20 10-year risk of estimated coronary event]helliprdquo The committee did not recommend CAC measurement in low risk patients [lt10 10-year risk of estimated coronary event] or in high risk patients [gt20 10-year risk of estimate coronary event] (Greenland et al 2007]
D22 Cardiology
Resting EKG and Stress Tests
46
Chobanian AV Bakris GL Black HR Cushman WC Green LA Izzo JL Jr Jones DW Materson BJ Oparil S Wright JT Jr Roccella EJ the National High Blood Pressure Education Program Coordinating Committee [2003] The seventh report of the Joint National Committee [JNC-7] on Prevention Detection Evaluation and Treatment of High Blood Pressure JAMA 2892560ndash2571
Gibbons RJ Balady GJ Bricker JT Chaitman BR Fletcher GF Froelicher VF Mark DB McCallister BD Mooss AN OrsquoReilly MG Winters WL Jr [2002] ACCAHA 2002 guideline update for exercise testing summary article a report of the ACCAHA Task Force on Practice Guidelines (Committee to Update the 1997 Exercise Testing guidelines) J Am Coll Cardiol 401531ndash 1540
Greenland et al [2007] ACCFAHA 2007 Clinical Expert Consensus Document on Coronary Artery Calcium Scoring By Computed Tomography in Global Cardiovascular Risk Assessment and in Evaluation of Patients With Chest Pain A Report of the American College of Cardiology Foundation Clinical Expert Consensus Task Force (ACCFAHA Writing Committee to Update the 2000 Expert Consensus Document on Electron Beam Computed Tomography) J Am Coll Cardiol 49378-402
Kales SN Tsismenakis AJ Zhang C Soteriades ES [2009] Blood pressure in fire fighters police officers and other emergency responders Am J Hypertens 2211-20
Schlant RC Adolph RJ DiMarco JP Dreifus LS Dunn MI Fisch C Garson A Jr Haywood LJ Levine HJ Murray JA Noble RJ Ronan JA Jr [1992] Guidelines for electrocardiography A report of the American College of CardiologyAmerican Heart Association Task Force on Assessment of Diagnostic and Therapeutic Cardiovascular Procedures (Committee on Electrocardiography) Circulation 85(3)1221-1228
Soteriades ES Kales SN Liarokapis D Christiani DC [2003] Prospective surveillance of hypertension in firefighters J Clin Hypertens 5315-320
47
ATTACHMENT F
48
1
Current 1582 (2007) language in reference to pregnancy 43 (4) Report to the fire department physician any medical condition that could interfere with the ability of the individual to safely perform essential job tasks such as illness or injury use of prescription or nonprescription drugs and pregnancy 6112 Category B medical conditions shall include the following (1) Pregnancy for its duration A7792 (e) If HIV prophylaxis is to be given the following tests should be done i CBC ii Glucose renal and hepatic chemical function iii Pregnancy test for females B121 Pregnancy and Reproduction Federal regulations as well as many court decisions including the US Supreme Courtrsquos decision in International Union et al v Johnson Controls Inc [499 US 187 111 S Ct 1196 (1991)] have interpreted the requirements of Title VII with respect to pregnancy and reproduction The AHJ should seek the advice of counsel in resolving specific questions concerning these requirements as well as other requirements that can be imposed by state or local laws C211 (4) Review health status with the individual being evaluated Contraindications for evaluations shall be reviewed addressing any changes in the individualrsquos health status since their last medical evaluation that would warrant deferring the evaluation including (g) Pregnancy Recommendations to language enhancement
A female employee who is assigned to regular fire line duty shall report a pregnancy immediately to their respective Supervisor and the fire department physician The employee will then be given the option of a non-hazardous alternative duty position for the duration of her pregnancy (can we say this or is it even appropriate) Any pregnant employee wishing to remain on regular line duty shall be informed of the possible risks and consequences to herself and her fetus that are associated with continued line fire fighting duty Among those risk factors are exposure to teratogens known to have negative effects on the developing fetus such as smoke diesel fumes hazardous chemicals and extreme heat
49
Page 2
appendix It is recommended that the pregnant employee complete a release of liability form signed by herself and her health care provider utilizing NFPArsquos 13 critical tasks as a reference This will inform the health care provider of specific job-related tasks that will need to be performed in order to continue regular line duty These tasks are basic physical standards that any entry level firefighter would have to be able to complete competently The employeersquos health condition will be kept confidential by the department in accordance with HIPAA standards Employees are allowed to remain on active regular duty until they are no longer able to perform their duties in a reasonable manner andor their protective gear no longer fits correctly It is the responsibility of the health care provider to evaluate the pregnant employee If at any time the health care provider feels the pregnant employee can no longer perform the job related tasks this should be reported to the employer by the employee immediately
50
ATTACHMENT G
51
From GLENN BENARICKTo Sawyer SteveSubject RE RE 7743Date Monday August 30 2010 21633 PM
Yes thats my understanding
Glenn P Benarick 211 Winged Elm CircleAiken SC 29803803-644-7093gbenarprodigynet
--- On Mon 83010 Sawyer Steve ltssawyerNFPAorggt wrote
From Sawyer Steve ltssawyerNFPAorggtSubject RE RE 7743To GLENN BENARICK ltgbenarprodigynetgtDate Monday August 30 2010 212 PM
So it should be ldquoorrdquo instead of ldquoandrdquo for now
Steven F Sawyer
Senior Fire Service Specialist
Executive Secretary IFMAFire Service Section
NFPA
1 Batterymarch Park
Quincy MA 02169
6179847423
Fax 6179847056
ssawyernfpaorg
From GLENN BENARICK [mailtogbenarprodigynet] Sent Monday August 30 2010 1202 PMTo Sawyer SteveSubject Fw RE 7743
52
Steve a couple of our docs agree with April Boyer
Glenn P Benarick 211 Winged Elm Circle
Aiken SC 29803
803-644-7093
gbenarprodigynet
--- On Mon 83010 David Prezant ltprezandfdnynycgovgt wrote
From David Prezant ltprezandfdnynycgovgtSubject RE 7743To Thomas R (CDCNIOSHDSHEFS) Hales lttrh1cdcgovgt GLENNBENARICK ltgbenarprodigynetgtCc Sandy Bogucki ltsandyboguckiyaleedugtDate Monday August 30 2010 1004 AM
agree
we should change this to NHANES III rather than Knudson we should alsomodify this to allow not only for predicted cutoffs but all for use of thelower limit of normal cutoff This is important to prevent false-classificationof spirometry as abnormal in older groups and in taller grps The latter ofparticular import to firefighter occupational health surveillance
thanks
David Prezant MDChief Medical Officer Office of Medical AffairsCo-Director WTC Medical Monitoring amp Treatment ProgramsNew York City Fire Department9 Metrotech Center - Rm 4W-1Brooklyn NY 11201Phone 718-999-2696Fax 718-999-0665
Life is full of twists and turns
53
This email may contain confidential information If you are the unintendedrecipient of this email please send it back and delete from your directory
gtgtgt Hales Thomas R (CDCNIOSHDSHEFS) lttrh1cdcgovgt 8302010955 AM gtgtgt
Glen
This seems like a very reasonable comment and illustrates the importance of having clinicians providefeedback on the std Im not familiar with the software program of the various spirometers (NHANES IIIvs KnudsonATS vs both) Given the large role both Dave Prezant and Sandy Bogucki had for thepulmonary section let me forward to them for clarification
Tom
From GLENN BENARICK [mailtogbenarprodigynet] Sent Sunday August 29 2010 456 PMTo Hales Thomas R (CDCNIOSHDSHEFS)Subject FW 7743
Tom is April Boyer correct
Glenn P Benarick 211 Winged Elm Circle
Aiken SC 29803
803-644-7093
gbenarprodigynet
--- On Thu 82610 Sawyer Steve ltssawyerNFPAorggt wrote
From Sawyer Steve ltssawyerNFPAorggtSubject FW 7743To GLENN BENARICK ltgbenarprodigynetgtDate Thursday August 26 2010 925 PM
FYI Do you have any answer She is write
Steven
54
Steven F Sawyer
Senior Fire Service Specialist
Executive Secretary IFMAFire Service Section
NFPA
1 Batterymarch Park
Quincy MA 02169
6179847423
Fax 6179847056
ssawyernfpaorg
From April Boyer [mailtoaboyerbicclinicorg] Sent Thursday August 26 2010 232 PMTo Sawyer SteveCc RobinMWebbmilstateorusSubject 7743
Steven
The spirometry tests cannot be corrected according to both references as the NFPA states because thereferences are contradictory The first part of 7743 states to follow the ATS guidelines and use theKnudsen (we at Basin Immediate Care use the Nhanes III) The second part states to follow the ACOEMguidelines and use the Nhanes III in the occupational setting if available with your unit (which is availableon ours) 7743 does not use the word OR regarding both requirements it uses the word AND whenreferring to the first and second parts thence making 7743 contradictory I realize the NFPA 1582 hasnot been updated since 2007 unless I have just not received an updated version
Our question to you is which part of 7743 do you want us to follow the first or the second part Anyfacility that has an updated computerized spirometry system (as we do) will not be able to follow bothrequired parts for obvious reasons We can either follow the first part of 7743 and use an oldercorrected version of the Knudson by going into our system and changing out of the Nhanes III conversionOR we can follow the second part of 7743 and use the newer corrected version of Nhanes III which ourunit offers too
If you have any questions you may contact me at anytime and I also have many references in regards toboth parts of 7743 if you would like to see them
55
Thank you~
April
Confidentiality NoticeThis message may contain information that isconfidential or privileged
If you are not the intended recipientPlease advise the sender immediately and delete this message
56
ATTACHMENT H
57
NFPA 1582 771(7) Proposed revisions
Why
Preliminary results of two prospective randomized trials on the PSA test were published in 2009 These studies resulted in medical organizations that previously providing guidance to modify their recommendations
Current language
771 Blood Tests Blood tests shall be performed annually and shall include the following
(7) Prostate specific antigen (PSA) after age 40 for positive family history if African American or if otherwise clinically indicated after age 50 for all other male member
Suggested Revision
771 Blood Tests Blood tests shall be performed annually and shall include the following
(7) Prostate specific antigen (PSA) after age 40 for positive family history if African American or if otherwise clinically indicated after age 50 for all other male member
772 Prostate-Specific Antigen (PSA) test At age 50 fire fighters shall have an opportunity to make an informed decision with either the Fire Department physician or their health care provider concerning the PSA test For fire fighters at increased risk of prostate cancer (African-Americans or those with a first degree relative diagnosed with prostate cancer before age 65) shall have the opportunity for this informed decision at age 40
A772 The PSA as a screening test for prostate cancer in asymptomatic men is controversial controversial for two reasons First there is no consensus that PSA screening actually saves lives For example the PSA test may detect small cancers that would never become life threatening Second it is unclear that the benefits of PSA screening outweigh the risks of follow-up diagnostic tests and cancer treatments For example the prostate biopsy used to diagnose prostate cancer may cause bleeding and infection And prostate cancer treatments such as surgery and radiation therapy may cause incontinence (inability to control urine flow) erectile dysfunction (erections inadequate for intercourse) and other complications For these reasons it is important that the benefits and risks of prostate diagnostic procedures and treatment be taken into account when considering the PSA screening test These considerations can be taken account during discussions with the fire department physician or onersquos health care provider
D211 Cancer Screening
Smith R A C J Mettlin K J Davis and H Eyre 2000 ldquoAmerican Cancer Society guidelines for the early detection of cancerrdquo CA J Clin 50(1)34ndash49
Added references
58
Carroll P Albertsen PC Greene K et al [2010] Prostate-specific antigen best practice statement 2009 update Am Urological Assoc Available at httpwwwauanetorgcontentguidelines-and-quality-careclinical-guidelinesmain-reportspsa09pdf Date accessed September 2010
Ferrini R Woolf SH [2009] Screening for prostate cancer in American men American College of Preventive Medicine Practice Policy Statement Available at httpwwwacpmorgprostatehtm Date accessed September 2010
National Cancer Institute [2009] Prostate-specific antigen test National Cancer Institute Fact Sheet Available at httpwwwcancergovcancertopicsfactsheetDetectionPSA Date accessed September 2010
Wolf AMD Wender RC Etzioni RB et al [2010] American Cancer Society guideline for the early detection of prostate cancer Update 2010 Available at httpcaonlineamcancersocorgcgicontentfullcaac20066v1 Date accessed September 2010
59
ATTACHMENT C
15
2012 ANNUAL REVISION CYCLE
PROCESS STAGE PROCESS STEP DATES
FOR TC DATES
FOR TCC 1 PRELIMINARY 10 Notification of intent to enter cycle 7910 7910
2 REPORT ON
PROPOSALS (ROP)
21 Proposal closing date 112310 112310 22 Final date for ROP meeting 22511 2411 23 Final date for mailing TC ballots 31811 21811 24 Receipt of (TC) ballots by staff liaison 42211 31111 25 Receipt of TC recirculation ballots 5611 31811 26 Final date for TCC meeting 41511 27 Final date for mailing TCC ballots 42211 28 Receipt of TCC ballots 51311 29 Receipt of TCC recirculation ballots 52011 210 Final copy (w ballot statements) to Secretary Standards Council 51311 52711 211 Completion of Reports 52011 6311 212 ROP Published and Posted 62411 62411
3 REPORT ON
COMMENTS
(ROC)
31 Comment closing date 83011 83011 32 Final date for ROC meeting 11411 10711 33 Final date for mailing TC ballots 111811 102111 34 Receipt of (TC) ballots by staff liaison 12211 111111 35 Receipt of TC recirculation ballots 12911 111811 36 Final date for TCC meeting 121611 37 Final date for mailing TCC ballots 122311 38 Receipt of TCC ballots 11312 39 Receipt of TCC recirculation ballots 12012 310 Final copy (w ballot statements) to Secretary Standards Council 122311 12712 311 Completion of Reports 11312 2312 312 ROC Published and Posted 22412 22412
4 TECH SESSION
PREPARATION amp
ISSUANCE OF
CONSENT
DOCUMENTS
41 Notice of Intent to Make a Motion (NITMAM) Closing Date 4612 4612 42 Posting of Filed NITMAM 5412 5412
43 Council Issuance Date for Consent Documents 52912 52912
44 Appeal Closing Date for Consent Documents 61312 61312
5 TECHNICAL
SESSION 50 Association Meeting for Documents with Certified Amending Motions
64-712 64-712
6
APPEALS amp
ISSUANCE OF
DOCUMENTS
WCAMS
61 Appeal closing date for Documents with Certified Amending Motions
62712 62712
62 Council issuance for Documents with Certified Amending Motions 8912 8912
Proposal Closing Dates may vary according to documents and schedules for Revision Cycles may change Please check the NFPA website (wwwnfpaorg) for the most up-to-date information on proposal closing dates and schedules
16
ATTACHMENT D
17
This weekrsquos conference call mentioned the Diabetes chapter written for the ACOEM document Guidance for the Medical Evaluation of the Law Enforcement Officer The task group working on this chapter (led Richard Miller of the Secret Service and our very own Dan Samo) worked with the ADA or over 2-3 years to come up with a consensus document
Please find the Chapter attached ltltDiabetes Guidance Sept 2010pdfgtgt
Regarding Dan Loeberrsquos points
1) Physical Evaluation Form - We could modify the LEO form (see end of the attached Chapter)
2) Duration required for stable regiment
1582 for IDDM Type 1 1 yr
Type 2 6 m
Oral Agents None specifically
ACOEM Police for IDDM Type 1 6m
Type 2 3m
Oral Agents 1m
The police document is much clearer about the decision regarding medical fitness for duty is the responsibility of the police physician with the treating diabetes-expert physician providing the data to the police physician to make an informed decision In this regard the police officer must provide the police physician with downloaded self monitoring glucose data for the 1 3 and 6 month time periods (see section 433)
3) HA1C ndash NFPA lt 8 over 3 month period
ACOEM Police ndash (Section 4333) Specifies the frequency on measurement and if gt8 requires further evaluation
Some other discrepancies End organ complications
NFPA ndash end organ complications (eye kidney heart neuro) ndash restriction
ACOEM Police ndash end organ complication -- requires further evaluation
18
Hypoglycemia (incapacitating ndash defined differently between the two documents (434)
NFPA ndash 0 episodes in past year le1 in past 5 yrs
ACOEM Police ndash 0 episodes in past year le2 in past 3 yrs
Given Dan Samorsquos and Richard Millerrsquos work with the ADALoeber it would be helpful to get their opinions on whether any of the changes requested by Loeber are appropriate for FF with DM
Tom
Thomas Hales MD MPH
Senior Medical Epidemiologist
NIOSH CDC
4676 Columbia Pkwy R-9
Cincinnati OH 45241
(513) 841-4583
trh1cdcgov
19
43 ndash DIABETES MELLITUS
431 ndash INTRODUCTION
The educated and motivated law enforcement officer (LEO) with well-managed diabetes mellitus can be capable of
safe and effective job performance1 However diabetes mellitus may place LEOs at risk for sudden incapacitation
thus jeopardizing their ability to perform critical job functions (These job functions include those listed in Sections
32 333 351 352 36 and 37 and discussed in Appendix A)
Therefore an individualized assessment of the LEOrsquos diabetes should be performed using the following evaluative
criteria to determine whether the individuals condition permits safe and effective job performance Such evaluation
must include the following key elements which are discussed in detail below
history of blood glucose control
knowledge of diabetes and its management
current stability of blood glucose
risk for significant hypoglycemia or hyperglycemia and
presence of diabetic complications
432 ndash OVERVIEW OF MEDICAL EVALUATION
The treating endocrinologist or other physician knowledgeable regarding diabetes management should provide
a narrative report certifying whether the LEO has or has not met the criteria set out in Sections 4321 through
4354 below In addition the physician should include supporting data (see Appendix B for the Physician Evalu-
ation Form)
4321 The LEO is under the care of an endocrinologist or other physician knowledgeable regarding diabetes
management Outpatient and in-patient medical record(s) for the last 3 years or since date of diagnosis
(whichever is shorter) should be reviewed by the treating physician and provided to the police physician
4322 If the LEO has type 1 diabetes the individual has been on a basalbolus regimena or an insulin pump
using analogue insulins for the 6 months prior to evaluation2
4323 If the LEO has type 2 diabetes on insulin the individual has been on a stable medication regimenb
for the 3 months prior to evaluation3 If on oral agents alone the LEO has been on a stable medication regimen
for the month prior to evaluationc
ACOEM Guidance for the Medical Evaluation of Law Enforcement Officers 1
43 ndash DIABETES MELLITUS
aA basalbolus insulin regimen consists of the use of a basal insulin (Glargine NPH) in a once or twice daily regimen to provide between-
meal insulin combined with the use of a short acting insulin (Regular Lispro Aspart or Glulisine) at mealtimes Insulin pumps are small
(beeper sized) battery powered devices that deliver small amounts of short-acting insulin in a constant infusion to meet basal insulin
requirements The wearer selects an additional mealtime bolus to be infused at the time of meals For more information on pumps visit
the manufacturerrsquos web sites ndash wwwMinimedcom wwwcozmorecom wwwanimascorpcom wwwdisetroniccom
bA stable insulin regimen is defined as maintaining the same types of insulin (long acting intermediate acting short or rapid acting)
Changes in insulin dose are part of the appropriate self-management of diabetes and do not disqualify an applicant or incumbent under
this section
cChanges in dose within the evaluation period will be allowed but addition of a new class of medications or insulin should result in a new
period of observation
one month for addition of a sulfonylurea or metformin
two months for the addition of a thiazolidinedione to insulin or a sulfonylurea or
three months for the addition of insulin
20
4324 If the LEO uses an insulin pump documentation is needed as follows
proper understanding and education in the use of the insulin pump
start date for the use of the pump
history of insulin site infectionsd
history of pump cessation and pump malfunction
backup plan for pump malfunction including use of injectable insulin and
frequency of infusion set changes
4325 The LEO has been educated in diabetes and its management and thoroughly informed of and under-
stands the procedures that must be followed to monitor and manage hisher diabetes and what procedures
should be followed if complications arise3
433 ndash QUANTITATIVE GLUCOSE MONITORING
4331 The LEO has documentation of ongoing self-monitoring of blood glucose
4332 This must be done with a glucose meter that stores every reading records date and time of reading
and from which data can be downloaded (Most meters now have this capability)
4333 Monitoring logs must be available covering the time period (1 3 or 6 months) as described in
Sections 4322 and 4323 The frequency of glucose monitoring must follow a schedule acceptable to the
police physician in consultation with the treating physician
Testing schedules are individual What follows is a common pattern but individual patterns may differ
2 ACOEM Guidance for the Medical Evaluation of Law Enforcement Officers
43 ndash DIABETES MELLITUS
dIndividual has not had more than one pump-site infection that caused him or her to miss work or usual daily activities in the preceding 6
months
THERAPEUTIC REGIMEN GLUCOSE TESTING SCHEDULE
Diet alone Once or twice a week
Metformin Thiazolidinediones or Alpha
Glucosidase inhibitors alone or in
combination
Once or twice a week
Sulfonylureas meglitanides nateglinide ndash
alone or in combination with the above group
Twice a day ndash AM and at supper with any
suspected hypoglycemic episodes
Insulin ndash one shot in combination with orals Twice a day ndash AM and at supper with any
suspected hypoglycemic episodes
2 to 3 times AM once a week
Insulin ndash two or more shots Insulin pump 3 to 4 times a day ndash at meals and bedtime
2 to 3 times AM once a week with any
suspected hypoglycemic episodes
21
4334 The LEO has had hemoglobin A1C measured at least 4 times a year (intervals of 2 to 3 months) over
the last 12 months prior to evaluation if diagnosis has been present for more than a year4 If hemoglobin A1C is
gt8 this may signal a problem with the LEOrsquos diabetes management that warrants further assessment5
434 ndash INCAPACITATING EVENTS
4341 The LEO has not had any incapacitating episodes within the past 1 year and no more than 2 episodes
in the past 3 years or since diagnosis of diabetes (whichever is shorter) of
43411 Severe hypoglycemia (loss of consciousness seizures or coma requiring assistance of others or
needing urgent treatment [glucagon injectionIV glucose]) or
43412 Blood sugar lt60 mgdl with unawareness demonstrated in current glucose logs6
435 ndash CHRONIC COMPLICATION SCREENING
4351 Chronic complications of diabetes are associated with increased risk for severe hypoglycemic
episodes and warrant further assessmente
4352 The components of screening for chronic complications are
43521 A complete eye exam by a qualified ophthalmologist or optometrist including a dilated retinal
exam demonstrating no more than mild background diabetic retinopathyf7
43522 Normal vibratory testing with a 128 Hz tuning forkg normal testing with 10 gram Semmes-
Weinstein monofilamentg and normal orthostatic blood pressureh and pulse testing89
ACOEM Guidance for the Medical Evaluation of Law Enforcement Officers 3
43 ndash DIABETES MELLITUS
ePresence of chronic complications of diabetes in and of themselves may not require the implementation of work restrictions
fNo more than one dot blot or flame-shaped hemorrhages or microaneurysm in all four fundus quadrants
gThe Michigan Diabetes Research and Training Center of the University of Michigan Health System recommends the following guidance
(see wwwmedumichedumdrtcprofsdocumentssviMNSI_howtopdf) for conducting vibratory and monofilament testing8
Vibration Sensation Vibration sensation should be performed with the great toe unsupported Vibration sensation will be tested bi-
laterally using a 128 Hz tuning fork placed over the dorsum of the great toe on the boney prominence of the DIP joint Patients whose
eyes are closed will be asked to indicate when they can no longer sense the vibration from the vibrating tuning fork In general the
examiner should be able to feel vibration from the hand-held tuning fork for 5 seconds longer on his distal forefinger than a normal subject
can at the great toe (eg examiners DIP joint of the first finger versus patients toe) If the examiner feels vibration for 10 or more seconds
on his or her finger then vibration is considered decreased A trial should be given when the tuning fork is not vibrating to be certain that
the patient is responding to vibration and not pressure or some other clue Vibration is scored as 1) present if the examiner senses the
vibration on his or her finger for lt10 seconds 2) reduced if sensed for 10 seconds or 3) absent (no vibration detection)
Monofilament Testing For this examination it is important that the patients foot be supported (ie allow the sole of the foot to rest on
a flat warm surface) The filament should initially be pre-stressed (4-6 perpendicular applications to the dorsum of the examiner s first
finger) The filament is then applied to the dorsum of the great toe midway between the nail fold and the DIP joint Do not hold the toe
directly The filament is applied perpendicularly and briefly (lt1 second) with an even pressure When the filament bends the force of
10 grams has been applied The patient whose eyes are closed is asked to respond yes if heshe feels the filament Eight correct responses
out of 10 applications is considered normal 1 to 7 correct responses indicates reduced sensation and no correct answers translates into
absent sensation
hOrthostatic hypotension is a physical finding defined by the American Autonomic Society and the American Academy of Neurology as a
systolic blood pressure decrease of at least 20 mm Hg or a diastolic blood pressure decrease of at least 10 mm Hg within 3 minutes of
standing
22
43523 Normal cardiac physical exam Cardiac stress testing to at least 12 METS is recommended and
should begin based on either the criteria of the American Heart AssociationAmerican College of
Cardiologyi10 or those of the American Diabetes Associationj11
Diabetics who have a normal cardiac stress test will be retested every one to three years based on
individual clinical assessment This assessment should consider
the age of the individual
the number and persistence of coronary artery disease (CAD) risk factors
the severity of CAD risk factors
43524 Microalbumincreatinine ratio 301 measured or calculatedk creatinine clearance
gt60 mlmin12
436 ndash ONGOING EVALUATION AND REQUIREMENTS
4361 Should have medical records and glucose meter logs reviewed periodically Because of the nature of
diabetes it is important that regular medical follow up be provided to the LEO The frequency and content of
the evaluation should be determined on an individual basis by the police physician in consultation with the
treating physicianl
4362 Must advise police physician of any change in type of medication
4363 Must advise police physician of any episodes of significant hypoglycemia or hyperglycemia
Urine microalbumincreatinine ratio _________________
III Treating Physician Statement
The above named individual meets all of the criteria provided on this form
Yes No ndash not recommended for position
No but IS recommended for position (letter of explanation attached)
It is my opinion that the above named individual is well-educated and well-motivated in diabetes self-management and has
achieved a level of diabetes management to be capable of safe and effective job performance as a law enforcement officer
I have reached this opinion after careful review of the above criteria
___________________________________________________________ ___________________________Signature of Physician Date
______________________________________________________________ ___________________________Printed or Typed Name of Physician Telephone Number
10 ACOEM Guidance for the Medical Evaluation of Law Enforcement Officers
43 ndash DIABETES MELLITUS
29
439 ndash REFERENCES
1 American Diabetes Association Diagnosis and classification of diabetes mellitus Diabetes Care 200427 Suppl
1S5-S10 See httpcarediabetesjournalsorgcgicontentfull27suppl_1s5
2 American Diabetes Association Continuous subcutaneous insulin infusion Diabetes Care 200427 Suppl 1S110
See httpcarediabetesjournalsorgcgicontentfull27suppl_1s110
3 Mensing C Boucher J Cypress M et al National standards for diabetes self-management education Diabetes
Care 200528 Suppl 1S72-9 See httpcarediabetesjournalsorgcgicontentfull28suppl_1s72
4 Goldstein DE Little RR Lorenz RA Malone JI Nathan DM Peterson CM American Diabetes Association Tests
of glycemia in diabetes Diabetes Care 200427 Suppl 1S91-3
See httpcarediabetesjournalsorgcgicontentfull27suppl_1s91
5 The Diabetes Control and Complications Trial Research Group Hypoglycemia in the Diabetes Control and
Complications Trial Diabetes 199746(2)271-86 See wwwncbinlmnihgovpubmed9000705 for abstract
6 American Diabetes Association Hypoglycemia and employmentlicensure Diabetes Care 200528 Suppl 1S61
See httpcarediabetesjournalsorgcgicontentfull28suppl_1s61
7 Viswanath K McGavin DD Diabetic Retinopathy Clinical Findings and Management J Comm Eye Health
200316(46)21-4 See wwwcehjournalorg0953-683316jceh_16_46_021html
8 Michigan Diabetes Research and Training Center University of Michigan Health System How to use the Michigan
Neuropathy Screening Instrument See wwwmedumichedumdrtcprofsdocumentssviMNSI_howtopdf
9 Bradley JG Davis KA Orthostatic hypotension Am Fam Physician 200368(12)2393-8
See wwwaafporgafp200312152393html
10 Gibbons RJ Balady GJ Bricker JT et al ACCAHA 2002 guideline update for exercise testing a report of the
American College of CardiologyAmerican Heart Association Task Force on Practice Guidelines (Committee on
Exercise Testing) J Am Coll Cardiol 200240(8)1531-40
See wwwaccorgqualityandscienceclinicalguidelinesexerciseexercise_cleanpdf
11 American Diabetes Association Standards of medical care in diabetes Diabetes Care 200528 Suppl 1S4-S36
Erratum in Diabetes Care 200528(4)990 See httpcarediabetesjournalsorgcgicontentfull28suppl_1s4
12 Molitch ME DeFronzo RA Franz MJ et al American Diabetes Association Nephropathy in diabetes Diabetes
Care 200427 Suppl 1S79-83 See httpcarediabetesjournalsorgcgicontentfull27suppl_1s79
13 Kitabchi AE Umpierrez GE Murphy MB et al American Diabetes Association Hyperglycemic crises in diabetes
Diabetes Care 200427 Suppl 1S94-102 See httpcarediabetesjournalsorgcgicontentfull27suppl_1s94
14 US Centers for Disease Control and Prevention National Diabetes Fact Sheet 2007
See wwwcdcgovdiabetespubspdfndfs_2007pdf
ACOEM Guidance for the Medical Evaluation of Law Enforcement Officers 11
43 ndash DIABETES MELLITUS
30
ATTACHMENT E
31
Typos A6921(2) 7th line down test should be plural 94201 Paragraph 2 target organ damage is used though end organ damage was defined earlier and in the appendix for that paragraph
A94201 Para A (1) d Id suggest deleting the phrases in brackets Im not sure either are predictably true or politically wise
a) tests for left ventricular hypertrophy Unfortunately use of the EKG to detect left ventricular hypertrophy is very insensitive (eg 5 sensitivity) The echocardiogram is the best test for diagnosing left ventricular hypertrophy but [it is relatively expensive and not readily available in small rural communities ] conducting echocardiograms on asymptomatic fire fighters with Stage 1 hypertension should be reserved only for those with long-standing hypertension
In addition
7761 A resting EKG shall be performed as part of the baseline medical evaluation and shall be obtained periodically thereafter
Changing from annually to periodically is noted has the language in the wellness-fitness initiative been changed as well Our previous decision was that we would support the W-F language since there was no compelling evidence to either support or refute it
Thanks
Sandy
32
NFPA 1582‐ HTN Draft 1
Reason for Revision
1) New classification of BP by the Joint National Commission [Chobanian et al 2002]
2) A high prevalence of FF have either HTN (~20) and Pre‐HTN (~20) [Soteriades et al 2003]
3) Among FF studies have shown a strong association between HTN and a number of adverse
cardiovascular events [Kales et al 2009]
4) A large percentage of on‐duty FF fatalities were found to have left ventricular hypertrophy a
complication of HTN at autopsy
Language in 2007 Edition with draft revisions in Red (Track changes)
611 The medical evaluation of a candidate shall include a medical history examination and any laboratory tests required to detect physical or medical condition(s) that could adversely affect hisher ability to safely perform the essential job tasks outlined in 511 A611 The medical history should include the candidates known health problems such as major illnesses surgeries medication use and allergies Symptom review is also important for detecting early signs of illness A medical history should also include a personal health history a family health history a health habit history an immunization history and a reproductive history
An occupational history should also be obtained to collect information about the persons past occupational and environmental exposures
(a) BP should be measured according to the Joint National Commission (JNC) -7 recommendations BP should be measured with a properly calibrated and validated instrument Patients should be seated quietly for at least 5 minutes in a chair with feet on the floor and arm supported at heart level An appropriate-sized cuff (cuff bladder encircling at least 80 of the arm) should be used to ensure accuracy At least 2 measurements should be made Systolic BP is the point at which the first of 2 or more sounds is heard (phase 1) and diastolic BP is the point before the disappearance of sounds (phase 5) [Chobanian et al 2003]
(2) Head eyes ears nose and throat (HEENT)
Formatted Font (Default) Times New RomanFont color Black
33
692 Vascular System 6921 Category A medical conditions shall include the following
(1) Uncontrolled or poorly controlled hypertension
(2) Hypertension with evidence of end organ damage
or not controlled by approved medications
A6921(1) Uncontrolled or poorly controlled hHypertension increases the risk of a sudden cardiac event This sudden cardiac event would cause sudden incapacitation which that is uncontrolled poorly controlled or requires medication likely to interferes with the safe performance of essential job tasks Uncontrolled or poorly controlled hypertension can be defined as the presence of end organ damage (see below) or stage 2 hypertension (BP systolic gt160 mmHg or BP diastolic gt100 mmHg) is an illness that can lead to functional impairment and potential for sudden incapacitation Individuals with pre- stage 1 or stage 2 hypertension should be referred to their primary care physician for evaluation lifestyle modification and treatment [QUESTION FOR GROUP _- WHAT ABOUT HAVING CANDIDATE RETURN IN ONE MONTH UNDER TREATMENT WITH NORMAL BP]
A6921(2)
Chronic hypertension can damage the eye (retinopathy) the kidneys (nephropathy) the vascular system (stroke transient ischemic attack or peripheral artery disease) or the heart (left ventricular hypertrophy and heart failure) These hypertension complications are known as end organ damage The cardiac and vascular complications are associated with an increased risk of sudden incapacitation and sudden cardiac death (Koren et al 1991) Unfortunately the cardiac complications are frequently asymptomatic and valid screening tests are not fast and are not inexpensive Therefore determining who to screen for cardiac complications (such as echocardiogram for LVH or a measurement of left ventricular ejection fraction for heart failure) should be based on the severity and the duration of HTN
76 Physical Examination The annual physical examination shall include each of the following components
(a) BP shall be measured according to the Joint National Commission (JNC)-7 recommendations
A76(1)(a) BP should be measured with a properly calibrated and validated instrument Patients should be seated quietly for at least 5 minutes in a chair with feet on the floor and arm supported at heart level An appropriate-sized cuff (cuff bladder encircling at least 80 of the arm) should be used to ensure accuracy At least 2 measurements should be made Systolic BP is the point at which the first of 2 or more sounds is heard (phase 1) and diastolic BP is the point before the disappearance of sounds (phase 5) [Chobanian et al 2003]
(2) Head eyes ears nose and throat (HEENT)
34
9420 Uncontrolled Hypertension 94201 Physician Evaluation Severe uncontrolled hypertension [defined as systolic pressure greater than 180 mm Hg diastolic pressure greater than 100 mm Hg or mean systolic blood
pressure ( systolic + diastolic) greater than 120 mm Hg] or malignant hypertension (defined as hypertension with the presence of target organ damage) compromises the members ability to safely perform essential job tasks 1 5 7 9 and 13 and the physician shall report the applicable job limitations to the fire department
Members with Pre-hypertention (systolic 120-139 mmHg or diastolic 80-89 mmHg) Stage 1 hypertension (systolic 140-159 mmHg or diastolic 90-99 mmHg) or Stage 2 hypertension (systolic ge160 mmHg or diastolic ge100 mmHg) should be referred to their primary care physician for evaluation lifestyle modification and treatment
(1) Members with Stage I hypertension should be followed-up not only by their primary care physician but also by the FD physician every 3 to 6 months to ensure their blood pressure is under control and to determine whether screening tests for asymptomatic end organ damage are appropriate
(2) Members with Stage 2 hypertension or with end organ damage (retinopathy nephropathy vascular or cardiac complications) compromises the members ability to safely perform essential job tasks 1 5 7 9 and 130 and the physician shall report the applicable job limitations to the fire department
A94201 Severe uncontrolled hypertension is a significant risk factor for the development of coronary artery disease congestive heart failure and stroke Blood pressure increases as a normal response to exercise This response is further exaggerated by the emotional and physical stress of performing these critical tasks while operating in personal protective clothing at extremes of temperature This normal elevation of blood pressure under these response conditions can lead to life-threatening hypertensive emergencies if a members daily blood pressure is already elevated to high levels In addition hypertension is a progressive illness that when uncontrolled ultimately and inevitably leads to target organ damage Target organs that are sensitive to the effects of elevated blood pressure are the central nervous system vision heart major blood vessels and kidneys
Chronic hypertension can damage the eye (retinopathy) the kidneys (nephropathy) the vascular system (stroke transient ischemic attack or peripheral artery disease) or the heart (left ventricular hypertrophy and heart failure) These hypertension complications are known as end organ damage The cardiac and vascular complications are associated with an increased risk of sudden incapacitation and sudden cardiac death (Koren et al 1991) Fortunately with proper evaluation life style modification and treatment these complications can be avoided Life style modification includes weight reduction DASH eating plan reduction in dietary sodium an increase in aerobic physical activity and moderation in alcohol consumption [Chobanian 2003]
Formatted Font (Default) Times New Roman12 pt Font color Black
Formatted Font (Default) Times New Roman12 pt Font color Black
35
A94201 (1) Members with Stage I hypertension whose BP returns to either pre-hypertenion or normal with lifestyle modification andor treatment can return to an annual medical evaluation For members with long-standing Stage I hypertension whose BP has not been reduced additional evaluation for possible end organ damage should be considered This evaluation could include any or all of the following
a) a compete patient history for symptoms of heart failure (eg shortness of breath upon exertion) or transient ischemic attacks (TIAs)
b) dilated eye examination for retinopathy
c) blood creatinine measurement for nephropathy
d) tests for left ventricular hypertrophy Unfortunately use of the resting EKG to detect left ventricular hypertrophy is very insensitive (eg 5 sensitivity) The echocardiogram is the best test for diagnosing left ventricular hypertrophy
A 94201 (2) Due to the high risk of a sudden cardiovascular event members with Stage 2 hypertension should be restricted until their BP can be brought under control Once the BP is brought under control they should be followed in the same manner as a member with Stage I hypertension
Formatted Font (Default) Times New Roman12 pt
36
D22 Cardiology Gibbons R J GJ Balady J W Beasley et al 1997 ACCAHA guidelines for exercise testing a report of American College of CardiologyAmerican Heart Association Task Force on Practice Guidelines (Committee on Exercise Testing) J Am Coll Cardiol 30260ndash311
Gibbons RJ Balady GJ Bricker JT Chaitman BR Fletcher GF Froelicher VF Mark DB McCallister BD Mooss AN OrsquoReilly MG Winters WL Jr [2002] ACCAHA 2002 guideline update for exercise testing summary article a report of the ACCAHA Task Force on Practice Guidelines (Committee to Update the 1997 Exercise Testing guidelines) J Am Coll Cardiol 401531ndash 40
Chobanian AV Bakris GL Black HR Cushman WC Green LA Izzo JL Jr Jones DW Materson BJ Oparil S Wright JT Jr Roccella EJ the National High Blood Pressure Education Program Coordinating Committee [2003] The seventh report of the Joint National Committee [JNC-7] on Prevention Detection Evaluation and Treatment of High Blood Pressure JAMA 2892560ndash2571
Soteriades ES Kales SN Liarokapis D Christiani DC [2003] Prospective surveillance of hypertension in firefighters J Clin Hypertens 5315-320
Kales SN Tsismenakis AJ Zhang C Soteriades ES [2009] Blood pressure in fire fighters police officers and other emergency responders Am J Hypertens 2211-20
37
NFPA 1582‐ HTN Draft 1
Reason for Revision
1) New classification of BP by the Joint National Commission [Chobanian et al 2002]
2) A high prevalence of FF have either HTN (~20) and Pre‐HTN (~20) [Soteriades et al 2003]
3) Among FF studies have shown a strong association between HTN and a number of adverse
cardiovascular events [Kales et al 2009]
4) A large percentage of on‐duty FF fatalities were found to have left ventricular hypertrophy a
complication of HTN at autopsy
Language in 2007 Edition with draft revisions in Red (Track changes)
611 The medical evaluation of a candidate shall include a medical history examination and any laboratory tests required to detect physical or medical condition(s) that could adversely affect hisher ability to safely perform the essential job tasks outlined in 511 A611 The medical history should include the candidates known health problems such as major illnesses surgeries medication use and allergies Symptom review is also important for detecting early signs of illness A medical history should also include a personal health history a family health history a health habit history an immunization history and a reproductive history
An occupational history should also be obtained to collect information about the persons past occupational and environmental exposures
(a) BP should be measured according to the Joint National Commission (JNC) -7 recommendations BP should be measured with a properly calibrated and validated instrument Patients should be seated quietly for at least 5 minutes in a chair with feet on the floor and arm supported at heart level An appropriate-sized cuff (cuff bladder encircling at least 80 of the arm) should be used to ensure accuracy At least 2 measurements should be made Systolic BP is the point at which the first of 2 or more sounds is heard (phase 1) and diastolic BP is the point before the disappearance of sounds (phase 5) [Chobanian et al 2003]
(2) Head eyes ears nose and throat
38
692 Vascular System 6921 Category A medical conditions shall include the following
(1) Uncontrolled or poorly controlled hypertension
(2) Hypertension with evidence of end organ damage
A6921(1) Uncontrolled or poorly controlled hypertension increases the risk of a sudden cardiac event This sudden cardiac event would cause sudden incapacitation which interferes with the safe performance of essential job tasks Uncontrolled or poorly controlled hypertension can be defined as the presence of end organ damage (see below) or stage 2 hypertension (BP systolic gt160 mmHg or BP diastolic gt100 mmHg) Individuals with pre- stage 1 or stage 2 hypertension should be referred to their primary care physician for evaluation lifestyle modification and treatment [QUESTION FOR GROUP _- WHAT ABOUT HAVING CANDIDATE RETURN IN ONE MONTH UNDER TREATMENT WITH NORMAL BP]
A6921(2)Chronic hypertension can damage the eye (retinopathy) the kidneys (nephropathy) the vascular system (stroke transient ischemic attack or peripheral artery disease) or the heart (left ventricular hypertrophy and heart failure) These hypertension complications are known as end organ damage The cardiac and vascular complications are associated with an increased risk of sudden incapacitation and sudden cardiac death (Koren et al 1991) Unfortunately the cardiac complications are frequently asymptomatic and valid screening tests are not fast and are not inexpensive Therefore determining who to screen for cardiac complications (such as echocardiogram for LVH or a measurement of left ventricular ejection fraction for heart failure) should be based on the severity and the duration of HTN
76 Physical Examination The annual physical examination shall include each of the following components
(a) BP shall be measured according to the Joint National Commission (JNC)-7 recommendations
A76(1)(a) BP should be measured with a properly calibrated and validated instrument Patients should be seated quietly for at least 5 minutes in a chair with feet on the floor and arm supported at heart level An appropriate-sized cuff (cuff bladder encircling at least 80 of the arm) should be used to ensure accuracy At least 2 measurements should be made Systolic BP is the point at which the first of 2 or more sounds is heard (phase 1) and diastolic BP is the point before the disappearance of sounds (phase 5) [Chobanian et al 2003]
(2) Head eyes ears nose and throat9420 Hypertension 94201 Physician Evaluation Members with Pre-hypertention (systolic 120-139 mmHg or diastolic 80-89 mmHg) Stage 1 hypertension (systolic 140-159 mmHg or diastolic 90-99 mmHg) or Stage 2 hypertension (systolic ge160 mmHg or diastolic ge100 mmHg) should be referred to their primary care physician for evaluation lifestyle modification and treatment
39
(1) Members with Stage I hypertension should be followed-up not only by their primary care physician but also by the FD physician every 3 to 6 months to ensure their blood pressure is under control and to determine whether screening tests for asymptomatic end organ damage are appropriate
(2) Members with Stage 2 hypertension or with end organ damage (retinopathy nephropathy vascular or cardiac complications) compromises the members ability to safely perform essential job tasks 1 5 7 9 and 130 and the physician shall report the applicable job limitations to the fire department
A94201 Chronic hypertension can damage the eye (retinopathy) the kidneys (nephropathy) the vascular system (stroke transient ischemic attack or peripheral artery disease) or the heart (left ventricular hypertrophy and heart failure) These hypertension complications are known as end organ damage The cardiac and vascular complications are associated with an increased risk of sudden incapacitation and sudden cardiac death (Koren et al 1991) Fortunately with proper evaluation life style modification and treatment these complications can be avoided Life style modification includes weight reduction DASH eating plan reduction in dietary sodium an increase in aerobic physical activity and moderation in alcohol consumption [Chobanian 2003]
A94201 (1) Members with Stage I hypertension whose BP returns to either pre-hypertenion or normal with lifestyle modification andor treatment can return to an annual medical evaluation For members with long-standing Stage I hypertension whose BP has not been reduced additional evaluation for possible end organ damage should be considered This evaluation could include any or all of the following
a) a compete patient history for symptoms of heart failure (eg shortness of breath upon exertion) or transient ischemic attacks (TIAs)
b) dilated eye examination for retinopathy
c) blood creatinine measurement for nephropathy
d) tests for left ventricular hypertrophy Unfortunately use of the resting EKG to detect left ventricular hypertrophy is very insensitive (eg 5 sensitivity) The echocardiogram is the best test for diagnosing left ventricular hypertrophy
A 94201 (2) Due to the high risk of a sudden cardiovascular event members with Stage 2 hypertension should be restricted until their BP can be brought under control Once the BP is brought under control they should be followed in the same manner as a member with Stage I hypertension
D22 Cardiology
40
Hypertension
Gibbons RJ Balady GJ Bricker JT Chaitman BR Fletcher GF Froelicher VF Mark DB McCallister BD Mooss AN OrsquoReilly MG Winters WL Jr [2002] ACCAHA 2002 guideline update for exercise testing summary article a report of the ACCAHA Task Force on Practice Guidelines (Committee to Update the 1997 Exercise Testing guidelines) J Am Coll Cardiol 401531ndash 40
Chobanian AV Bakris GL Black HR Cushman WC Green LA Izzo JL Jr Jones DW Materson BJ Oparil S Wright JT Jr Roccella EJ the National High Blood Pressure Education Program Coordinating Committee [2003] The seventh report of the Joint National Committee [JNC-7] on Prevention Detection Evaluation and Treatment of High Blood Pressure JAMA 2892560ndash2571
Soteriades ES Kales SN Liarokapis D Christiani DC [2003] Prospective surveillance of hypertension in firefighters J Clin Hypertens 5315-320
Kales SN Tsismenakis AJ Zhang C Soteriades ES [2009] Blood pressure in fire fighters police officers and other emergency responders Am J Hypertens 2211-20
41
NFPA 1582‐ Draft Revisions for CVDHTN
EKG and stress tests
Reason for Revision
1) Change requirement for annual resting EKG to periodically to be more consistent with ACCAHA
recommendation (Schlant et al 1992)
2) Add language to clarify what constitutes a positive ST
3) Make criteria for conducting diagnostic ST in asymptomatic patients consistent with the
ACCAHA
Language in 2007 Edition with draft revisions in Red (Track changes)
776 Electrocardiograms (EKG)) and Stress Tests 7761 A resting EKG shall be performed as part of the baseline medical evaluation and shall be obtained periodically (every 1 to 5 years) annually thereafter
A7761 A baseline resting EKGs shall be conducted Follow-up resting EKGs should be conducted as clinically indicated but at a minimum of every 1 to 5 years The frequency of these follow-up resting EKGs should increase as a members age increases or with increasing number andor severity of coronary heart disease risk factors Members above the age of 40 should have annual resting EKGs (Schlant et al 1992)
7762 The fire department physician or other qualified medical evaluator shall compare EKGs obtained during yearly evaluations with baseline and subsequent EKGs
7763 Stress testing EKG with or without echocardiography or radionuclide scanning shall be performed as clinically indicated by history or symptoms
A7761 Baseline electrocardiography should be conducted (Periodic resting electrocardiograms have not been shown to be useful but can be reasonable as a members agefactors increase)
A7763 No firm guidelines for stress testingelectrocardiography in asymptomatic individuals have been developed Stress testingelectrocardiography as a screening tool is used as part of an evaluation of aerobic capacity during the annual occupational fitness evaluation Submaximal stress testingelectrocardiography testing to 85 percent is commonly used as part of this screening
Submaximal stress electrocardiography testing should not be used for diagnostic purposes Cardiology evaluation with maximal stress testingelectrocardiography together with imaging techniques (eg echocardiography technetium Tc99m sestamibi study andor coronary angiography) is necessary for diagnosticprognostic purposes for the following
42
(1) Fire fighters with positive or questionably positive changes on screening submaximal stress tests
(2) Fire fighters with new onset chest pain or other symptoms suggestive of coronary artery disease (CAD)
(3) Fire fighters with diabetes mellitus who
(a) are gt35 years old or
(b) have type I diabetes for more than 15 years or
(c) have type II diabetes for more than 10 years or
(d) have any other CHD risk factor (see below) or
(e) have the presence of microvascular disease (proliferative retinopathy)
(4) Fire fighters over the age of 45 (for men) and 55 (for women) with onetwo or more risk factors for CAD Risk factors for CAD include hypercholesterolemia (total cholesterol greater than 240 mgdL) hypertension (systolic gt140 mmHg or diastolic gt90 mmHg) smoking or family history of premature CAD (heart attack or sudden cardiac death in a first degree relative less than 60 years of age)
as defined below if stress electrocardiography with imaging is negative then repeat as clinically indicated or at least every 5 years
(5) Fire fighters with a Framingham Risk Score gt10 Risk calculator is available at [httphp2010nhlbihinnetatpiiicalculatorasp]
(6) Fire fighters identified in 9431
Negative stress tests should be repeated as clinically indicated or at least every 2 to 5 years
Interpreting stress tests as ldquopositiverdquo or ldquonegativerdquo is beyond the scope of this document However factors that should be taken into consideration should include the individualrsquos exercise capacity symptoms blood pressure response heart rate response EKG changes and the presence of arrhythmias (Gibbon et al 2002)
Risk factors for CAD include hypercholesterolemia (total cholesterol greater than 240 mgdL) hypertension (systolic greater than 140 andor diastolic greater than 90) smoking diabetes mellitus or family history of premature CAD (heart attack or sudden cardiac death in a first degree relative less than 60 years of age)
There are other non-invasive tests to screen for coronary artery disease One of the most promising appears to be coronary artery calcium (CAD) scoring by computed tomography In 2007 an expert committee published an update to their original guidance document The committeersquos consensus was that ldquoit may be reasonable to consider use of CAC measurement in such patients [between 10 and 20 10-year risk of estimated coronary event]helliprdquo The committee did not recommend CAC measurement in low risk patients [lt10 10-year risk of estimated coronary event] or in high risk patients [gt20 10-year risk of estimate coronary event] (Greenland et al 2007]
43
D22 Cardiology
Chobanian AV Bakris GL Black HR Cushman WC Green LA Izzo JL Jr Jones DW Materson BJ Oparil S Wright JT Jr Roccella EJ the National High Blood Pressure Education Program Coordinating Committee [2003] The seventh report of the Joint National Committee [JNC-7] on Prevention Detection Evaluation and Treatment of High Blood Pressure JAMA 2892560ndash2571
Gibbons RJ Balady GJ Bricker JT Chaitman BR Fletcher GF Froelicher VF Mark DB McCallister BD Mooss AN OrsquoReilly MG Winters WL Jr [2002] ACCAHA 2002 guideline update for exercise testing summary article a report of the ACCAHA Task Force on Practice Guidelines (Committee to Update the 1997 Exercise Testing guidelines) J Am Coll Cardiol 401531ndash 1540
Greenland et al [2007] ACCFAHA 2007 Clinical Expert Consensus Document on Coronary Artery Calcium Scoring By Computed Tomography in Global Cardiovascular Risk Assessment and in Evaluation of Patients With Chest Pain A Report of the American College of Cardiology Foundation Clinical Expert Consensus Task Force (ACCFAHA Writing Committee to Update the 2000 Expert Consensus Document on Electron Beam Computed Tomography) J Am Coll Cardiol 49378-402
Kales SN Tsismenakis AJ Zhang C Soteriades ES [2009] Blood pressure in fire fighters police officers and other emergency responders Am J Hypertens 2211-20
Schlant RC Adolph RJ DiMarco JP Dreifus LS Dunn MI Fisch C Garson A Jr Haywood LJ Levine HJ Murray JA Noble RJ Ronan JA Jr [1992] Guidelines for electrocardiography A report of the American College of CardiologyAmerican Heart Association Task Force on Assessment of Diagnostic and Therapeutic Cardiovascular Procedures (Committee on Electrocardiography) Circulation 85(3)1221-1228
Soteriades ES Kales SN Liarokapis D Christiani DC [2003] Prospective surveillance of hypertension in firefighters J Clin Hypertens 5315-320
Formatted Font Italic
Formatted Line spacing single
Formatted Font Italic
Formatted Font Italic
44
NFPA 1582‐ Draft Revisions for CVDHTN
EKG and stress tests
Reason for Revision
1) Change requirement for annual resting EKG to periodically to be more consistent with ACCAHA
recommendation (Schlant et al 1992)
2) Add language to clarify what constitutes a positive ST
3) Make criteria for conducting diagnostic ST in asymptomatic patients consistent with the
ACCAHA
Language in 2007 Edition with draft revisions in Red (Track changes)
776 Electrocardiograms (EKG) and Stress Tests 7761 A resting EKG shall be performed as part of the baseline medical evaluation and shall be obtained periodically (every 1 to 5 years) thereafter
A7761 A baseline resting EKGs shall be conducted Follow-up resting EKGs should be conducted as clinically indicated but at a minimum of every 1 to 5 years The frequency of these follow-up resting EKGs should increase as a members age increases or with increasing number andor severity of coronary heart disease risk factors Members above the age of 40 should have annual resting EKGs (Schlant et al 1992)
7762 The fire department physician or other qualified medical evaluator shall compare baseline and subsequent EKGs
7763 Stress testing with or without echocardiography or radionuclide scanning shall be performed as clinically indicated by history or symptoms
A7763 No firm guidelines for stress testing in asymptomatic individuals have been developed Stress testing as a screening tool is used as part of an evaluation of aerobic capacity during the annual occupational fitness evaluation Submaximal stress testing testing to 85 percent is commonly used as part of this screening
Submaximal stress testing should not be used for diagnostic purposes Cardiology evaluation with maximal stress testing together with imaging techniques (eg echocardiography technetium Tc99m sestamibi study) is necessary for diagnosticprognostic purposes for the following
(1) Fire fighters with positive or questionably positive changes on screening submaximal stress tests
(2) Fire fighters with new onset chest pain or other symptoms suggestive of coronary artery disease (CAD)
45
(3) Fire fighters with diabetes mellitus who
(a) are gt35 years old or
(b) have type I diabetes for more than 15 years or
(c) have type II diabetes for more than 10 years or
(d) have any other CHD risk factor (see below) or
(e) have the presence of microvascular disease (proliferative retinopathy)
(4) Fire fighters over the age of 45 (for men) and 55 (for women) with one or more risk factors for CAD Risk factors for CAD include hypercholesterolemia (total cholesterol greater than 240 mgdL) hypertension (systolic gt140 mmHg or diastolic gt90 mmHg) smoking or family history of premature CAD (heart attack or sudden cardiac death in a first degree relative less than 60 years of age)
(5) Fire fighters with a Framingham Risk Score gt10 Risk calculator is available at [httphp2010nhlbihinnetatpiiicalculatorasp]
(6) Fire fighters identified in 9431
Negative stress tests should be repeated as clinically indicated or at least every 2 to 5 years
Interpreting stress tests as ldquopositiverdquo or ldquonegativerdquo is beyond the scope of this document However factors that should be taken into consideration should include the individualrsquos exercise capacity symptoms blood pressure response heart rate response EKG changes and the presence of arrhythmias (Gibbon et al 2002)
There are other non-invasive tests to screen for coronary artery disease One of the most promising appears to be coronary artery calcium (CAD) scoring by computed tomography In 2007 an expert committee published an update to their original guidance document The committeersquos consensus was that ldquoit may be reasonable to consider use of CAC measurement in such patients [between 10 and 20 10-year risk of estimated coronary event]helliprdquo The committee did not recommend CAC measurement in low risk patients [lt10 10-year risk of estimated coronary event] or in high risk patients [gt20 10-year risk of estimate coronary event] (Greenland et al 2007]
D22 Cardiology
Resting EKG and Stress Tests
46
Chobanian AV Bakris GL Black HR Cushman WC Green LA Izzo JL Jr Jones DW Materson BJ Oparil S Wright JT Jr Roccella EJ the National High Blood Pressure Education Program Coordinating Committee [2003] The seventh report of the Joint National Committee [JNC-7] on Prevention Detection Evaluation and Treatment of High Blood Pressure JAMA 2892560ndash2571
Gibbons RJ Balady GJ Bricker JT Chaitman BR Fletcher GF Froelicher VF Mark DB McCallister BD Mooss AN OrsquoReilly MG Winters WL Jr [2002] ACCAHA 2002 guideline update for exercise testing summary article a report of the ACCAHA Task Force on Practice Guidelines (Committee to Update the 1997 Exercise Testing guidelines) J Am Coll Cardiol 401531ndash 1540
Greenland et al [2007] ACCFAHA 2007 Clinical Expert Consensus Document on Coronary Artery Calcium Scoring By Computed Tomography in Global Cardiovascular Risk Assessment and in Evaluation of Patients With Chest Pain A Report of the American College of Cardiology Foundation Clinical Expert Consensus Task Force (ACCFAHA Writing Committee to Update the 2000 Expert Consensus Document on Electron Beam Computed Tomography) J Am Coll Cardiol 49378-402
Kales SN Tsismenakis AJ Zhang C Soteriades ES [2009] Blood pressure in fire fighters police officers and other emergency responders Am J Hypertens 2211-20
Schlant RC Adolph RJ DiMarco JP Dreifus LS Dunn MI Fisch C Garson A Jr Haywood LJ Levine HJ Murray JA Noble RJ Ronan JA Jr [1992] Guidelines for electrocardiography A report of the American College of CardiologyAmerican Heart Association Task Force on Assessment of Diagnostic and Therapeutic Cardiovascular Procedures (Committee on Electrocardiography) Circulation 85(3)1221-1228
Soteriades ES Kales SN Liarokapis D Christiani DC [2003] Prospective surveillance of hypertension in firefighters J Clin Hypertens 5315-320
47
ATTACHMENT F
48
1
Current 1582 (2007) language in reference to pregnancy 43 (4) Report to the fire department physician any medical condition that could interfere with the ability of the individual to safely perform essential job tasks such as illness or injury use of prescription or nonprescription drugs and pregnancy 6112 Category B medical conditions shall include the following (1) Pregnancy for its duration A7792 (e) If HIV prophylaxis is to be given the following tests should be done i CBC ii Glucose renal and hepatic chemical function iii Pregnancy test for females B121 Pregnancy and Reproduction Federal regulations as well as many court decisions including the US Supreme Courtrsquos decision in International Union et al v Johnson Controls Inc [499 US 187 111 S Ct 1196 (1991)] have interpreted the requirements of Title VII with respect to pregnancy and reproduction The AHJ should seek the advice of counsel in resolving specific questions concerning these requirements as well as other requirements that can be imposed by state or local laws C211 (4) Review health status with the individual being evaluated Contraindications for evaluations shall be reviewed addressing any changes in the individualrsquos health status since their last medical evaluation that would warrant deferring the evaluation including (g) Pregnancy Recommendations to language enhancement
A female employee who is assigned to regular fire line duty shall report a pregnancy immediately to their respective Supervisor and the fire department physician The employee will then be given the option of a non-hazardous alternative duty position for the duration of her pregnancy (can we say this or is it even appropriate) Any pregnant employee wishing to remain on regular line duty shall be informed of the possible risks and consequences to herself and her fetus that are associated with continued line fire fighting duty Among those risk factors are exposure to teratogens known to have negative effects on the developing fetus such as smoke diesel fumes hazardous chemicals and extreme heat
49
Page 2
appendix It is recommended that the pregnant employee complete a release of liability form signed by herself and her health care provider utilizing NFPArsquos 13 critical tasks as a reference This will inform the health care provider of specific job-related tasks that will need to be performed in order to continue regular line duty These tasks are basic physical standards that any entry level firefighter would have to be able to complete competently The employeersquos health condition will be kept confidential by the department in accordance with HIPAA standards Employees are allowed to remain on active regular duty until they are no longer able to perform their duties in a reasonable manner andor their protective gear no longer fits correctly It is the responsibility of the health care provider to evaluate the pregnant employee If at any time the health care provider feels the pregnant employee can no longer perform the job related tasks this should be reported to the employer by the employee immediately
50
ATTACHMENT G
51
From GLENN BENARICKTo Sawyer SteveSubject RE RE 7743Date Monday August 30 2010 21633 PM
Yes thats my understanding
Glenn P Benarick 211 Winged Elm CircleAiken SC 29803803-644-7093gbenarprodigynet
--- On Mon 83010 Sawyer Steve ltssawyerNFPAorggt wrote
From Sawyer Steve ltssawyerNFPAorggtSubject RE RE 7743To GLENN BENARICK ltgbenarprodigynetgtDate Monday August 30 2010 212 PM
So it should be ldquoorrdquo instead of ldquoandrdquo for now
Steven F Sawyer
Senior Fire Service Specialist
Executive Secretary IFMAFire Service Section
NFPA
1 Batterymarch Park
Quincy MA 02169
6179847423
Fax 6179847056
ssawyernfpaorg
From GLENN BENARICK [mailtogbenarprodigynet] Sent Monday August 30 2010 1202 PMTo Sawyer SteveSubject Fw RE 7743
52
Steve a couple of our docs agree with April Boyer
Glenn P Benarick 211 Winged Elm Circle
Aiken SC 29803
803-644-7093
gbenarprodigynet
--- On Mon 83010 David Prezant ltprezandfdnynycgovgt wrote
From David Prezant ltprezandfdnynycgovgtSubject RE 7743To Thomas R (CDCNIOSHDSHEFS) Hales lttrh1cdcgovgt GLENNBENARICK ltgbenarprodigynetgtCc Sandy Bogucki ltsandyboguckiyaleedugtDate Monday August 30 2010 1004 AM
agree
we should change this to NHANES III rather than Knudson we should alsomodify this to allow not only for predicted cutoffs but all for use of thelower limit of normal cutoff This is important to prevent false-classificationof spirometry as abnormal in older groups and in taller grps The latter ofparticular import to firefighter occupational health surveillance
thanks
David Prezant MDChief Medical Officer Office of Medical AffairsCo-Director WTC Medical Monitoring amp Treatment ProgramsNew York City Fire Department9 Metrotech Center - Rm 4W-1Brooklyn NY 11201Phone 718-999-2696Fax 718-999-0665
Life is full of twists and turns
53
This email may contain confidential information If you are the unintendedrecipient of this email please send it back and delete from your directory
gtgtgt Hales Thomas R (CDCNIOSHDSHEFS) lttrh1cdcgovgt 8302010955 AM gtgtgt
Glen
This seems like a very reasonable comment and illustrates the importance of having clinicians providefeedback on the std Im not familiar with the software program of the various spirometers (NHANES IIIvs KnudsonATS vs both) Given the large role both Dave Prezant and Sandy Bogucki had for thepulmonary section let me forward to them for clarification
Tom
From GLENN BENARICK [mailtogbenarprodigynet] Sent Sunday August 29 2010 456 PMTo Hales Thomas R (CDCNIOSHDSHEFS)Subject FW 7743
Tom is April Boyer correct
Glenn P Benarick 211 Winged Elm Circle
Aiken SC 29803
803-644-7093
gbenarprodigynet
--- On Thu 82610 Sawyer Steve ltssawyerNFPAorggt wrote
From Sawyer Steve ltssawyerNFPAorggtSubject FW 7743To GLENN BENARICK ltgbenarprodigynetgtDate Thursday August 26 2010 925 PM
FYI Do you have any answer She is write
Steven
54
Steven F Sawyer
Senior Fire Service Specialist
Executive Secretary IFMAFire Service Section
NFPA
1 Batterymarch Park
Quincy MA 02169
6179847423
Fax 6179847056
ssawyernfpaorg
From April Boyer [mailtoaboyerbicclinicorg] Sent Thursday August 26 2010 232 PMTo Sawyer SteveCc RobinMWebbmilstateorusSubject 7743
Steven
The spirometry tests cannot be corrected according to both references as the NFPA states because thereferences are contradictory The first part of 7743 states to follow the ATS guidelines and use theKnudsen (we at Basin Immediate Care use the Nhanes III) The second part states to follow the ACOEMguidelines and use the Nhanes III in the occupational setting if available with your unit (which is availableon ours) 7743 does not use the word OR regarding both requirements it uses the word AND whenreferring to the first and second parts thence making 7743 contradictory I realize the NFPA 1582 hasnot been updated since 2007 unless I have just not received an updated version
Our question to you is which part of 7743 do you want us to follow the first or the second part Anyfacility that has an updated computerized spirometry system (as we do) will not be able to follow bothrequired parts for obvious reasons We can either follow the first part of 7743 and use an oldercorrected version of the Knudson by going into our system and changing out of the Nhanes III conversionOR we can follow the second part of 7743 and use the newer corrected version of Nhanes III which ourunit offers too
If you have any questions you may contact me at anytime and I also have many references in regards toboth parts of 7743 if you would like to see them
55
Thank you~
April
Confidentiality NoticeThis message may contain information that isconfidential or privileged
If you are not the intended recipientPlease advise the sender immediately and delete this message
56
ATTACHMENT H
57
NFPA 1582 771(7) Proposed revisions
Why
Preliminary results of two prospective randomized trials on the PSA test were published in 2009 These studies resulted in medical organizations that previously providing guidance to modify their recommendations
Current language
771 Blood Tests Blood tests shall be performed annually and shall include the following
(7) Prostate specific antigen (PSA) after age 40 for positive family history if African American or if otherwise clinically indicated after age 50 for all other male member
Suggested Revision
771 Blood Tests Blood tests shall be performed annually and shall include the following
(7) Prostate specific antigen (PSA) after age 40 for positive family history if African American or if otherwise clinically indicated after age 50 for all other male member
772 Prostate-Specific Antigen (PSA) test At age 50 fire fighters shall have an opportunity to make an informed decision with either the Fire Department physician or their health care provider concerning the PSA test For fire fighters at increased risk of prostate cancer (African-Americans or those with a first degree relative diagnosed with prostate cancer before age 65) shall have the opportunity for this informed decision at age 40
A772 The PSA as a screening test for prostate cancer in asymptomatic men is controversial controversial for two reasons First there is no consensus that PSA screening actually saves lives For example the PSA test may detect small cancers that would never become life threatening Second it is unclear that the benefits of PSA screening outweigh the risks of follow-up diagnostic tests and cancer treatments For example the prostate biopsy used to diagnose prostate cancer may cause bleeding and infection And prostate cancer treatments such as surgery and radiation therapy may cause incontinence (inability to control urine flow) erectile dysfunction (erections inadequate for intercourse) and other complications For these reasons it is important that the benefits and risks of prostate diagnostic procedures and treatment be taken into account when considering the PSA screening test These considerations can be taken account during discussions with the fire department physician or onersquos health care provider
D211 Cancer Screening
Smith R A C J Mettlin K J Davis and H Eyre 2000 ldquoAmerican Cancer Society guidelines for the early detection of cancerrdquo CA J Clin 50(1)34ndash49
Added references
58
Carroll P Albertsen PC Greene K et al [2010] Prostate-specific antigen best practice statement 2009 update Am Urological Assoc Available at httpwwwauanetorgcontentguidelines-and-quality-careclinical-guidelinesmain-reportspsa09pdf Date accessed September 2010
Ferrini R Woolf SH [2009] Screening for prostate cancer in American men American College of Preventive Medicine Practice Policy Statement Available at httpwwwacpmorgprostatehtm Date accessed September 2010
National Cancer Institute [2009] Prostate-specific antigen test National Cancer Institute Fact Sheet Available at httpwwwcancergovcancertopicsfactsheetDetectionPSA Date accessed September 2010
Wolf AMD Wender RC Etzioni RB et al [2010] American Cancer Society guideline for the early detection of prostate cancer Update 2010 Available at httpcaonlineamcancersocorgcgicontentfullcaac20066v1 Date accessed September 2010
59
2012 ANNUAL REVISION CYCLE
PROCESS STAGE PROCESS STEP DATES
FOR TC DATES
FOR TCC 1 PRELIMINARY 10 Notification of intent to enter cycle 7910 7910
2 REPORT ON
PROPOSALS (ROP)
21 Proposal closing date 112310 112310 22 Final date for ROP meeting 22511 2411 23 Final date for mailing TC ballots 31811 21811 24 Receipt of (TC) ballots by staff liaison 42211 31111 25 Receipt of TC recirculation ballots 5611 31811 26 Final date for TCC meeting 41511 27 Final date for mailing TCC ballots 42211 28 Receipt of TCC ballots 51311 29 Receipt of TCC recirculation ballots 52011 210 Final copy (w ballot statements) to Secretary Standards Council 51311 52711 211 Completion of Reports 52011 6311 212 ROP Published and Posted 62411 62411
3 REPORT ON
COMMENTS
(ROC)
31 Comment closing date 83011 83011 32 Final date for ROC meeting 11411 10711 33 Final date for mailing TC ballots 111811 102111 34 Receipt of (TC) ballots by staff liaison 12211 111111 35 Receipt of TC recirculation ballots 12911 111811 36 Final date for TCC meeting 121611 37 Final date for mailing TCC ballots 122311 38 Receipt of TCC ballots 11312 39 Receipt of TCC recirculation ballots 12012 310 Final copy (w ballot statements) to Secretary Standards Council 122311 12712 311 Completion of Reports 11312 2312 312 ROC Published and Posted 22412 22412
4 TECH SESSION
PREPARATION amp
ISSUANCE OF
CONSENT
DOCUMENTS
41 Notice of Intent to Make a Motion (NITMAM) Closing Date 4612 4612 42 Posting of Filed NITMAM 5412 5412
43 Council Issuance Date for Consent Documents 52912 52912
44 Appeal Closing Date for Consent Documents 61312 61312
5 TECHNICAL
SESSION 50 Association Meeting for Documents with Certified Amending Motions
64-712 64-712
6
APPEALS amp
ISSUANCE OF
DOCUMENTS
WCAMS
61 Appeal closing date for Documents with Certified Amending Motions
62712 62712
62 Council issuance for Documents with Certified Amending Motions 8912 8912
Proposal Closing Dates may vary according to documents and schedules for Revision Cycles may change Please check the NFPA website (wwwnfpaorg) for the most up-to-date information on proposal closing dates and schedules
16
ATTACHMENT D
17
This weekrsquos conference call mentioned the Diabetes chapter written for the ACOEM document Guidance for the Medical Evaluation of the Law Enforcement Officer The task group working on this chapter (led Richard Miller of the Secret Service and our very own Dan Samo) worked with the ADA or over 2-3 years to come up with a consensus document
Please find the Chapter attached ltltDiabetes Guidance Sept 2010pdfgtgt
Regarding Dan Loeberrsquos points
1) Physical Evaluation Form - We could modify the LEO form (see end of the attached Chapter)
2) Duration required for stable regiment
1582 for IDDM Type 1 1 yr
Type 2 6 m
Oral Agents None specifically
ACOEM Police for IDDM Type 1 6m
Type 2 3m
Oral Agents 1m
The police document is much clearer about the decision regarding medical fitness for duty is the responsibility of the police physician with the treating diabetes-expert physician providing the data to the police physician to make an informed decision In this regard the police officer must provide the police physician with downloaded self monitoring glucose data for the 1 3 and 6 month time periods (see section 433)
3) HA1C ndash NFPA lt 8 over 3 month period
ACOEM Police ndash (Section 4333) Specifies the frequency on measurement and if gt8 requires further evaluation
Some other discrepancies End organ complications
NFPA ndash end organ complications (eye kidney heart neuro) ndash restriction
ACOEM Police ndash end organ complication -- requires further evaluation
18
Hypoglycemia (incapacitating ndash defined differently between the two documents (434)
NFPA ndash 0 episodes in past year le1 in past 5 yrs
ACOEM Police ndash 0 episodes in past year le2 in past 3 yrs
Given Dan Samorsquos and Richard Millerrsquos work with the ADALoeber it would be helpful to get their opinions on whether any of the changes requested by Loeber are appropriate for FF with DM
Tom
Thomas Hales MD MPH
Senior Medical Epidemiologist
NIOSH CDC
4676 Columbia Pkwy R-9
Cincinnati OH 45241
(513) 841-4583
trh1cdcgov
19
43 ndash DIABETES MELLITUS
431 ndash INTRODUCTION
The educated and motivated law enforcement officer (LEO) with well-managed diabetes mellitus can be capable of
safe and effective job performance1 However diabetes mellitus may place LEOs at risk for sudden incapacitation
thus jeopardizing their ability to perform critical job functions (These job functions include those listed in Sections
32 333 351 352 36 and 37 and discussed in Appendix A)
Therefore an individualized assessment of the LEOrsquos diabetes should be performed using the following evaluative
criteria to determine whether the individuals condition permits safe and effective job performance Such evaluation
must include the following key elements which are discussed in detail below
history of blood glucose control
knowledge of diabetes and its management
current stability of blood glucose
risk for significant hypoglycemia or hyperglycemia and
presence of diabetic complications
432 ndash OVERVIEW OF MEDICAL EVALUATION
The treating endocrinologist or other physician knowledgeable regarding diabetes management should provide
a narrative report certifying whether the LEO has or has not met the criteria set out in Sections 4321 through
4354 below In addition the physician should include supporting data (see Appendix B for the Physician Evalu-
ation Form)
4321 The LEO is under the care of an endocrinologist or other physician knowledgeable regarding diabetes
management Outpatient and in-patient medical record(s) for the last 3 years or since date of diagnosis
(whichever is shorter) should be reviewed by the treating physician and provided to the police physician
4322 If the LEO has type 1 diabetes the individual has been on a basalbolus regimena or an insulin pump
using analogue insulins for the 6 months prior to evaluation2
4323 If the LEO has type 2 diabetes on insulin the individual has been on a stable medication regimenb
for the 3 months prior to evaluation3 If on oral agents alone the LEO has been on a stable medication regimen
for the month prior to evaluationc
ACOEM Guidance for the Medical Evaluation of Law Enforcement Officers 1
43 ndash DIABETES MELLITUS
aA basalbolus insulin regimen consists of the use of a basal insulin (Glargine NPH) in a once or twice daily regimen to provide between-
meal insulin combined with the use of a short acting insulin (Regular Lispro Aspart or Glulisine) at mealtimes Insulin pumps are small
(beeper sized) battery powered devices that deliver small amounts of short-acting insulin in a constant infusion to meet basal insulin
requirements The wearer selects an additional mealtime bolus to be infused at the time of meals For more information on pumps visit
the manufacturerrsquos web sites ndash wwwMinimedcom wwwcozmorecom wwwanimascorpcom wwwdisetroniccom
bA stable insulin regimen is defined as maintaining the same types of insulin (long acting intermediate acting short or rapid acting)
Changes in insulin dose are part of the appropriate self-management of diabetes and do not disqualify an applicant or incumbent under
this section
cChanges in dose within the evaluation period will be allowed but addition of a new class of medications or insulin should result in a new
period of observation
one month for addition of a sulfonylurea or metformin
two months for the addition of a thiazolidinedione to insulin or a sulfonylurea or
three months for the addition of insulin
20
4324 If the LEO uses an insulin pump documentation is needed as follows
proper understanding and education in the use of the insulin pump
start date for the use of the pump
history of insulin site infectionsd
history of pump cessation and pump malfunction
backup plan for pump malfunction including use of injectable insulin and
frequency of infusion set changes
4325 The LEO has been educated in diabetes and its management and thoroughly informed of and under-
stands the procedures that must be followed to monitor and manage hisher diabetes and what procedures
should be followed if complications arise3
433 ndash QUANTITATIVE GLUCOSE MONITORING
4331 The LEO has documentation of ongoing self-monitoring of blood glucose
4332 This must be done with a glucose meter that stores every reading records date and time of reading
and from which data can be downloaded (Most meters now have this capability)
4333 Monitoring logs must be available covering the time period (1 3 or 6 months) as described in
Sections 4322 and 4323 The frequency of glucose monitoring must follow a schedule acceptable to the
police physician in consultation with the treating physician
Testing schedules are individual What follows is a common pattern but individual patterns may differ
2 ACOEM Guidance for the Medical Evaluation of Law Enforcement Officers
43 ndash DIABETES MELLITUS
dIndividual has not had more than one pump-site infection that caused him or her to miss work or usual daily activities in the preceding 6
months
THERAPEUTIC REGIMEN GLUCOSE TESTING SCHEDULE
Diet alone Once or twice a week
Metformin Thiazolidinediones or Alpha
Glucosidase inhibitors alone or in
combination
Once or twice a week
Sulfonylureas meglitanides nateglinide ndash
alone or in combination with the above group
Twice a day ndash AM and at supper with any
suspected hypoglycemic episodes
Insulin ndash one shot in combination with orals Twice a day ndash AM and at supper with any
suspected hypoglycemic episodes
2 to 3 times AM once a week
Insulin ndash two or more shots Insulin pump 3 to 4 times a day ndash at meals and bedtime
2 to 3 times AM once a week with any
suspected hypoglycemic episodes
21
4334 The LEO has had hemoglobin A1C measured at least 4 times a year (intervals of 2 to 3 months) over
the last 12 months prior to evaluation if diagnosis has been present for more than a year4 If hemoglobin A1C is
gt8 this may signal a problem with the LEOrsquos diabetes management that warrants further assessment5
434 ndash INCAPACITATING EVENTS
4341 The LEO has not had any incapacitating episodes within the past 1 year and no more than 2 episodes
in the past 3 years or since diagnosis of diabetes (whichever is shorter) of
43411 Severe hypoglycemia (loss of consciousness seizures or coma requiring assistance of others or
needing urgent treatment [glucagon injectionIV glucose]) or
43412 Blood sugar lt60 mgdl with unawareness demonstrated in current glucose logs6
435 ndash CHRONIC COMPLICATION SCREENING
4351 Chronic complications of diabetes are associated with increased risk for severe hypoglycemic
episodes and warrant further assessmente
4352 The components of screening for chronic complications are
43521 A complete eye exam by a qualified ophthalmologist or optometrist including a dilated retinal
exam demonstrating no more than mild background diabetic retinopathyf7
43522 Normal vibratory testing with a 128 Hz tuning forkg normal testing with 10 gram Semmes-
Weinstein monofilamentg and normal orthostatic blood pressureh and pulse testing89
ACOEM Guidance for the Medical Evaluation of Law Enforcement Officers 3
43 ndash DIABETES MELLITUS
ePresence of chronic complications of diabetes in and of themselves may not require the implementation of work restrictions
fNo more than one dot blot or flame-shaped hemorrhages or microaneurysm in all four fundus quadrants
gThe Michigan Diabetes Research and Training Center of the University of Michigan Health System recommends the following guidance
(see wwwmedumichedumdrtcprofsdocumentssviMNSI_howtopdf) for conducting vibratory and monofilament testing8
Vibration Sensation Vibration sensation should be performed with the great toe unsupported Vibration sensation will be tested bi-
laterally using a 128 Hz tuning fork placed over the dorsum of the great toe on the boney prominence of the DIP joint Patients whose
eyes are closed will be asked to indicate when they can no longer sense the vibration from the vibrating tuning fork In general the
examiner should be able to feel vibration from the hand-held tuning fork for 5 seconds longer on his distal forefinger than a normal subject
can at the great toe (eg examiners DIP joint of the first finger versus patients toe) If the examiner feels vibration for 10 or more seconds
on his or her finger then vibration is considered decreased A trial should be given when the tuning fork is not vibrating to be certain that
the patient is responding to vibration and not pressure or some other clue Vibration is scored as 1) present if the examiner senses the
vibration on his or her finger for lt10 seconds 2) reduced if sensed for 10 seconds or 3) absent (no vibration detection)
Monofilament Testing For this examination it is important that the patients foot be supported (ie allow the sole of the foot to rest on
a flat warm surface) The filament should initially be pre-stressed (4-6 perpendicular applications to the dorsum of the examiner s first
finger) The filament is then applied to the dorsum of the great toe midway between the nail fold and the DIP joint Do not hold the toe
directly The filament is applied perpendicularly and briefly (lt1 second) with an even pressure When the filament bends the force of
10 grams has been applied The patient whose eyes are closed is asked to respond yes if heshe feels the filament Eight correct responses
out of 10 applications is considered normal 1 to 7 correct responses indicates reduced sensation and no correct answers translates into
absent sensation
hOrthostatic hypotension is a physical finding defined by the American Autonomic Society and the American Academy of Neurology as a
systolic blood pressure decrease of at least 20 mm Hg or a diastolic blood pressure decrease of at least 10 mm Hg within 3 minutes of
standing
22
43523 Normal cardiac physical exam Cardiac stress testing to at least 12 METS is recommended and
should begin based on either the criteria of the American Heart AssociationAmerican College of
Cardiologyi10 or those of the American Diabetes Associationj11
Diabetics who have a normal cardiac stress test will be retested every one to three years based on
individual clinical assessment This assessment should consider
the age of the individual
the number and persistence of coronary artery disease (CAD) risk factors
the severity of CAD risk factors
43524 Microalbumincreatinine ratio 301 measured or calculatedk creatinine clearance
gt60 mlmin12
436 ndash ONGOING EVALUATION AND REQUIREMENTS
4361 Should have medical records and glucose meter logs reviewed periodically Because of the nature of
diabetes it is important that regular medical follow up be provided to the LEO The frequency and content of
the evaluation should be determined on an individual basis by the police physician in consultation with the
treating physicianl
4362 Must advise police physician of any change in type of medication
4363 Must advise police physician of any episodes of significant hypoglycemia or hyperglycemia
Urine microalbumincreatinine ratio _________________
III Treating Physician Statement
The above named individual meets all of the criteria provided on this form
Yes No ndash not recommended for position
No but IS recommended for position (letter of explanation attached)
It is my opinion that the above named individual is well-educated and well-motivated in diabetes self-management and has
achieved a level of diabetes management to be capable of safe and effective job performance as a law enforcement officer
I have reached this opinion after careful review of the above criteria
___________________________________________________________ ___________________________Signature of Physician Date
______________________________________________________________ ___________________________Printed or Typed Name of Physician Telephone Number
10 ACOEM Guidance for the Medical Evaluation of Law Enforcement Officers
43 ndash DIABETES MELLITUS
29
439 ndash REFERENCES
1 American Diabetes Association Diagnosis and classification of diabetes mellitus Diabetes Care 200427 Suppl
1S5-S10 See httpcarediabetesjournalsorgcgicontentfull27suppl_1s5
2 American Diabetes Association Continuous subcutaneous insulin infusion Diabetes Care 200427 Suppl 1S110
See httpcarediabetesjournalsorgcgicontentfull27suppl_1s110
3 Mensing C Boucher J Cypress M et al National standards for diabetes self-management education Diabetes
Care 200528 Suppl 1S72-9 See httpcarediabetesjournalsorgcgicontentfull28suppl_1s72
4 Goldstein DE Little RR Lorenz RA Malone JI Nathan DM Peterson CM American Diabetes Association Tests
of glycemia in diabetes Diabetes Care 200427 Suppl 1S91-3
See httpcarediabetesjournalsorgcgicontentfull27suppl_1s91
5 The Diabetes Control and Complications Trial Research Group Hypoglycemia in the Diabetes Control and
Complications Trial Diabetes 199746(2)271-86 See wwwncbinlmnihgovpubmed9000705 for abstract
6 American Diabetes Association Hypoglycemia and employmentlicensure Diabetes Care 200528 Suppl 1S61
See httpcarediabetesjournalsorgcgicontentfull28suppl_1s61
7 Viswanath K McGavin DD Diabetic Retinopathy Clinical Findings and Management J Comm Eye Health
200316(46)21-4 See wwwcehjournalorg0953-683316jceh_16_46_021html
8 Michigan Diabetes Research and Training Center University of Michigan Health System How to use the Michigan
Neuropathy Screening Instrument See wwwmedumichedumdrtcprofsdocumentssviMNSI_howtopdf
9 Bradley JG Davis KA Orthostatic hypotension Am Fam Physician 200368(12)2393-8
See wwwaafporgafp200312152393html
10 Gibbons RJ Balady GJ Bricker JT et al ACCAHA 2002 guideline update for exercise testing a report of the
American College of CardiologyAmerican Heart Association Task Force on Practice Guidelines (Committee on
Exercise Testing) J Am Coll Cardiol 200240(8)1531-40
See wwwaccorgqualityandscienceclinicalguidelinesexerciseexercise_cleanpdf
11 American Diabetes Association Standards of medical care in diabetes Diabetes Care 200528 Suppl 1S4-S36
Erratum in Diabetes Care 200528(4)990 See httpcarediabetesjournalsorgcgicontentfull28suppl_1s4
12 Molitch ME DeFronzo RA Franz MJ et al American Diabetes Association Nephropathy in diabetes Diabetes
Care 200427 Suppl 1S79-83 See httpcarediabetesjournalsorgcgicontentfull27suppl_1s79
13 Kitabchi AE Umpierrez GE Murphy MB et al American Diabetes Association Hyperglycemic crises in diabetes
Diabetes Care 200427 Suppl 1S94-102 See httpcarediabetesjournalsorgcgicontentfull27suppl_1s94
14 US Centers for Disease Control and Prevention National Diabetes Fact Sheet 2007
See wwwcdcgovdiabetespubspdfndfs_2007pdf
ACOEM Guidance for the Medical Evaluation of Law Enforcement Officers 11
43 ndash DIABETES MELLITUS
30
ATTACHMENT E
31
Typos A6921(2) 7th line down test should be plural 94201 Paragraph 2 target organ damage is used though end organ damage was defined earlier and in the appendix for that paragraph
A94201 Para A (1) d Id suggest deleting the phrases in brackets Im not sure either are predictably true or politically wise
a) tests for left ventricular hypertrophy Unfortunately use of the EKG to detect left ventricular hypertrophy is very insensitive (eg 5 sensitivity) The echocardiogram is the best test for diagnosing left ventricular hypertrophy but [it is relatively expensive and not readily available in small rural communities ] conducting echocardiograms on asymptomatic fire fighters with Stage 1 hypertension should be reserved only for those with long-standing hypertension
In addition
7761 A resting EKG shall be performed as part of the baseline medical evaluation and shall be obtained periodically thereafter
Changing from annually to periodically is noted has the language in the wellness-fitness initiative been changed as well Our previous decision was that we would support the W-F language since there was no compelling evidence to either support or refute it
Thanks
Sandy
32
NFPA 1582‐ HTN Draft 1
Reason for Revision
1) New classification of BP by the Joint National Commission [Chobanian et al 2002]
2) A high prevalence of FF have either HTN (~20) and Pre‐HTN (~20) [Soteriades et al 2003]
3) Among FF studies have shown a strong association between HTN and a number of adverse
cardiovascular events [Kales et al 2009]
4) A large percentage of on‐duty FF fatalities were found to have left ventricular hypertrophy a
complication of HTN at autopsy
Language in 2007 Edition with draft revisions in Red (Track changes)
611 The medical evaluation of a candidate shall include a medical history examination and any laboratory tests required to detect physical or medical condition(s) that could adversely affect hisher ability to safely perform the essential job tasks outlined in 511 A611 The medical history should include the candidates known health problems such as major illnesses surgeries medication use and allergies Symptom review is also important for detecting early signs of illness A medical history should also include a personal health history a family health history a health habit history an immunization history and a reproductive history
An occupational history should also be obtained to collect information about the persons past occupational and environmental exposures
(a) BP should be measured according to the Joint National Commission (JNC) -7 recommendations BP should be measured with a properly calibrated and validated instrument Patients should be seated quietly for at least 5 minutes in a chair with feet on the floor and arm supported at heart level An appropriate-sized cuff (cuff bladder encircling at least 80 of the arm) should be used to ensure accuracy At least 2 measurements should be made Systolic BP is the point at which the first of 2 or more sounds is heard (phase 1) and diastolic BP is the point before the disappearance of sounds (phase 5) [Chobanian et al 2003]
(2) Head eyes ears nose and throat (HEENT)
Formatted Font (Default) Times New RomanFont color Black
33
692 Vascular System 6921 Category A medical conditions shall include the following
(1) Uncontrolled or poorly controlled hypertension
(2) Hypertension with evidence of end organ damage
or not controlled by approved medications
A6921(1) Uncontrolled or poorly controlled hHypertension increases the risk of a sudden cardiac event This sudden cardiac event would cause sudden incapacitation which that is uncontrolled poorly controlled or requires medication likely to interferes with the safe performance of essential job tasks Uncontrolled or poorly controlled hypertension can be defined as the presence of end organ damage (see below) or stage 2 hypertension (BP systolic gt160 mmHg or BP diastolic gt100 mmHg) is an illness that can lead to functional impairment and potential for sudden incapacitation Individuals with pre- stage 1 or stage 2 hypertension should be referred to their primary care physician for evaluation lifestyle modification and treatment [QUESTION FOR GROUP _- WHAT ABOUT HAVING CANDIDATE RETURN IN ONE MONTH UNDER TREATMENT WITH NORMAL BP]
A6921(2)
Chronic hypertension can damage the eye (retinopathy) the kidneys (nephropathy) the vascular system (stroke transient ischemic attack or peripheral artery disease) or the heart (left ventricular hypertrophy and heart failure) These hypertension complications are known as end organ damage The cardiac and vascular complications are associated with an increased risk of sudden incapacitation and sudden cardiac death (Koren et al 1991) Unfortunately the cardiac complications are frequently asymptomatic and valid screening tests are not fast and are not inexpensive Therefore determining who to screen for cardiac complications (such as echocardiogram for LVH or a measurement of left ventricular ejection fraction for heart failure) should be based on the severity and the duration of HTN
76 Physical Examination The annual physical examination shall include each of the following components
(a) BP shall be measured according to the Joint National Commission (JNC)-7 recommendations
A76(1)(a) BP should be measured with a properly calibrated and validated instrument Patients should be seated quietly for at least 5 minutes in a chair with feet on the floor and arm supported at heart level An appropriate-sized cuff (cuff bladder encircling at least 80 of the arm) should be used to ensure accuracy At least 2 measurements should be made Systolic BP is the point at which the first of 2 or more sounds is heard (phase 1) and diastolic BP is the point before the disappearance of sounds (phase 5) [Chobanian et al 2003]
(2) Head eyes ears nose and throat (HEENT)
34
9420 Uncontrolled Hypertension 94201 Physician Evaluation Severe uncontrolled hypertension [defined as systolic pressure greater than 180 mm Hg diastolic pressure greater than 100 mm Hg or mean systolic blood
pressure ( systolic + diastolic) greater than 120 mm Hg] or malignant hypertension (defined as hypertension with the presence of target organ damage) compromises the members ability to safely perform essential job tasks 1 5 7 9 and 13 and the physician shall report the applicable job limitations to the fire department
Members with Pre-hypertention (systolic 120-139 mmHg or diastolic 80-89 mmHg) Stage 1 hypertension (systolic 140-159 mmHg or diastolic 90-99 mmHg) or Stage 2 hypertension (systolic ge160 mmHg or diastolic ge100 mmHg) should be referred to their primary care physician for evaluation lifestyle modification and treatment
(1) Members with Stage I hypertension should be followed-up not only by their primary care physician but also by the FD physician every 3 to 6 months to ensure their blood pressure is under control and to determine whether screening tests for asymptomatic end organ damage are appropriate
(2) Members with Stage 2 hypertension or with end organ damage (retinopathy nephropathy vascular or cardiac complications) compromises the members ability to safely perform essential job tasks 1 5 7 9 and 130 and the physician shall report the applicable job limitations to the fire department
A94201 Severe uncontrolled hypertension is a significant risk factor for the development of coronary artery disease congestive heart failure and stroke Blood pressure increases as a normal response to exercise This response is further exaggerated by the emotional and physical stress of performing these critical tasks while operating in personal protective clothing at extremes of temperature This normal elevation of blood pressure under these response conditions can lead to life-threatening hypertensive emergencies if a members daily blood pressure is already elevated to high levels In addition hypertension is a progressive illness that when uncontrolled ultimately and inevitably leads to target organ damage Target organs that are sensitive to the effects of elevated blood pressure are the central nervous system vision heart major blood vessels and kidneys
Chronic hypertension can damage the eye (retinopathy) the kidneys (nephropathy) the vascular system (stroke transient ischemic attack or peripheral artery disease) or the heart (left ventricular hypertrophy and heart failure) These hypertension complications are known as end organ damage The cardiac and vascular complications are associated with an increased risk of sudden incapacitation and sudden cardiac death (Koren et al 1991) Fortunately with proper evaluation life style modification and treatment these complications can be avoided Life style modification includes weight reduction DASH eating plan reduction in dietary sodium an increase in aerobic physical activity and moderation in alcohol consumption [Chobanian 2003]
Formatted Font (Default) Times New Roman12 pt Font color Black
Formatted Font (Default) Times New Roman12 pt Font color Black
35
A94201 (1) Members with Stage I hypertension whose BP returns to either pre-hypertenion or normal with lifestyle modification andor treatment can return to an annual medical evaluation For members with long-standing Stage I hypertension whose BP has not been reduced additional evaluation for possible end organ damage should be considered This evaluation could include any or all of the following
a) a compete patient history for symptoms of heart failure (eg shortness of breath upon exertion) or transient ischemic attacks (TIAs)
b) dilated eye examination for retinopathy
c) blood creatinine measurement for nephropathy
d) tests for left ventricular hypertrophy Unfortunately use of the resting EKG to detect left ventricular hypertrophy is very insensitive (eg 5 sensitivity) The echocardiogram is the best test for diagnosing left ventricular hypertrophy
A 94201 (2) Due to the high risk of a sudden cardiovascular event members with Stage 2 hypertension should be restricted until their BP can be brought under control Once the BP is brought under control they should be followed in the same manner as a member with Stage I hypertension
Formatted Font (Default) Times New Roman12 pt
36
D22 Cardiology Gibbons R J GJ Balady J W Beasley et al 1997 ACCAHA guidelines for exercise testing a report of American College of CardiologyAmerican Heart Association Task Force on Practice Guidelines (Committee on Exercise Testing) J Am Coll Cardiol 30260ndash311
Gibbons RJ Balady GJ Bricker JT Chaitman BR Fletcher GF Froelicher VF Mark DB McCallister BD Mooss AN OrsquoReilly MG Winters WL Jr [2002] ACCAHA 2002 guideline update for exercise testing summary article a report of the ACCAHA Task Force on Practice Guidelines (Committee to Update the 1997 Exercise Testing guidelines) J Am Coll Cardiol 401531ndash 40
Chobanian AV Bakris GL Black HR Cushman WC Green LA Izzo JL Jr Jones DW Materson BJ Oparil S Wright JT Jr Roccella EJ the National High Blood Pressure Education Program Coordinating Committee [2003] The seventh report of the Joint National Committee [JNC-7] on Prevention Detection Evaluation and Treatment of High Blood Pressure JAMA 2892560ndash2571
Soteriades ES Kales SN Liarokapis D Christiani DC [2003] Prospective surveillance of hypertension in firefighters J Clin Hypertens 5315-320
Kales SN Tsismenakis AJ Zhang C Soteriades ES [2009] Blood pressure in fire fighters police officers and other emergency responders Am J Hypertens 2211-20
37
NFPA 1582‐ HTN Draft 1
Reason for Revision
1) New classification of BP by the Joint National Commission [Chobanian et al 2002]
2) A high prevalence of FF have either HTN (~20) and Pre‐HTN (~20) [Soteriades et al 2003]
3) Among FF studies have shown a strong association between HTN and a number of adverse
cardiovascular events [Kales et al 2009]
4) A large percentage of on‐duty FF fatalities were found to have left ventricular hypertrophy a
complication of HTN at autopsy
Language in 2007 Edition with draft revisions in Red (Track changes)
611 The medical evaluation of a candidate shall include a medical history examination and any laboratory tests required to detect physical or medical condition(s) that could adversely affect hisher ability to safely perform the essential job tasks outlined in 511 A611 The medical history should include the candidates known health problems such as major illnesses surgeries medication use and allergies Symptom review is also important for detecting early signs of illness A medical history should also include a personal health history a family health history a health habit history an immunization history and a reproductive history
An occupational history should also be obtained to collect information about the persons past occupational and environmental exposures
(a) BP should be measured according to the Joint National Commission (JNC) -7 recommendations BP should be measured with a properly calibrated and validated instrument Patients should be seated quietly for at least 5 minutes in a chair with feet on the floor and arm supported at heart level An appropriate-sized cuff (cuff bladder encircling at least 80 of the arm) should be used to ensure accuracy At least 2 measurements should be made Systolic BP is the point at which the first of 2 or more sounds is heard (phase 1) and diastolic BP is the point before the disappearance of sounds (phase 5) [Chobanian et al 2003]
(2) Head eyes ears nose and throat
38
692 Vascular System 6921 Category A medical conditions shall include the following
(1) Uncontrolled or poorly controlled hypertension
(2) Hypertension with evidence of end organ damage
A6921(1) Uncontrolled or poorly controlled hypertension increases the risk of a sudden cardiac event This sudden cardiac event would cause sudden incapacitation which interferes with the safe performance of essential job tasks Uncontrolled or poorly controlled hypertension can be defined as the presence of end organ damage (see below) or stage 2 hypertension (BP systolic gt160 mmHg or BP diastolic gt100 mmHg) Individuals with pre- stage 1 or stage 2 hypertension should be referred to their primary care physician for evaluation lifestyle modification and treatment [QUESTION FOR GROUP _- WHAT ABOUT HAVING CANDIDATE RETURN IN ONE MONTH UNDER TREATMENT WITH NORMAL BP]
A6921(2)Chronic hypertension can damage the eye (retinopathy) the kidneys (nephropathy) the vascular system (stroke transient ischemic attack or peripheral artery disease) or the heart (left ventricular hypertrophy and heart failure) These hypertension complications are known as end organ damage The cardiac and vascular complications are associated with an increased risk of sudden incapacitation and sudden cardiac death (Koren et al 1991) Unfortunately the cardiac complications are frequently asymptomatic and valid screening tests are not fast and are not inexpensive Therefore determining who to screen for cardiac complications (such as echocardiogram for LVH or a measurement of left ventricular ejection fraction for heart failure) should be based on the severity and the duration of HTN
76 Physical Examination The annual physical examination shall include each of the following components
(a) BP shall be measured according to the Joint National Commission (JNC)-7 recommendations
A76(1)(a) BP should be measured with a properly calibrated and validated instrument Patients should be seated quietly for at least 5 minutes in a chair with feet on the floor and arm supported at heart level An appropriate-sized cuff (cuff bladder encircling at least 80 of the arm) should be used to ensure accuracy At least 2 measurements should be made Systolic BP is the point at which the first of 2 or more sounds is heard (phase 1) and diastolic BP is the point before the disappearance of sounds (phase 5) [Chobanian et al 2003]
(2) Head eyes ears nose and throat9420 Hypertension 94201 Physician Evaluation Members with Pre-hypertention (systolic 120-139 mmHg or diastolic 80-89 mmHg) Stage 1 hypertension (systolic 140-159 mmHg or diastolic 90-99 mmHg) or Stage 2 hypertension (systolic ge160 mmHg or diastolic ge100 mmHg) should be referred to their primary care physician for evaluation lifestyle modification and treatment
39
(1) Members with Stage I hypertension should be followed-up not only by their primary care physician but also by the FD physician every 3 to 6 months to ensure their blood pressure is under control and to determine whether screening tests for asymptomatic end organ damage are appropriate
(2) Members with Stage 2 hypertension or with end organ damage (retinopathy nephropathy vascular or cardiac complications) compromises the members ability to safely perform essential job tasks 1 5 7 9 and 130 and the physician shall report the applicable job limitations to the fire department
A94201 Chronic hypertension can damage the eye (retinopathy) the kidneys (nephropathy) the vascular system (stroke transient ischemic attack or peripheral artery disease) or the heart (left ventricular hypertrophy and heart failure) These hypertension complications are known as end organ damage The cardiac and vascular complications are associated with an increased risk of sudden incapacitation and sudden cardiac death (Koren et al 1991) Fortunately with proper evaluation life style modification and treatment these complications can be avoided Life style modification includes weight reduction DASH eating plan reduction in dietary sodium an increase in aerobic physical activity and moderation in alcohol consumption [Chobanian 2003]
A94201 (1) Members with Stage I hypertension whose BP returns to either pre-hypertenion or normal with lifestyle modification andor treatment can return to an annual medical evaluation For members with long-standing Stage I hypertension whose BP has not been reduced additional evaluation for possible end organ damage should be considered This evaluation could include any or all of the following
a) a compete patient history for symptoms of heart failure (eg shortness of breath upon exertion) or transient ischemic attacks (TIAs)
b) dilated eye examination for retinopathy
c) blood creatinine measurement for nephropathy
d) tests for left ventricular hypertrophy Unfortunately use of the resting EKG to detect left ventricular hypertrophy is very insensitive (eg 5 sensitivity) The echocardiogram is the best test for diagnosing left ventricular hypertrophy
A 94201 (2) Due to the high risk of a sudden cardiovascular event members with Stage 2 hypertension should be restricted until their BP can be brought under control Once the BP is brought under control they should be followed in the same manner as a member with Stage I hypertension
D22 Cardiology
40
Hypertension
Gibbons RJ Balady GJ Bricker JT Chaitman BR Fletcher GF Froelicher VF Mark DB McCallister BD Mooss AN OrsquoReilly MG Winters WL Jr [2002] ACCAHA 2002 guideline update for exercise testing summary article a report of the ACCAHA Task Force on Practice Guidelines (Committee to Update the 1997 Exercise Testing guidelines) J Am Coll Cardiol 401531ndash 40
Chobanian AV Bakris GL Black HR Cushman WC Green LA Izzo JL Jr Jones DW Materson BJ Oparil S Wright JT Jr Roccella EJ the National High Blood Pressure Education Program Coordinating Committee [2003] The seventh report of the Joint National Committee [JNC-7] on Prevention Detection Evaluation and Treatment of High Blood Pressure JAMA 2892560ndash2571
Soteriades ES Kales SN Liarokapis D Christiani DC [2003] Prospective surveillance of hypertension in firefighters J Clin Hypertens 5315-320
Kales SN Tsismenakis AJ Zhang C Soteriades ES [2009] Blood pressure in fire fighters police officers and other emergency responders Am J Hypertens 2211-20
41
NFPA 1582‐ Draft Revisions for CVDHTN
EKG and stress tests
Reason for Revision
1) Change requirement for annual resting EKG to periodically to be more consistent with ACCAHA
recommendation (Schlant et al 1992)
2) Add language to clarify what constitutes a positive ST
3) Make criteria for conducting diagnostic ST in asymptomatic patients consistent with the
ACCAHA
Language in 2007 Edition with draft revisions in Red (Track changes)
776 Electrocardiograms (EKG)) and Stress Tests 7761 A resting EKG shall be performed as part of the baseline medical evaluation and shall be obtained periodically (every 1 to 5 years) annually thereafter
A7761 A baseline resting EKGs shall be conducted Follow-up resting EKGs should be conducted as clinically indicated but at a minimum of every 1 to 5 years The frequency of these follow-up resting EKGs should increase as a members age increases or with increasing number andor severity of coronary heart disease risk factors Members above the age of 40 should have annual resting EKGs (Schlant et al 1992)
7762 The fire department physician or other qualified medical evaluator shall compare EKGs obtained during yearly evaluations with baseline and subsequent EKGs
7763 Stress testing EKG with or without echocardiography or radionuclide scanning shall be performed as clinically indicated by history or symptoms
A7761 Baseline electrocardiography should be conducted (Periodic resting electrocardiograms have not been shown to be useful but can be reasonable as a members agefactors increase)
A7763 No firm guidelines for stress testingelectrocardiography in asymptomatic individuals have been developed Stress testingelectrocardiography as a screening tool is used as part of an evaluation of aerobic capacity during the annual occupational fitness evaluation Submaximal stress testingelectrocardiography testing to 85 percent is commonly used as part of this screening
Submaximal stress electrocardiography testing should not be used for diagnostic purposes Cardiology evaluation with maximal stress testingelectrocardiography together with imaging techniques (eg echocardiography technetium Tc99m sestamibi study andor coronary angiography) is necessary for diagnosticprognostic purposes for the following
42
(1) Fire fighters with positive or questionably positive changes on screening submaximal stress tests
(2) Fire fighters with new onset chest pain or other symptoms suggestive of coronary artery disease (CAD)
(3) Fire fighters with diabetes mellitus who
(a) are gt35 years old or
(b) have type I diabetes for more than 15 years or
(c) have type II diabetes for more than 10 years or
(d) have any other CHD risk factor (see below) or
(e) have the presence of microvascular disease (proliferative retinopathy)
(4) Fire fighters over the age of 45 (for men) and 55 (for women) with onetwo or more risk factors for CAD Risk factors for CAD include hypercholesterolemia (total cholesterol greater than 240 mgdL) hypertension (systolic gt140 mmHg or diastolic gt90 mmHg) smoking or family history of premature CAD (heart attack or sudden cardiac death in a first degree relative less than 60 years of age)
as defined below if stress electrocardiography with imaging is negative then repeat as clinically indicated or at least every 5 years
(5) Fire fighters with a Framingham Risk Score gt10 Risk calculator is available at [httphp2010nhlbihinnetatpiiicalculatorasp]
(6) Fire fighters identified in 9431
Negative stress tests should be repeated as clinically indicated or at least every 2 to 5 years
Interpreting stress tests as ldquopositiverdquo or ldquonegativerdquo is beyond the scope of this document However factors that should be taken into consideration should include the individualrsquos exercise capacity symptoms blood pressure response heart rate response EKG changes and the presence of arrhythmias (Gibbon et al 2002)
Risk factors for CAD include hypercholesterolemia (total cholesterol greater than 240 mgdL) hypertension (systolic greater than 140 andor diastolic greater than 90) smoking diabetes mellitus or family history of premature CAD (heart attack or sudden cardiac death in a first degree relative less than 60 years of age)
There are other non-invasive tests to screen for coronary artery disease One of the most promising appears to be coronary artery calcium (CAD) scoring by computed tomography In 2007 an expert committee published an update to their original guidance document The committeersquos consensus was that ldquoit may be reasonable to consider use of CAC measurement in such patients [between 10 and 20 10-year risk of estimated coronary event]helliprdquo The committee did not recommend CAC measurement in low risk patients [lt10 10-year risk of estimated coronary event] or in high risk patients [gt20 10-year risk of estimate coronary event] (Greenland et al 2007]
43
D22 Cardiology
Chobanian AV Bakris GL Black HR Cushman WC Green LA Izzo JL Jr Jones DW Materson BJ Oparil S Wright JT Jr Roccella EJ the National High Blood Pressure Education Program Coordinating Committee [2003] The seventh report of the Joint National Committee [JNC-7] on Prevention Detection Evaluation and Treatment of High Blood Pressure JAMA 2892560ndash2571
Gibbons RJ Balady GJ Bricker JT Chaitman BR Fletcher GF Froelicher VF Mark DB McCallister BD Mooss AN OrsquoReilly MG Winters WL Jr [2002] ACCAHA 2002 guideline update for exercise testing summary article a report of the ACCAHA Task Force on Practice Guidelines (Committee to Update the 1997 Exercise Testing guidelines) J Am Coll Cardiol 401531ndash 1540
Greenland et al [2007] ACCFAHA 2007 Clinical Expert Consensus Document on Coronary Artery Calcium Scoring By Computed Tomography in Global Cardiovascular Risk Assessment and in Evaluation of Patients With Chest Pain A Report of the American College of Cardiology Foundation Clinical Expert Consensus Task Force (ACCFAHA Writing Committee to Update the 2000 Expert Consensus Document on Electron Beam Computed Tomography) J Am Coll Cardiol 49378-402
Kales SN Tsismenakis AJ Zhang C Soteriades ES [2009] Blood pressure in fire fighters police officers and other emergency responders Am J Hypertens 2211-20
Schlant RC Adolph RJ DiMarco JP Dreifus LS Dunn MI Fisch C Garson A Jr Haywood LJ Levine HJ Murray JA Noble RJ Ronan JA Jr [1992] Guidelines for electrocardiography A report of the American College of CardiologyAmerican Heart Association Task Force on Assessment of Diagnostic and Therapeutic Cardiovascular Procedures (Committee on Electrocardiography) Circulation 85(3)1221-1228
Soteriades ES Kales SN Liarokapis D Christiani DC [2003] Prospective surveillance of hypertension in firefighters J Clin Hypertens 5315-320
Formatted Font Italic
Formatted Line spacing single
Formatted Font Italic
Formatted Font Italic
44
NFPA 1582‐ Draft Revisions for CVDHTN
EKG and stress tests
Reason for Revision
1) Change requirement for annual resting EKG to periodically to be more consistent with ACCAHA
recommendation (Schlant et al 1992)
2) Add language to clarify what constitutes a positive ST
3) Make criteria for conducting diagnostic ST in asymptomatic patients consistent with the
ACCAHA
Language in 2007 Edition with draft revisions in Red (Track changes)
776 Electrocardiograms (EKG) and Stress Tests 7761 A resting EKG shall be performed as part of the baseline medical evaluation and shall be obtained periodically (every 1 to 5 years) thereafter
A7761 A baseline resting EKGs shall be conducted Follow-up resting EKGs should be conducted as clinically indicated but at a minimum of every 1 to 5 years The frequency of these follow-up resting EKGs should increase as a members age increases or with increasing number andor severity of coronary heart disease risk factors Members above the age of 40 should have annual resting EKGs (Schlant et al 1992)
7762 The fire department physician or other qualified medical evaluator shall compare baseline and subsequent EKGs
7763 Stress testing with or without echocardiography or radionuclide scanning shall be performed as clinically indicated by history or symptoms
A7763 No firm guidelines for stress testing in asymptomatic individuals have been developed Stress testing as a screening tool is used as part of an evaluation of aerobic capacity during the annual occupational fitness evaluation Submaximal stress testing testing to 85 percent is commonly used as part of this screening
Submaximal stress testing should not be used for diagnostic purposes Cardiology evaluation with maximal stress testing together with imaging techniques (eg echocardiography technetium Tc99m sestamibi study) is necessary for diagnosticprognostic purposes for the following
(1) Fire fighters with positive or questionably positive changes on screening submaximal stress tests
(2) Fire fighters with new onset chest pain or other symptoms suggestive of coronary artery disease (CAD)
45
(3) Fire fighters with diabetes mellitus who
(a) are gt35 years old or
(b) have type I diabetes for more than 15 years or
(c) have type II diabetes for more than 10 years or
(d) have any other CHD risk factor (see below) or
(e) have the presence of microvascular disease (proliferative retinopathy)
(4) Fire fighters over the age of 45 (for men) and 55 (for women) with one or more risk factors for CAD Risk factors for CAD include hypercholesterolemia (total cholesterol greater than 240 mgdL) hypertension (systolic gt140 mmHg or diastolic gt90 mmHg) smoking or family history of premature CAD (heart attack or sudden cardiac death in a first degree relative less than 60 years of age)
(5) Fire fighters with a Framingham Risk Score gt10 Risk calculator is available at [httphp2010nhlbihinnetatpiiicalculatorasp]
(6) Fire fighters identified in 9431
Negative stress tests should be repeated as clinically indicated or at least every 2 to 5 years
Interpreting stress tests as ldquopositiverdquo or ldquonegativerdquo is beyond the scope of this document However factors that should be taken into consideration should include the individualrsquos exercise capacity symptoms blood pressure response heart rate response EKG changes and the presence of arrhythmias (Gibbon et al 2002)
There are other non-invasive tests to screen for coronary artery disease One of the most promising appears to be coronary artery calcium (CAD) scoring by computed tomography In 2007 an expert committee published an update to their original guidance document The committeersquos consensus was that ldquoit may be reasonable to consider use of CAC measurement in such patients [between 10 and 20 10-year risk of estimated coronary event]helliprdquo The committee did not recommend CAC measurement in low risk patients [lt10 10-year risk of estimated coronary event] or in high risk patients [gt20 10-year risk of estimate coronary event] (Greenland et al 2007]
D22 Cardiology
Resting EKG and Stress Tests
46
Chobanian AV Bakris GL Black HR Cushman WC Green LA Izzo JL Jr Jones DW Materson BJ Oparil S Wright JT Jr Roccella EJ the National High Blood Pressure Education Program Coordinating Committee [2003] The seventh report of the Joint National Committee [JNC-7] on Prevention Detection Evaluation and Treatment of High Blood Pressure JAMA 2892560ndash2571
Gibbons RJ Balady GJ Bricker JT Chaitman BR Fletcher GF Froelicher VF Mark DB McCallister BD Mooss AN OrsquoReilly MG Winters WL Jr [2002] ACCAHA 2002 guideline update for exercise testing summary article a report of the ACCAHA Task Force on Practice Guidelines (Committee to Update the 1997 Exercise Testing guidelines) J Am Coll Cardiol 401531ndash 1540
Greenland et al [2007] ACCFAHA 2007 Clinical Expert Consensus Document on Coronary Artery Calcium Scoring By Computed Tomography in Global Cardiovascular Risk Assessment and in Evaluation of Patients With Chest Pain A Report of the American College of Cardiology Foundation Clinical Expert Consensus Task Force (ACCFAHA Writing Committee to Update the 2000 Expert Consensus Document on Electron Beam Computed Tomography) J Am Coll Cardiol 49378-402
Kales SN Tsismenakis AJ Zhang C Soteriades ES [2009] Blood pressure in fire fighters police officers and other emergency responders Am J Hypertens 2211-20
Schlant RC Adolph RJ DiMarco JP Dreifus LS Dunn MI Fisch C Garson A Jr Haywood LJ Levine HJ Murray JA Noble RJ Ronan JA Jr [1992] Guidelines for electrocardiography A report of the American College of CardiologyAmerican Heart Association Task Force on Assessment of Diagnostic and Therapeutic Cardiovascular Procedures (Committee on Electrocardiography) Circulation 85(3)1221-1228
Soteriades ES Kales SN Liarokapis D Christiani DC [2003] Prospective surveillance of hypertension in firefighters J Clin Hypertens 5315-320
47
ATTACHMENT F
48
1
Current 1582 (2007) language in reference to pregnancy 43 (4) Report to the fire department physician any medical condition that could interfere with the ability of the individual to safely perform essential job tasks such as illness or injury use of prescription or nonprescription drugs and pregnancy 6112 Category B medical conditions shall include the following (1) Pregnancy for its duration A7792 (e) If HIV prophylaxis is to be given the following tests should be done i CBC ii Glucose renal and hepatic chemical function iii Pregnancy test for females B121 Pregnancy and Reproduction Federal regulations as well as many court decisions including the US Supreme Courtrsquos decision in International Union et al v Johnson Controls Inc [499 US 187 111 S Ct 1196 (1991)] have interpreted the requirements of Title VII with respect to pregnancy and reproduction The AHJ should seek the advice of counsel in resolving specific questions concerning these requirements as well as other requirements that can be imposed by state or local laws C211 (4) Review health status with the individual being evaluated Contraindications for evaluations shall be reviewed addressing any changes in the individualrsquos health status since their last medical evaluation that would warrant deferring the evaluation including (g) Pregnancy Recommendations to language enhancement
A female employee who is assigned to regular fire line duty shall report a pregnancy immediately to their respective Supervisor and the fire department physician The employee will then be given the option of a non-hazardous alternative duty position for the duration of her pregnancy (can we say this or is it even appropriate) Any pregnant employee wishing to remain on regular line duty shall be informed of the possible risks and consequences to herself and her fetus that are associated with continued line fire fighting duty Among those risk factors are exposure to teratogens known to have negative effects on the developing fetus such as smoke diesel fumes hazardous chemicals and extreme heat
49
Page 2
appendix It is recommended that the pregnant employee complete a release of liability form signed by herself and her health care provider utilizing NFPArsquos 13 critical tasks as a reference This will inform the health care provider of specific job-related tasks that will need to be performed in order to continue regular line duty These tasks are basic physical standards that any entry level firefighter would have to be able to complete competently The employeersquos health condition will be kept confidential by the department in accordance with HIPAA standards Employees are allowed to remain on active regular duty until they are no longer able to perform their duties in a reasonable manner andor their protective gear no longer fits correctly It is the responsibility of the health care provider to evaluate the pregnant employee If at any time the health care provider feels the pregnant employee can no longer perform the job related tasks this should be reported to the employer by the employee immediately
50
ATTACHMENT G
51
From GLENN BENARICKTo Sawyer SteveSubject RE RE 7743Date Monday August 30 2010 21633 PM
Yes thats my understanding
Glenn P Benarick 211 Winged Elm CircleAiken SC 29803803-644-7093gbenarprodigynet
--- On Mon 83010 Sawyer Steve ltssawyerNFPAorggt wrote
From Sawyer Steve ltssawyerNFPAorggtSubject RE RE 7743To GLENN BENARICK ltgbenarprodigynetgtDate Monday August 30 2010 212 PM
So it should be ldquoorrdquo instead of ldquoandrdquo for now
Steven F Sawyer
Senior Fire Service Specialist
Executive Secretary IFMAFire Service Section
NFPA
1 Batterymarch Park
Quincy MA 02169
6179847423
Fax 6179847056
ssawyernfpaorg
From GLENN BENARICK [mailtogbenarprodigynet] Sent Monday August 30 2010 1202 PMTo Sawyer SteveSubject Fw RE 7743
52
Steve a couple of our docs agree with April Boyer
Glenn P Benarick 211 Winged Elm Circle
Aiken SC 29803
803-644-7093
gbenarprodigynet
--- On Mon 83010 David Prezant ltprezandfdnynycgovgt wrote
From David Prezant ltprezandfdnynycgovgtSubject RE 7743To Thomas R (CDCNIOSHDSHEFS) Hales lttrh1cdcgovgt GLENNBENARICK ltgbenarprodigynetgtCc Sandy Bogucki ltsandyboguckiyaleedugtDate Monday August 30 2010 1004 AM
agree
we should change this to NHANES III rather than Knudson we should alsomodify this to allow not only for predicted cutoffs but all for use of thelower limit of normal cutoff This is important to prevent false-classificationof spirometry as abnormal in older groups and in taller grps The latter ofparticular import to firefighter occupational health surveillance
thanks
David Prezant MDChief Medical Officer Office of Medical AffairsCo-Director WTC Medical Monitoring amp Treatment ProgramsNew York City Fire Department9 Metrotech Center - Rm 4W-1Brooklyn NY 11201Phone 718-999-2696Fax 718-999-0665
Life is full of twists and turns
53
This email may contain confidential information If you are the unintendedrecipient of this email please send it back and delete from your directory
gtgtgt Hales Thomas R (CDCNIOSHDSHEFS) lttrh1cdcgovgt 8302010955 AM gtgtgt
Glen
This seems like a very reasonable comment and illustrates the importance of having clinicians providefeedback on the std Im not familiar with the software program of the various spirometers (NHANES IIIvs KnudsonATS vs both) Given the large role both Dave Prezant and Sandy Bogucki had for thepulmonary section let me forward to them for clarification
Tom
From GLENN BENARICK [mailtogbenarprodigynet] Sent Sunday August 29 2010 456 PMTo Hales Thomas R (CDCNIOSHDSHEFS)Subject FW 7743
Tom is April Boyer correct
Glenn P Benarick 211 Winged Elm Circle
Aiken SC 29803
803-644-7093
gbenarprodigynet
--- On Thu 82610 Sawyer Steve ltssawyerNFPAorggt wrote
From Sawyer Steve ltssawyerNFPAorggtSubject FW 7743To GLENN BENARICK ltgbenarprodigynetgtDate Thursday August 26 2010 925 PM
FYI Do you have any answer She is write
Steven
54
Steven F Sawyer
Senior Fire Service Specialist
Executive Secretary IFMAFire Service Section
NFPA
1 Batterymarch Park
Quincy MA 02169
6179847423
Fax 6179847056
ssawyernfpaorg
From April Boyer [mailtoaboyerbicclinicorg] Sent Thursday August 26 2010 232 PMTo Sawyer SteveCc RobinMWebbmilstateorusSubject 7743
Steven
The spirometry tests cannot be corrected according to both references as the NFPA states because thereferences are contradictory The first part of 7743 states to follow the ATS guidelines and use theKnudsen (we at Basin Immediate Care use the Nhanes III) The second part states to follow the ACOEMguidelines and use the Nhanes III in the occupational setting if available with your unit (which is availableon ours) 7743 does not use the word OR regarding both requirements it uses the word AND whenreferring to the first and second parts thence making 7743 contradictory I realize the NFPA 1582 hasnot been updated since 2007 unless I have just not received an updated version
Our question to you is which part of 7743 do you want us to follow the first or the second part Anyfacility that has an updated computerized spirometry system (as we do) will not be able to follow bothrequired parts for obvious reasons We can either follow the first part of 7743 and use an oldercorrected version of the Knudson by going into our system and changing out of the Nhanes III conversionOR we can follow the second part of 7743 and use the newer corrected version of Nhanes III which ourunit offers too
If you have any questions you may contact me at anytime and I also have many references in regards toboth parts of 7743 if you would like to see them
55
Thank you~
April
Confidentiality NoticeThis message may contain information that isconfidential or privileged
If you are not the intended recipientPlease advise the sender immediately and delete this message
56
ATTACHMENT H
57
NFPA 1582 771(7) Proposed revisions
Why
Preliminary results of two prospective randomized trials on the PSA test were published in 2009 These studies resulted in medical organizations that previously providing guidance to modify their recommendations
Current language
771 Blood Tests Blood tests shall be performed annually and shall include the following
(7) Prostate specific antigen (PSA) after age 40 for positive family history if African American or if otherwise clinically indicated after age 50 for all other male member
Suggested Revision
771 Blood Tests Blood tests shall be performed annually and shall include the following
(7) Prostate specific antigen (PSA) after age 40 for positive family history if African American or if otherwise clinically indicated after age 50 for all other male member
772 Prostate-Specific Antigen (PSA) test At age 50 fire fighters shall have an opportunity to make an informed decision with either the Fire Department physician or their health care provider concerning the PSA test For fire fighters at increased risk of prostate cancer (African-Americans or those with a first degree relative diagnosed with prostate cancer before age 65) shall have the opportunity for this informed decision at age 40
A772 The PSA as a screening test for prostate cancer in asymptomatic men is controversial controversial for two reasons First there is no consensus that PSA screening actually saves lives For example the PSA test may detect small cancers that would never become life threatening Second it is unclear that the benefits of PSA screening outweigh the risks of follow-up diagnostic tests and cancer treatments For example the prostate biopsy used to diagnose prostate cancer may cause bleeding and infection And prostate cancer treatments such as surgery and radiation therapy may cause incontinence (inability to control urine flow) erectile dysfunction (erections inadequate for intercourse) and other complications For these reasons it is important that the benefits and risks of prostate diagnostic procedures and treatment be taken into account when considering the PSA screening test These considerations can be taken account during discussions with the fire department physician or onersquos health care provider
D211 Cancer Screening
Smith R A C J Mettlin K J Davis and H Eyre 2000 ldquoAmerican Cancer Society guidelines for the early detection of cancerrdquo CA J Clin 50(1)34ndash49
Added references
58
Carroll P Albertsen PC Greene K et al [2010] Prostate-specific antigen best practice statement 2009 update Am Urological Assoc Available at httpwwwauanetorgcontentguidelines-and-quality-careclinical-guidelinesmain-reportspsa09pdf Date accessed September 2010
Ferrini R Woolf SH [2009] Screening for prostate cancer in American men American College of Preventive Medicine Practice Policy Statement Available at httpwwwacpmorgprostatehtm Date accessed September 2010
National Cancer Institute [2009] Prostate-specific antigen test National Cancer Institute Fact Sheet Available at httpwwwcancergovcancertopicsfactsheetDetectionPSA Date accessed September 2010
Wolf AMD Wender RC Etzioni RB et al [2010] American Cancer Society guideline for the early detection of prostate cancer Update 2010 Available at httpcaonlineamcancersocorgcgicontentfullcaac20066v1 Date accessed September 2010
59
ATTACHMENT D
17
This weekrsquos conference call mentioned the Diabetes chapter written for the ACOEM document Guidance for the Medical Evaluation of the Law Enforcement Officer The task group working on this chapter (led Richard Miller of the Secret Service and our very own Dan Samo) worked with the ADA or over 2-3 years to come up with a consensus document
Please find the Chapter attached ltltDiabetes Guidance Sept 2010pdfgtgt
Regarding Dan Loeberrsquos points
1) Physical Evaluation Form - We could modify the LEO form (see end of the attached Chapter)
2) Duration required for stable regiment
1582 for IDDM Type 1 1 yr
Type 2 6 m
Oral Agents None specifically
ACOEM Police for IDDM Type 1 6m
Type 2 3m
Oral Agents 1m
The police document is much clearer about the decision regarding medical fitness for duty is the responsibility of the police physician with the treating diabetes-expert physician providing the data to the police physician to make an informed decision In this regard the police officer must provide the police physician with downloaded self monitoring glucose data for the 1 3 and 6 month time periods (see section 433)
3) HA1C ndash NFPA lt 8 over 3 month period
ACOEM Police ndash (Section 4333) Specifies the frequency on measurement and if gt8 requires further evaluation
Some other discrepancies End organ complications
NFPA ndash end organ complications (eye kidney heart neuro) ndash restriction
ACOEM Police ndash end organ complication -- requires further evaluation
18
Hypoglycemia (incapacitating ndash defined differently between the two documents (434)
NFPA ndash 0 episodes in past year le1 in past 5 yrs
ACOEM Police ndash 0 episodes in past year le2 in past 3 yrs
Given Dan Samorsquos and Richard Millerrsquos work with the ADALoeber it would be helpful to get their opinions on whether any of the changes requested by Loeber are appropriate for FF with DM
Tom
Thomas Hales MD MPH
Senior Medical Epidemiologist
NIOSH CDC
4676 Columbia Pkwy R-9
Cincinnati OH 45241
(513) 841-4583
trh1cdcgov
19
43 ndash DIABETES MELLITUS
431 ndash INTRODUCTION
The educated and motivated law enforcement officer (LEO) with well-managed diabetes mellitus can be capable of
safe and effective job performance1 However diabetes mellitus may place LEOs at risk for sudden incapacitation
thus jeopardizing their ability to perform critical job functions (These job functions include those listed in Sections
32 333 351 352 36 and 37 and discussed in Appendix A)
Therefore an individualized assessment of the LEOrsquos diabetes should be performed using the following evaluative
criteria to determine whether the individuals condition permits safe and effective job performance Such evaluation
must include the following key elements which are discussed in detail below
history of blood glucose control
knowledge of diabetes and its management
current stability of blood glucose
risk for significant hypoglycemia or hyperglycemia and
presence of diabetic complications
432 ndash OVERVIEW OF MEDICAL EVALUATION
The treating endocrinologist or other physician knowledgeable regarding diabetes management should provide
a narrative report certifying whether the LEO has or has not met the criteria set out in Sections 4321 through
4354 below In addition the physician should include supporting data (see Appendix B for the Physician Evalu-
ation Form)
4321 The LEO is under the care of an endocrinologist or other physician knowledgeable regarding diabetes
management Outpatient and in-patient medical record(s) for the last 3 years or since date of diagnosis
(whichever is shorter) should be reviewed by the treating physician and provided to the police physician
4322 If the LEO has type 1 diabetes the individual has been on a basalbolus regimena or an insulin pump
using analogue insulins for the 6 months prior to evaluation2
4323 If the LEO has type 2 diabetes on insulin the individual has been on a stable medication regimenb
for the 3 months prior to evaluation3 If on oral agents alone the LEO has been on a stable medication regimen
for the month prior to evaluationc
ACOEM Guidance for the Medical Evaluation of Law Enforcement Officers 1
43 ndash DIABETES MELLITUS
aA basalbolus insulin regimen consists of the use of a basal insulin (Glargine NPH) in a once or twice daily regimen to provide between-
meal insulin combined with the use of a short acting insulin (Regular Lispro Aspart or Glulisine) at mealtimes Insulin pumps are small
(beeper sized) battery powered devices that deliver small amounts of short-acting insulin in a constant infusion to meet basal insulin
requirements The wearer selects an additional mealtime bolus to be infused at the time of meals For more information on pumps visit
the manufacturerrsquos web sites ndash wwwMinimedcom wwwcozmorecom wwwanimascorpcom wwwdisetroniccom
bA stable insulin regimen is defined as maintaining the same types of insulin (long acting intermediate acting short or rapid acting)
Changes in insulin dose are part of the appropriate self-management of diabetes and do not disqualify an applicant or incumbent under
this section
cChanges in dose within the evaluation period will be allowed but addition of a new class of medications or insulin should result in a new
period of observation
one month for addition of a sulfonylurea or metformin
two months for the addition of a thiazolidinedione to insulin or a sulfonylurea or
three months for the addition of insulin
20
4324 If the LEO uses an insulin pump documentation is needed as follows
proper understanding and education in the use of the insulin pump
start date for the use of the pump
history of insulin site infectionsd
history of pump cessation and pump malfunction
backup plan for pump malfunction including use of injectable insulin and
frequency of infusion set changes
4325 The LEO has been educated in diabetes and its management and thoroughly informed of and under-
stands the procedures that must be followed to monitor and manage hisher diabetes and what procedures
should be followed if complications arise3
433 ndash QUANTITATIVE GLUCOSE MONITORING
4331 The LEO has documentation of ongoing self-monitoring of blood glucose
4332 This must be done with a glucose meter that stores every reading records date and time of reading
and from which data can be downloaded (Most meters now have this capability)
4333 Monitoring logs must be available covering the time period (1 3 or 6 months) as described in
Sections 4322 and 4323 The frequency of glucose monitoring must follow a schedule acceptable to the
police physician in consultation with the treating physician
Testing schedules are individual What follows is a common pattern but individual patterns may differ
2 ACOEM Guidance for the Medical Evaluation of Law Enforcement Officers
43 ndash DIABETES MELLITUS
dIndividual has not had more than one pump-site infection that caused him or her to miss work or usual daily activities in the preceding 6
months
THERAPEUTIC REGIMEN GLUCOSE TESTING SCHEDULE
Diet alone Once or twice a week
Metformin Thiazolidinediones or Alpha
Glucosidase inhibitors alone or in
combination
Once or twice a week
Sulfonylureas meglitanides nateglinide ndash
alone or in combination with the above group
Twice a day ndash AM and at supper with any
suspected hypoglycemic episodes
Insulin ndash one shot in combination with orals Twice a day ndash AM and at supper with any
suspected hypoglycemic episodes
2 to 3 times AM once a week
Insulin ndash two or more shots Insulin pump 3 to 4 times a day ndash at meals and bedtime
2 to 3 times AM once a week with any
suspected hypoglycemic episodes
21
4334 The LEO has had hemoglobin A1C measured at least 4 times a year (intervals of 2 to 3 months) over
the last 12 months prior to evaluation if diagnosis has been present for more than a year4 If hemoglobin A1C is
gt8 this may signal a problem with the LEOrsquos diabetes management that warrants further assessment5
434 ndash INCAPACITATING EVENTS
4341 The LEO has not had any incapacitating episodes within the past 1 year and no more than 2 episodes
in the past 3 years or since diagnosis of diabetes (whichever is shorter) of
43411 Severe hypoglycemia (loss of consciousness seizures or coma requiring assistance of others or
needing urgent treatment [glucagon injectionIV glucose]) or
43412 Blood sugar lt60 mgdl with unawareness demonstrated in current glucose logs6
435 ndash CHRONIC COMPLICATION SCREENING
4351 Chronic complications of diabetes are associated with increased risk for severe hypoglycemic
episodes and warrant further assessmente
4352 The components of screening for chronic complications are
43521 A complete eye exam by a qualified ophthalmologist or optometrist including a dilated retinal
exam demonstrating no more than mild background diabetic retinopathyf7
43522 Normal vibratory testing with a 128 Hz tuning forkg normal testing with 10 gram Semmes-
Weinstein monofilamentg and normal orthostatic blood pressureh and pulse testing89
ACOEM Guidance for the Medical Evaluation of Law Enforcement Officers 3
43 ndash DIABETES MELLITUS
ePresence of chronic complications of diabetes in and of themselves may not require the implementation of work restrictions
fNo more than one dot blot or flame-shaped hemorrhages or microaneurysm in all four fundus quadrants
gThe Michigan Diabetes Research and Training Center of the University of Michigan Health System recommends the following guidance
(see wwwmedumichedumdrtcprofsdocumentssviMNSI_howtopdf) for conducting vibratory and monofilament testing8
Vibration Sensation Vibration sensation should be performed with the great toe unsupported Vibration sensation will be tested bi-
laterally using a 128 Hz tuning fork placed over the dorsum of the great toe on the boney prominence of the DIP joint Patients whose
eyes are closed will be asked to indicate when they can no longer sense the vibration from the vibrating tuning fork In general the
examiner should be able to feel vibration from the hand-held tuning fork for 5 seconds longer on his distal forefinger than a normal subject
can at the great toe (eg examiners DIP joint of the first finger versus patients toe) If the examiner feels vibration for 10 or more seconds
on his or her finger then vibration is considered decreased A trial should be given when the tuning fork is not vibrating to be certain that
the patient is responding to vibration and not pressure or some other clue Vibration is scored as 1) present if the examiner senses the
vibration on his or her finger for lt10 seconds 2) reduced if sensed for 10 seconds or 3) absent (no vibration detection)
Monofilament Testing For this examination it is important that the patients foot be supported (ie allow the sole of the foot to rest on
a flat warm surface) The filament should initially be pre-stressed (4-6 perpendicular applications to the dorsum of the examiner s first
finger) The filament is then applied to the dorsum of the great toe midway between the nail fold and the DIP joint Do not hold the toe
directly The filament is applied perpendicularly and briefly (lt1 second) with an even pressure When the filament bends the force of
10 grams has been applied The patient whose eyes are closed is asked to respond yes if heshe feels the filament Eight correct responses
out of 10 applications is considered normal 1 to 7 correct responses indicates reduced sensation and no correct answers translates into
absent sensation
hOrthostatic hypotension is a physical finding defined by the American Autonomic Society and the American Academy of Neurology as a
systolic blood pressure decrease of at least 20 mm Hg or a diastolic blood pressure decrease of at least 10 mm Hg within 3 minutes of
standing
22
43523 Normal cardiac physical exam Cardiac stress testing to at least 12 METS is recommended and
should begin based on either the criteria of the American Heart AssociationAmerican College of
Cardiologyi10 or those of the American Diabetes Associationj11
Diabetics who have a normal cardiac stress test will be retested every one to three years based on
individual clinical assessment This assessment should consider
the age of the individual
the number and persistence of coronary artery disease (CAD) risk factors
the severity of CAD risk factors
43524 Microalbumincreatinine ratio 301 measured or calculatedk creatinine clearance
gt60 mlmin12
436 ndash ONGOING EVALUATION AND REQUIREMENTS
4361 Should have medical records and glucose meter logs reviewed periodically Because of the nature of
diabetes it is important that regular medical follow up be provided to the LEO The frequency and content of
the evaluation should be determined on an individual basis by the police physician in consultation with the
treating physicianl
4362 Must advise police physician of any change in type of medication
4363 Must advise police physician of any episodes of significant hypoglycemia or hyperglycemia
Urine microalbumincreatinine ratio _________________
III Treating Physician Statement
The above named individual meets all of the criteria provided on this form
Yes No ndash not recommended for position
No but IS recommended for position (letter of explanation attached)
It is my opinion that the above named individual is well-educated and well-motivated in diabetes self-management and has
achieved a level of diabetes management to be capable of safe and effective job performance as a law enforcement officer
I have reached this opinion after careful review of the above criteria
___________________________________________________________ ___________________________Signature of Physician Date
______________________________________________________________ ___________________________Printed or Typed Name of Physician Telephone Number
10 ACOEM Guidance for the Medical Evaluation of Law Enforcement Officers
43 ndash DIABETES MELLITUS
29
439 ndash REFERENCES
1 American Diabetes Association Diagnosis and classification of diabetes mellitus Diabetes Care 200427 Suppl
1S5-S10 See httpcarediabetesjournalsorgcgicontentfull27suppl_1s5
2 American Diabetes Association Continuous subcutaneous insulin infusion Diabetes Care 200427 Suppl 1S110
See httpcarediabetesjournalsorgcgicontentfull27suppl_1s110
3 Mensing C Boucher J Cypress M et al National standards for diabetes self-management education Diabetes
Care 200528 Suppl 1S72-9 See httpcarediabetesjournalsorgcgicontentfull28suppl_1s72
4 Goldstein DE Little RR Lorenz RA Malone JI Nathan DM Peterson CM American Diabetes Association Tests
of glycemia in diabetes Diabetes Care 200427 Suppl 1S91-3
See httpcarediabetesjournalsorgcgicontentfull27suppl_1s91
5 The Diabetes Control and Complications Trial Research Group Hypoglycemia in the Diabetes Control and
Complications Trial Diabetes 199746(2)271-86 See wwwncbinlmnihgovpubmed9000705 for abstract
6 American Diabetes Association Hypoglycemia and employmentlicensure Diabetes Care 200528 Suppl 1S61
See httpcarediabetesjournalsorgcgicontentfull28suppl_1s61
7 Viswanath K McGavin DD Diabetic Retinopathy Clinical Findings and Management J Comm Eye Health
200316(46)21-4 See wwwcehjournalorg0953-683316jceh_16_46_021html
8 Michigan Diabetes Research and Training Center University of Michigan Health System How to use the Michigan
Neuropathy Screening Instrument See wwwmedumichedumdrtcprofsdocumentssviMNSI_howtopdf
9 Bradley JG Davis KA Orthostatic hypotension Am Fam Physician 200368(12)2393-8
See wwwaafporgafp200312152393html
10 Gibbons RJ Balady GJ Bricker JT et al ACCAHA 2002 guideline update for exercise testing a report of the
American College of CardiologyAmerican Heart Association Task Force on Practice Guidelines (Committee on
Exercise Testing) J Am Coll Cardiol 200240(8)1531-40
See wwwaccorgqualityandscienceclinicalguidelinesexerciseexercise_cleanpdf
11 American Diabetes Association Standards of medical care in diabetes Diabetes Care 200528 Suppl 1S4-S36
Erratum in Diabetes Care 200528(4)990 See httpcarediabetesjournalsorgcgicontentfull28suppl_1s4
12 Molitch ME DeFronzo RA Franz MJ et al American Diabetes Association Nephropathy in diabetes Diabetes
Care 200427 Suppl 1S79-83 See httpcarediabetesjournalsorgcgicontentfull27suppl_1s79
13 Kitabchi AE Umpierrez GE Murphy MB et al American Diabetes Association Hyperglycemic crises in diabetes
Diabetes Care 200427 Suppl 1S94-102 See httpcarediabetesjournalsorgcgicontentfull27suppl_1s94
14 US Centers for Disease Control and Prevention National Diabetes Fact Sheet 2007
See wwwcdcgovdiabetespubspdfndfs_2007pdf
ACOEM Guidance for the Medical Evaluation of Law Enforcement Officers 11
43 ndash DIABETES MELLITUS
30
ATTACHMENT E
31
Typos A6921(2) 7th line down test should be plural 94201 Paragraph 2 target organ damage is used though end organ damage was defined earlier and in the appendix for that paragraph
A94201 Para A (1) d Id suggest deleting the phrases in brackets Im not sure either are predictably true or politically wise
a) tests for left ventricular hypertrophy Unfortunately use of the EKG to detect left ventricular hypertrophy is very insensitive (eg 5 sensitivity) The echocardiogram is the best test for diagnosing left ventricular hypertrophy but [it is relatively expensive and not readily available in small rural communities ] conducting echocardiograms on asymptomatic fire fighters with Stage 1 hypertension should be reserved only for those with long-standing hypertension
In addition
7761 A resting EKG shall be performed as part of the baseline medical evaluation and shall be obtained periodically thereafter
Changing from annually to periodically is noted has the language in the wellness-fitness initiative been changed as well Our previous decision was that we would support the W-F language since there was no compelling evidence to either support or refute it
Thanks
Sandy
32
NFPA 1582‐ HTN Draft 1
Reason for Revision
1) New classification of BP by the Joint National Commission [Chobanian et al 2002]
2) A high prevalence of FF have either HTN (~20) and Pre‐HTN (~20) [Soteriades et al 2003]
3) Among FF studies have shown a strong association between HTN and a number of adverse
cardiovascular events [Kales et al 2009]
4) A large percentage of on‐duty FF fatalities were found to have left ventricular hypertrophy a
complication of HTN at autopsy
Language in 2007 Edition with draft revisions in Red (Track changes)
611 The medical evaluation of a candidate shall include a medical history examination and any laboratory tests required to detect physical or medical condition(s) that could adversely affect hisher ability to safely perform the essential job tasks outlined in 511 A611 The medical history should include the candidates known health problems such as major illnesses surgeries medication use and allergies Symptom review is also important for detecting early signs of illness A medical history should also include a personal health history a family health history a health habit history an immunization history and a reproductive history
An occupational history should also be obtained to collect information about the persons past occupational and environmental exposures
(a) BP should be measured according to the Joint National Commission (JNC) -7 recommendations BP should be measured with a properly calibrated and validated instrument Patients should be seated quietly for at least 5 minutes in a chair with feet on the floor and arm supported at heart level An appropriate-sized cuff (cuff bladder encircling at least 80 of the arm) should be used to ensure accuracy At least 2 measurements should be made Systolic BP is the point at which the first of 2 or more sounds is heard (phase 1) and diastolic BP is the point before the disappearance of sounds (phase 5) [Chobanian et al 2003]
(2) Head eyes ears nose and throat (HEENT)
Formatted Font (Default) Times New RomanFont color Black
33
692 Vascular System 6921 Category A medical conditions shall include the following
(1) Uncontrolled or poorly controlled hypertension
(2) Hypertension with evidence of end organ damage
or not controlled by approved medications
A6921(1) Uncontrolled or poorly controlled hHypertension increases the risk of a sudden cardiac event This sudden cardiac event would cause sudden incapacitation which that is uncontrolled poorly controlled or requires medication likely to interferes with the safe performance of essential job tasks Uncontrolled or poorly controlled hypertension can be defined as the presence of end organ damage (see below) or stage 2 hypertension (BP systolic gt160 mmHg or BP diastolic gt100 mmHg) is an illness that can lead to functional impairment and potential for sudden incapacitation Individuals with pre- stage 1 or stage 2 hypertension should be referred to their primary care physician for evaluation lifestyle modification and treatment [QUESTION FOR GROUP _- WHAT ABOUT HAVING CANDIDATE RETURN IN ONE MONTH UNDER TREATMENT WITH NORMAL BP]
A6921(2)
Chronic hypertension can damage the eye (retinopathy) the kidneys (nephropathy) the vascular system (stroke transient ischemic attack or peripheral artery disease) or the heart (left ventricular hypertrophy and heart failure) These hypertension complications are known as end organ damage The cardiac and vascular complications are associated with an increased risk of sudden incapacitation and sudden cardiac death (Koren et al 1991) Unfortunately the cardiac complications are frequently asymptomatic and valid screening tests are not fast and are not inexpensive Therefore determining who to screen for cardiac complications (such as echocardiogram for LVH or a measurement of left ventricular ejection fraction for heart failure) should be based on the severity and the duration of HTN
76 Physical Examination The annual physical examination shall include each of the following components
(a) BP shall be measured according to the Joint National Commission (JNC)-7 recommendations
A76(1)(a) BP should be measured with a properly calibrated and validated instrument Patients should be seated quietly for at least 5 minutes in a chair with feet on the floor and arm supported at heart level An appropriate-sized cuff (cuff bladder encircling at least 80 of the arm) should be used to ensure accuracy At least 2 measurements should be made Systolic BP is the point at which the first of 2 or more sounds is heard (phase 1) and diastolic BP is the point before the disappearance of sounds (phase 5) [Chobanian et al 2003]
(2) Head eyes ears nose and throat (HEENT)
34
9420 Uncontrolled Hypertension 94201 Physician Evaluation Severe uncontrolled hypertension [defined as systolic pressure greater than 180 mm Hg diastolic pressure greater than 100 mm Hg or mean systolic blood
pressure ( systolic + diastolic) greater than 120 mm Hg] or malignant hypertension (defined as hypertension with the presence of target organ damage) compromises the members ability to safely perform essential job tasks 1 5 7 9 and 13 and the physician shall report the applicable job limitations to the fire department
Members with Pre-hypertention (systolic 120-139 mmHg or diastolic 80-89 mmHg) Stage 1 hypertension (systolic 140-159 mmHg or diastolic 90-99 mmHg) or Stage 2 hypertension (systolic ge160 mmHg or diastolic ge100 mmHg) should be referred to their primary care physician for evaluation lifestyle modification and treatment
(1) Members with Stage I hypertension should be followed-up not only by their primary care physician but also by the FD physician every 3 to 6 months to ensure their blood pressure is under control and to determine whether screening tests for asymptomatic end organ damage are appropriate
(2) Members with Stage 2 hypertension or with end organ damage (retinopathy nephropathy vascular or cardiac complications) compromises the members ability to safely perform essential job tasks 1 5 7 9 and 130 and the physician shall report the applicable job limitations to the fire department
A94201 Severe uncontrolled hypertension is a significant risk factor for the development of coronary artery disease congestive heart failure and stroke Blood pressure increases as a normal response to exercise This response is further exaggerated by the emotional and physical stress of performing these critical tasks while operating in personal protective clothing at extremes of temperature This normal elevation of blood pressure under these response conditions can lead to life-threatening hypertensive emergencies if a members daily blood pressure is already elevated to high levels In addition hypertension is a progressive illness that when uncontrolled ultimately and inevitably leads to target organ damage Target organs that are sensitive to the effects of elevated blood pressure are the central nervous system vision heart major blood vessels and kidneys
Chronic hypertension can damage the eye (retinopathy) the kidneys (nephropathy) the vascular system (stroke transient ischemic attack or peripheral artery disease) or the heart (left ventricular hypertrophy and heart failure) These hypertension complications are known as end organ damage The cardiac and vascular complications are associated with an increased risk of sudden incapacitation and sudden cardiac death (Koren et al 1991) Fortunately with proper evaluation life style modification and treatment these complications can be avoided Life style modification includes weight reduction DASH eating plan reduction in dietary sodium an increase in aerobic physical activity and moderation in alcohol consumption [Chobanian 2003]
Formatted Font (Default) Times New Roman12 pt Font color Black
Formatted Font (Default) Times New Roman12 pt Font color Black
35
A94201 (1) Members with Stage I hypertension whose BP returns to either pre-hypertenion or normal with lifestyle modification andor treatment can return to an annual medical evaluation For members with long-standing Stage I hypertension whose BP has not been reduced additional evaluation for possible end organ damage should be considered This evaluation could include any or all of the following
a) a compete patient history for symptoms of heart failure (eg shortness of breath upon exertion) or transient ischemic attacks (TIAs)
b) dilated eye examination for retinopathy
c) blood creatinine measurement for nephropathy
d) tests for left ventricular hypertrophy Unfortunately use of the resting EKG to detect left ventricular hypertrophy is very insensitive (eg 5 sensitivity) The echocardiogram is the best test for diagnosing left ventricular hypertrophy
A 94201 (2) Due to the high risk of a sudden cardiovascular event members with Stage 2 hypertension should be restricted until their BP can be brought under control Once the BP is brought under control they should be followed in the same manner as a member with Stage I hypertension
Formatted Font (Default) Times New Roman12 pt
36
D22 Cardiology Gibbons R J GJ Balady J W Beasley et al 1997 ACCAHA guidelines for exercise testing a report of American College of CardiologyAmerican Heart Association Task Force on Practice Guidelines (Committee on Exercise Testing) J Am Coll Cardiol 30260ndash311
Gibbons RJ Balady GJ Bricker JT Chaitman BR Fletcher GF Froelicher VF Mark DB McCallister BD Mooss AN OrsquoReilly MG Winters WL Jr [2002] ACCAHA 2002 guideline update for exercise testing summary article a report of the ACCAHA Task Force on Practice Guidelines (Committee to Update the 1997 Exercise Testing guidelines) J Am Coll Cardiol 401531ndash 40
Chobanian AV Bakris GL Black HR Cushman WC Green LA Izzo JL Jr Jones DW Materson BJ Oparil S Wright JT Jr Roccella EJ the National High Blood Pressure Education Program Coordinating Committee [2003] The seventh report of the Joint National Committee [JNC-7] on Prevention Detection Evaluation and Treatment of High Blood Pressure JAMA 2892560ndash2571
Soteriades ES Kales SN Liarokapis D Christiani DC [2003] Prospective surveillance of hypertension in firefighters J Clin Hypertens 5315-320
Kales SN Tsismenakis AJ Zhang C Soteriades ES [2009] Blood pressure in fire fighters police officers and other emergency responders Am J Hypertens 2211-20
37
NFPA 1582‐ HTN Draft 1
Reason for Revision
1) New classification of BP by the Joint National Commission [Chobanian et al 2002]
2) A high prevalence of FF have either HTN (~20) and Pre‐HTN (~20) [Soteriades et al 2003]
3) Among FF studies have shown a strong association between HTN and a number of adverse
cardiovascular events [Kales et al 2009]
4) A large percentage of on‐duty FF fatalities were found to have left ventricular hypertrophy a
complication of HTN at autopsy
Language in 2007 Edition with draft revisions in Red (Track changes)
611 The medical evaluation of a candidate shall include a medical history examination and any laboratory tests required to detect physical or medical condition(s) that could adversely affect hisher ability to safely perform the essential job tasks outlined in 511 A611 The medical history should include the candidates known health problems such as major illnesses surgeries medication use and allergies Symptom review is also important for detecting early signs of illness A medical history should also include a personal health history a family health history a health habit history an immunization history and a reproductive history
An occupational history should also be obtained to collect information about the persons past occupational and environmental exposures
(a) BP should be measured according to the Joint National Commission (JNC) -7 recommendations BP should be measured with a properly calibrated and validated instrument Patients should be seated quietly for at least 5 minutes in a chair with feet on the floor and arm supported at heart level An appropriate-sized cuff (cuff bladder encircling at least 80 of the arm) should be used to ensure accuracy At least 2 measurements should be made Systolic BP is the point at which the first of 2 or more sounds is heard (phase 1) and diastolic BP is the point before the disappearance of sounds (phase 5) [Chobanian et al 2003]
(2) Head eyes ears nose and throat
38
692 Vascular System 6921 Category A medical conditions shall include the following
(1) Uncontrolled or poorly controlled hypertension
(2) Hypertension with evidence of end organ damage
A6921(1) Uncontrolled or poorly controlled hypertension increases the risk of a sudden cardiac event This sudden cardiac event would cause sudden incapacitation which interferes with the safe performance of essential job tasks Uncontrolled or poorly controlled hypertension can be defined as the presence of end organ damage (see below) or stage 2 hypertension (BP systolic gt160 mmHg or BP diastolic gt100 mmHg) Individuals with pre- stage 1 or stage 2 hypertension should be referred to their primary care physician for evaluation lifestyle modification and treatment [QUESTION FOR GROUP _- WHAT ABOUT HAVING CANDIDATE RETURN IN ONE MONTH UNDER TREATMENT WITH NORMAL BP]
A6921(2)Chronic hypertension can damage the eye (retinopathy) the kidneys (nephropathy) the vascular system (stroke transient ischemic attack or peripheral artery disease) or the heart (left ventricular hypertrophy and heart failure) These hypertension complications are known as end organ damage The cardiac and vascular complications are associated with an increased risk of sudden incapacitation and sudden cardiac death (Koren et al 1991) Unfortunately the cardiac complications are frequently asymptomatic and valid screening tests are not fast and are not inexpensive Therefore determining who to screen for cardiac complications (such as echocardiogram for LVH or a measurement of left ventricular ejection fraction for heart failure) should be based on the severity and the duration of HTN
76 Physical Examination The annual physical examination shall include each of the following components
(a) BP shall be measured according to the Joint National Commission (JNC)-7 recommendations
A76(1)(a) BP should be measured with a properly calibrated and validated instrument Patients should be seated quietly for at least 5 minutes in a chair with feet on the floor and arm supported at heart level An appropriate-sized cuff (cuff bladder encircling at least 80 of the arm) should be used to ensure accuracy At least 2 measurements should be made Systolic BP is the point at which the first of 2 or more sounds is heard (phase 1) and diastolic BP is the point before the disappearance of sounds (phase 5) [Chobanian et al 2003]
(2) Head eyes ears nose and throat9420 Hypertension 94201 Physician Evaluation Members with Pre-hypertention (systolic 120-139 mmHg or diastolic 80-89 mmHg) Stage 1 hypertension (systolic 140-159 mmHg or diastolic 90-99 mmHg) or Stage 2 hypertension (systolic ge160 mmHg or diastolic ge100 mmHg) should be referred to their primary care physician for evaluation lifestyle modification and treatment
39
(1) Members with Stage I hypertension should be followed-up not only by their primary care physician but also by the FD physician every 3 to 6 months to ensure their blood pressure is under control and to determine whether screening tests for asymptomatic end organ damage are appropriate
(2) Members with Stage 2 hypertension or with end organ damage (retinopathy nephropathy vascular or cardiac complications) compromises the members ability to safely perform essential job tasks 1 5 7 9 and 130 and the physician shall report the applicable job limitations to the fire department
A94201 Chronic hypertension can damage the eye (retinopathy) the kidneys (nephropathy) the vascular system (stroke transient ischemic attack or peripheral artery disease) or the heart (left ventricular hypertrophy and heart failure) These hypertension complications are known as end organ damage The cardiac and vascular complications are associated with an increased risk of sudden incapacitation and sudden cardiac death (Koren et al 1991) Fortunately with proper evaluation life style modification and treatment these complications can be avoided Life style modification includes weight reduction DASH eating plan reduction in dietary sodium an increase in aerobic physical activity and moderation in alcohol consumption [Chobanian 2003]
A94201 (1) Members with Stage I hypertension whose BP returns to either pre-hypertenion or normal with lifestyle modification andor treatment can return to an annual medical evaluation For members with long-standing Stage I hypertension whose BP has not been reduced additional evaluation for possible end organ damage should be considered This evaluation could include any or all of the following
a) a compete patient history for symptoms of heart failure (eg shortness of breath upon exertion) or transient ischemic attacks (TIAs)
b) dilated eye examination for retinopathy
c) blood creatinine measurement for nephropathy
d) tests for left ventricular hypertrophy Unfortunately use of the resting EKG to detect left ventricular hypertrophy is very insensitive (eg 5 sensitivity) The echocardiogram is the best test for diagnosing left ventricular hypertrophy
A 94201 (2) Due to the high risk of a sudden cardiovascular event members with Stage 2 hypertension should be restricted until their BP can be brought under control Once the BP is brought under control they should be followed in the same manner as a member with Stage I hypertension
D22 Cardiology
40
Hypertension
Gibbons RJ Balady GJ Bricker JT Chaitman BR Fletcher GF Froelicher VF Mark DB McCallister BD Mooss AN OrsquoReilly MG Winters WL Jr [2002] ACCAHA 2002 guideline update for exercise testing summary article a report of the ACCAHA Task Force on Practice Guidelines (Committee to Update the 1997 Exercise Testing guidelines) J Am Coll Cardiol 401531ndash 40
Chobanian AV Bakris GL Black HR Cushman WC Green LA Izzo JL Jr Jones DW Materson BJ Oparil S Wright JT Jr Roccella EJ the National High Blood Pressure Education Program Coordinating Committee [2003] The seventh report of the Joint National Committee [JNC-7] on Prevention Detection Evaluation and Treatment of High Blood Pressure JAMA 2892560ndash2571
Soteriades ES Kales SN Liarokapis D Christiani DC [2003] Prospective surveillance of hypertension in firefighters J Clin Hypertens 5315-320
Kales SN Tsismenakis AJ Zhang C Soteriades ES [2009] Blood pressure in fire fighters police officers and other emergency responders Am J Hypertens 2211-20
41
NFPA 1582‐ Draft Revisions for CVDHTN
EKG and stress tests
Reason for Revision
1) Change requirement for annual resting EKG to periodically to be more consistent with ACCAHA
recommendation (Schlant et al 1992)
2) Add language to clarify what constitutes a positive ST
3) Make criteria for conducting diagnostic ST in asymptomatic patients consistent with the
ACCAHA
Language in 2007 Edition with draft revisions in Red (Track changes)
776 Electrocardiograms (EKG)) and Stress Tests 7761 A resting EKG shall be performed as part of the baseline medical evaluation and shall be obtained periodically (every 1 to 5 years) annually thereafter
A7761 A baseline resting EKGs shall be conducted Follow-up resting EKGs should be conducted as clinically indicated but at a minimum of every 1 to 5 years The frequency of these follow-up resting EKGs should increase as a members age increases or with increasing number andor severity of coronary heart disease risk factors Members above the age of 40 should have annual resting EKGs (Schlant et al 1992)
7762 The fire department physician or other qualified medical evaluator shall compare EKGs obtained during yearly evaluations with baseline and subsequent EKGs
7763 Stress testing EKG with or without echocardiography or radionuclide scanning shall be performed as clinically indicated by history or symptoms
A7761 Baseline electrocardiography should be conducted (Periodic resting electrocardiograms have not been shown to be useful but can be reasonable as a members agefactors increase)
A7763 No firm guidelines for stress testingelectrocardiography in asymptomatic individuals have been developed Stress testingelectrocardiography as a screening tool is used as part of an evaluation of aerobic capacity during the annual occupational fitness evaluation Submaximal stress testingelectrocardiography testing to 85 percent is commonly used as part of this screening
Submaximal stress electrocardiography testing should not be used for diagnostic purposes Cardiology evaluation with maximal stress testingelectrocardiography together with imaging techniques (eg echocardiography technetium Tc99m sestamibi study andor coronary angiography) is necessary for diagnosticprognostic purposes for the following
42
(1) Fire fighters with positive or questionably positive changes on screening submaximal stress tests
(2) Fire fighters with new onset chest pain or other symptoms suggestive of coronary artery disease (CAD)
(3) Fire fighters with diabetes mellitus who
(a) are gt35 years old or
(b) have type I diabetes for more than 15 years or
(c) have type II diabetes for more than 10 years or
(d) have any other CHD risk factor (see below) or
(e) have the presence of microvascular disease (proliferative retinopathy)
(4) Fire fighters over the age of 45 (for men) and 55 (for women) with onetwo or more risk factors for CAD Risk factors for CAD include hypercholesterolemia (total cholesterol greater than 240 mgdL) hypertension (systolic gt140 mmHg or diastolic gt90 mmHg) smoking or family history of premature CAD (heart attack or sudden cardiac death in a first degree relative less than 60 years of age)
as defined below if stress electrocardiography with imaging is negative then repeat as clinically indicated or at least every 5 years
(5) Fire fighters with a Framingham Risk Score gt10 Risk calculator is available at [httphp2010nhlbihinnetatpiiicalculatorasp]
(6) Fire fighters identified in 9431
Negative stress tests should be repeated as clinically indicated or at least every 2 to 5 years
Interpreting stress tests as ldquopositiverdquo or ldquonegativerdquo is beyond the scope of this document However factors that should be taken into consideration should include the individualrsquos exercise capacity symptoms blood pressure response heart rate response EKG changes and the presence of arrhythmias (Gibbon et al 2002)
Risk factors for CAD include hypercholesterolemia (total cholesterol greater than 240 mgdL) hypertension (systolic greater than 140 andor diastolic greater than 90) smoking diabetes mellitus or family history of premature CAD (heart attack or sudden cardiac death in a first degree relative less than 60 years of age)
There are other non-invasive tests to screen for coronary artery disease One of the most promising appears to be coronary artery calcium (CAD) scoring by computed tomography In 2007 an expert committee published an update to their original guidance document The committeersquos consensus was that ldquoit may be reasonable to consider use of CAC measurement in such patients [between 10 and 20 10-year risk of estimated coronary event]helliprdquo The committee did not recommend CAC measurement in low risk patients [lt10 10-year risk of estimated coronary event] or in high risk patients [gt20 10-year risk of estimate coronary event] (Greenland et al 2007]
43
D22 Cardiology
Chobanian AV Bakris GL Black HR Cushman WC Green LA Izzo JL Jr Jones DW Materson BJ Oparil S Wright JT Jr Roccella EJ the National High Blood Pressure Education Program Coordinating Committee [2003] The seventh report of the Joint National Committee [JNC-7] on Prevention Detection Evaluation and Treatment of High Blood Pressure JAMA 2892560ndash2571
Gibbons RJ Balady GJ Bricker JT Chaitman BR Fletcher GF Froelicher VF Mark DB McCallister BD Mooss AN OrsquoReilly MG Winters WL Jr [2002] ACCAHA 2002 guideline update for exercise testing summary article a report of the ACCAHA Task Force on Practice Guidelines (Committee to Update the 1997 Exercise Testing guidelines) J Am Coll Cardiol 401531ndash 1540
Greenland et al [2007] ACCFAHA 2007 Clinical Expert Consensus Document on Coronary Artery Calcium Scoring By Computed Tomography in Global Cardiovascular Risk Assessment and in Evaluation of Patients With Chest Pain A Report of the American College of Cardiology Foundation Clinical Expert Consensus Task Force (ACCFAHA Writing Committee to Update the 2000 Expert Consensus Document on Electron Beam Computed Tomography) J Am Coll Cardiol 49378-402
Kales SN Tsismenakis AJ Zhang C Soteriades ES [2009] Blood pressure in fire fighters police officers and other emergency responders Am J Hypertens 2211-20
Schlant RC Adolph RJ DiMarco JP Dreifus LS Dunn MI Fisch C Garson A Jr Haywood LJ Levine HJ Murray JA Noble RJ Ronan JA Jr [1992] Guidelines for electrocardiography A report of the American College of CardiologyAmerican Heart Association Task Force on Assessment of Diagnostic and Therapeutic Cardiovascular Procedures (Committee on Electrocardiography) Circulation 85(3)1221-1228
Soteriades ES Kales SN Liarokapis D Christiani DC [2003] Prospective surveillance of hypertension in firefighters J Clin Hypertens 5315-320
Formatted Font Italic
Formatted Line spacing single
Formatted Font Italic
Formatted Font Italic
44
NFPA 1582‐ Draft Revisions for CVDHTN
EKG and stress tests
Reason for Revision
1) Change requirement for annual resting EKG to periodically to be more consistent with ACCAHA
recommendation (Schlant et al 1992)
2) Add language to clarify what constitutes a positive ST
3) Make criteria for conducting diagnostic ST in asymptomatic patients consistent with the
ACCAHA
Language in 2007 Edition with draft revisions in Red (Track changes)
776 Electrocardiograms (EKG) and Stress Tests 7761 A resting EKG shall be performed as part of the baseline medical evaluation and shall be obtained periodically (every 1 to 5 years) thereafter
A7761 A baseline resting EKGs shall be conducted Follow-up resting EKGs should be conducted as clinically indicated but at a minimum of every 1 to 5 years The frequency of these follow-up resting EKGs should increase as a members age increases or with increasing number andor severity of coronary heart disease risk factors Members above the age of 40 should have annual resting EKGs (Schlant et al 1992)
7762 The fire department physician or other qualified medical evaluator shall compare baseline and subsequent EKGs
7763 Stress testing with or without echocardiography or radionuclide scanning shall be performed as clinically indicated by history or symptoms
A7763 No firm guidelines for stress testing in asymptomatic individuals have been developed Stress testing as a screening tool is used as part of an evaluation of aerobic capacity during the annual occupational fitness evaluation Submaximal stress testing testing to 85 percent is commonly used as part of this screening
Submaximal stress testing should not be used for diagnostic purposes Cardiology evaluation with maximal stress testing together with imaging techniques (eg echocardiography technetium Tc99m sestamibi study) is necessary for diagnosticprognostic purposes for the following
(1) Fire fighters with positive or questionably positive changes on screening submaximal stress tests
(2) Fire fighters with new onset chest pain or other symptoms suggestive of coronary artery disease (CAD)
45
(3) Fire fighters with diabetes mellitus who
(a) are gt35 years old or
(b) have type I diabetes for more than 15 years or
(c) have type II diabetes for more than 10 years or
(d) have any other CHD risk factor (see below) or
(e) have the presence of microvascular disease (proliferative retinopathy)
(4) Fire fighters over the age of 45 (for men) and 55 (for women) with one or more risk factors for CAD Risk factors for CAD include hypercholesterolemia (total cholesterol greater than 240 mgdL) hypertension (systolic gt140 mmHg or diastolic gt90 mmHg) smoking or family history of premature CAD (heart attack or sudden cardiac death in a first degree relative less than 60 years of age)
(5) Fire fighters with a Framingham Risk Score gt10 Risk calculator is available at [httphp2010nhlbihinnetatpiiicalculatorasp]
(6) Fire fighters identified in 9431
Negative stress tests should be repeated as clinically indicated or at least every 2 to 5 years
Interpreting stress tests as ldquopositiverdquo or ldquonegativerdquo is beyond the scope of this document However factors that should be taken into consideration should include the individualrsquos exercise capacity symptoms blood pressure response heart rate response EKG changes and the presence of arrhythmias (Gibbon et al 2002)
There are other non-invasive tests to screen for coronary artery disease One of the most promising appears to be coronary artery calcium (CAD) scoring by computed tomography In 2007 an expert committee published an update to their original guidance document The committeersquos consensus was that ldquoit may be reasonable to consider use of CAC measurement in such patients [between 10 and 20 10-year risk of estimated coronary event]helliprdquo The committee did not recommend CAC measurement in low risk patients [lt10 10-year risk of estimated coronary event] or in high risk patients [gt20 10-year risk of estimate coronary event] (Greenland et al 2007]
D22 Cardiology
Resting EKG and Stress Tests
46
Chobanian AV Bakris GL Black HR Cushman WC Green LA Izzo JL Jr Jones DW Materson BJ Oparil S Wright JT Jr Roccella EJ the National High Blood Pressure Education Program Coordinating Committee [2003] The seventh report of the Joint National Committee [JNC-7] on Prevention Detection Evaluation and Treatment of High Blood Pressure JAMA 2892560ndash2571
Gibbons RJ Balady GJ Bricker JT Chaitman BR Fletcher GF Froelicher VF Mark DB McCallister BD Mooss AN OrsquoReilly MG Winters WL Jr [2002] ACCAHA 2002 guideline update for exercise testing summary article a report of the ACCAHA Task Force on Practice Guidelines (Committee to Update the 1997 Exercise Testing guidelines) J Am Coll Cardiol 401531ndash 1540
Greenland et al [2007] ACCFAHA 2007 Clinical Expert Consensus Document on Coronary Artery Calcium Scoring By Computed Tomography in Global Cardiovascular Risk Assessment and in Evaluation of Patients With Chest Pain A Report of the American College of Cardiology Foundation Clinical Expert Consensus Task Force (ACCFAHA Writing Committee to Update the 2000 Expert Consensus Document on Electron Beam Computed Tomography) J Am Coll Cardiol 49378-402
Kales SN Tsismenakis AJ Zhang C Soteriades ES [2009] Blood pressure in fire fighters police officers and other emergency responders Am J Hypertens 2211-20
Schlant RC Adolph RJ DiMarco JP Dreifus LS Dunn MI Fisch C Garson A Jr Haywood LJ Levine HJ Murray JA Noble RJ Ronan JA Jr [1992] Guidelines for electrocardiography A report of the American College of CardiologyAmerican Heart Association Task Force on Assessment of Diagnostic and Therapeutic Cardiovascular Procedures (Committee on Electrocardiography) Circulation 85(3)1221-1228
Soteriades ES Kales SN Liarokapis D Christiani DC [2003] Prospective surveillance of hypertension in firefighters J Clin Hypertens 5315-320
47
ATTACHMENT F
48
1
Current 1582 (2007) language in reference to pregnancy 43 (4) Report to the fire department physician any medical condition that could interfere with the ability of the individual to safely perform essential job tasks such as illness or injury use of prescription or nonprescription drugs and pregnancy 6112 Category B medical conditions shall include the following (1) Pregnancy for its duration A7792 (e) If HIV prophylaxis is to be given the following tests should be done i CBC ii Glucose renal and hepatic chemical function iii Pregnancy test for females B121 Pregnancy and Reproduction Federal regulations as well as many court decisions including the US Supreme Courtrsquos decision in International Union et al v Johnson Controls Inc [499 US 187 111 S Ct 1196 (1991)] have interpreted the requirements of Title VII with respect to pregnancy and reproduction The AHJ should seek the advice of counsel in resolving specific questions concerning these requirements as well as other requirements that can be imposed by state or local laws C211 (4) Review health status with the individual being evaluated Contraindications for evaluations shall be reviewed addressing any changes in the individualrsquos health status since their last medical evaluation that would warrant deferring the evaluation including (g) Pregnancy Recommendations to language enhancement
A female employee who is assigned to regular fire line duty shall report a pregnancy immediately to their respective Supervisor and the fire department physician The employee will then be given the option of a non-hazardous alternative duty position for the duration of her pregnancy (can we say this or is it even appropriate) Any pregnant employee wishing to remain on regular line duty shall be informed of the possible risks and consequences to herself and her fetus that are associated with continued line fire fighting duty Among those risk factors are exposure to teratogens known to have negative effects on the developing fetus such as smoke diesel fumes hazardous chemicals and extreme heat
49
Page 2
appendix It is recommended that the pregnant employee complete a release of liability form signed by herself and her health care provider utilizing NFPArsquos 13 critical tasks as a reference This will inform the health care provider of specific job-related tasks that will need to be performed in order to continue regular line duty These tasks are basic physical standards that any entry level firefighter would have to be able to complete competently The employeersquos health condition will be kept confidential by the department in accordance with HIPAA standards Employees are allowed to remain on active regular duty until they are no longer able to perform their duties in a reasonable manner andor their protective gear no longer fits correctly It is the responsibility of the health care provider to evaluate the pregnant employee If at any time the health care provider feels the pregnant employee can no longer perform the job related tasks this should be reported to the employer by the employee immediately
50
ATTACHMENT G
51
From GLENN BENARICKTo Sawyer SteveSubject RE RE 7743Date Monday August 30 2010 21633 PM
Yes thats my understanding
Glenn P Benarick 211 Winged Elm CircleAiken SC 29803803-644-7093gbenarprodigynet
--- On Mon 83010 Sawyer Steve ltssawyerNFPAorggt wrote
From Sawyer Steve ltssawyerNFPAorggtSubject RE RE 7743To GLENN BENARICK ltgbenarprodigynetgtDate Monday August 30 2010 212 PM
So it should be ldquoorrdquo instead of ldquoandrdquo for now
Steven F Sawyer
Senior Fire Service Specialist
Executive Secretary IFMAFire Service Section
NFPA
1 Batterymarch Park
Quincy MA 02169
6179847423
Fax 6179847056
ssawyernfpaorg
From GLENN BENARICK [mailtogbenarprodigynet] Sent Monday August 30 2010 1202 PMTo Sawyer SteveSubject Fw RE 7743
52
Steve a couple of our docs agree with April Boyer
Glenn P Benarick 211 Winged Elm Circle
Aiken SC 29803
803-644-7093
gbenarprodigynet
--- On Mon 83010 David Prezant ltprezandfdnynycgovgt wrote
From David Prezant ltprezandfdnynycgovgtSubject RE 7743To Thomas R (CDCNIOSHDSHEFS) Hales lttrh1cdcgovgt GLENNBENARICK ltgbenarprodigynetgtCc Sandy Bogucki ltsandyboguckiyaleedugtDate Monday August 30 2010 1004 AM
agree
we should change this to NHANES III rather than Knudson we should alsomodify this to allow not only for predicted cutoffs but all for use of thelower limit of normal cutoff This is important to prevent false-classificationof spirometry as abnormal in older groups and in taller grps The latter ofparticular import to firefighter occupational health surveillance
thanks
David Prezant MDChief Medical Officer Office of Medical AffairsCo-Director WTC Medical Monitoring amp Treatment ProgramsNew York City Fire Department9 Metrotech Center - Rm 4W-1Brooklyn NY 11201Phone 718-999-2696Fax 718-999-0665
Life is full of twists and turns
53
This email may contain confidential information If you are the unintendedrecipient of this email please send it back and delete from your directory
gtgtgt Hales Thomas R (CDCNIOSHDSHEFS) lttrh1cdcgovgt 8302010955 AM gtgtgt
Glen
This seems like a very reasonable comment and illustrates the importance of having clinicians providefeedback on the std Im not familiar with the software program of the various spirometers (NHANES IIIvs KnudsonATS vs both) Given the large role both Dave Prezant and Sandy Bogucki had for thepulmonary section let me forward to them for clarification
Tom
From GLENN BENARICK [mailtogbenarprodigynet] Sent Sunday August 29 2010 456 PMTo Hales Thomas R (CDCNIOSHDSHEFS)Subject FW 7743
Tom is April Boyer correct
Glenn P Benarick 211 Winged Elm Circle
Aiken SC 29803
803-644-7093
gbenarprodigynet
--- On Thu 82610 Sawyer Steve ltssawyerNFPAorggt wrote
From Sawyer Steve ltssawyerNFPAorggtSubject FW 7743To GLENN BENARICK ltgbenarprodigynetgtDate Thursday August 26 2010 925 PM
FYI Do you have any answer She is write
Steven
54
Steven F Sawyer
Senior Fire Service Specialist
Executive Secretary IFMAFire Service Section
NFPA
1 Batterymarch Park
Quincy MA 02169
6179847423
Fax 6179847056
ssawyernfpaorg
From April Boyer [mailtoaboyerbicclinicorg] Sent Thursday August 26 2010 232 PMTo Sawyer SteveCc RobinMWebbmilstateorusSubject 7743
Steven
The spirometry tests cannot be corrected according to both references as the NFPA states because thereferences are contradictory The first part of 7743 states to follow the ATS guidelines and use theKnudsen (we at Basin Immediate Care use the Nhanes III) The second part states to follow the ACOEMguidelines and use the Nhanes III in the occupational setting if available with your unit (which is availableon ours) 7743 does not use the word OR regarding both requirements it uses the word AND whenreferring to the first and second parts thence making 7743 contradictory I realize the NFPA 1582 hasnot been updated since 2007 unless I have just not received an updated version
Our question to you is which part of 7743 do you want us to follow the first or the second part Anyfacility that has an updated computerized spirometry system (as we do) will not be able to follow bothrequired parts for obvious reasons We can either follow the first part of 7743 and use an oldercorrected version of the Knudson by going into our system and changing out of the Nhanes III conversionOR we can follow the second part of 7743 and use the newer corrected version of Nhanes III which ourunit offers too
If you have any questions you may contact me at anytime and I also have many references in regards toboth parts of 7743 if you would like to see them
55
Thank you~
April
Confidentiality NoticeThis message may contain information that isconfidential or privileged
If you are not the intended recipientPlease advise the sender immediately and delete this message
56
ATTACHMENT H
57
NFPA 1582 771(7) Proposed revisions
Why
Preliminary results of two prospective randomized trials on the PSA test were published in 2009 These studies resulted in medical organizations that previously providing guidance to modify their recommendations
Current language
771 Blood Tests Blood tests shall be performed annually and shall include the following
(7) Prostate specific antigen (PSA) after age 40 for positive family history if African American or if otherwise clinically indicated after age 50 for all other male member
Suggested Revision
771 Blood Tests Blood tests shall be performed annually and shall include the following
(7) Prostate specific antigen (PSA) after age 40 for positive family history if African American or if otherwise clinically indicated after age 50 for all other male member
772 Prostate-Specific Antigen (PSA) test At age 50 fire fighters shall have an opportunity to make an informed decision with either the Fire Department physician or their health care provider concerning the PSA test For fire fighters at increased risk of prostate cancer (African-Americans or those with a first degree relative diagnosed with prostate cancer before age 65) shall have the opportunity for this informed decision at age 40
A772 The PSA as a screening test for prostate cancer in asymptomatic men is controversial controversial for two reasons First there is no consensus that PSA screening actually saves lives For example the PSA test may detect small cancers that would never become life threatening Second it is unclear that the benefits of PSA screening outweigh the risks of follow-up diagnostic tests and cancer treatments For example the prostate biopsy used to diagnose prostate cancer may cause bleeding and infection And prostate cancer treatments such as surgery and radiation therapy may cause incontinence (inability to control urine flow) erectile dysfunction (erections inadequate for intercourse) and other complications For these reasons it is important that the benefits and risks of prostate diagnostic procedures and treatment be taken into account when considering the PSA screening test These considerations can be taken account during discussions with the fire department physician or onersquos health care provider
D211 Cancer Screening
Smith R A C J Mettlin K J Davis and H Eyre 2000 ldquoAmerican Cancer Society guidelines for the early detection of cancerrdquo CA J Clin 50(1)34ndash49
Added references
58
Carroll P Albertsen PC Greene K et al [2010] Prostate-specific antigen best practice statement 2009 update Am Urological Assoc Available at httpwwwauanetorgcontentguidelines-and-quality-careclinical-guidelinesmain-reportspsa09pdf Date accessed September 2010
Ferrini R Woolf SH [2009] Screening for prostate cancer in American men American College of Preventive Medicine Practice Policy Statement Available at httpwwwacpmorgprostatehtm Date accessed September 2010
National Cancer Institute [2009] Prostate-specific antigen test National Cancer Institute Fact Sheet Available at httpwwwcancergovcancertopicsfactsheetDetectionPSA Date accessed September 2010
Wolf AMD Wender RC Etzioni RB et al [2010] American Cancer Society guideline for the early detection of prostate cancer Update 2010 Available at httpcaonlineamcancersocorgcgicontentfullcaac20066v1 Date accessed September 2010
59
This weekrsquos conference call mentioned the Diabetes chapter written for the ACOEM document Guidance for the Medical Evaluation of the Law Enforcement Officer The task group working on this chapter (led Richard Miller of the Secret Service and our very own Dan Samo) worked with the ADA or over 2-3 years to come up with a consensus document
Please find the Chapter attached ltltDiabetes Guidance Sept 2010pdfgtgt
Regarding Dan Loeberrsquos points
1) Physical Evaluation Form - We could modify the LEO form (see end of the attached Chapter)
2) Duration required for stable regiment
1582 for IDDM Type 1 1 yr
Type 2 6 m
Oral Agents None specifically
ACOEM Police for IDDM Type 1 6m
Type 2 3m
Oral Agents 1m
The police document is much clearer about the decision regarding medical fitness for duty is the responsibility of the police physician with the treating diabetes-expert physician providing the data to the police physician to make an informed decision In this regard the police officer must provide the police physician with downloaded self monitoring glucose data for the 1 3 and 6 month time periods (see section 433)
3) HA1C ndash NFPA lt 8 over 3 month period
ACOEM Police ndash (Section 4333) Specifies the frequency on measurement and if gt8 requires further evaluation
Some other discrepancies End organ complications
NFPA ndash end organ complications (eye kidney heart neuro) ndash restriction
ACOEM Police ndash end organ complication -- requires further evaluation
18
Hypoglycemia (incapacitating ndash defined differently between the two documents (434)
NFPA ndash 0 episodes in past year le1 in past 5 yrs
ACOEM Police ndash 0 episodes in past year le2 in past 3 yrs
Given Dan Samorsquos and Richard Millerrsquos work with the ADALoeber it would be helpful to get their opinions on whether any of the changes requested by Loeber are appropriate for FF with DM
Tom
Thomas Hales MD MPH
Senior Medical Epidemiologist
NIOSH CDC
4676 Columbia Pkwy R-9
Cincinnati OH 45241
(513) 841-4583
trh1cdcgov
19
43 ndash DIABETES MELLITUS
431 ndash INTRODUCTION
The educated and motivated law enforcement officer (LEO) with well-managed diabetes mellitus can be capable of
safe and effective job performance1 However diabetes mellitus may place LEOs at risk for sudden incapacitation
thus jeopardizing their ability to perform critical job functions (These job functions include those listed in Sections
32 333 351 352 36 and 37 and discussed in Appendix A)
Therefore an individualized assessment of the LEOrsquos diabetes should be performed using the following evaluative
criteria to determine whether the individuals condition permits safe and effective job performance Such evaluation
must include the following key elements which are discussed in detail below
history of blood glucose control
knowledge of diabetes and its management
current stability of blood glucose
risk for significant hypoglycemia or hyperglycemia and
presence of diabetic complications
432 ndash OVERVIEW OF MEDICAL EVALUATION
The treating endocrinologist or other physician knowledgeable regarding diabetes management should provide
a narrative report certifying whether the LEO has or has not met the criteria set out in Sections 4321 through
4354 below In addition the physician should include supporting data (see Appendix B for the Physician Evalu-
ation Form)
4321 The LEO is under the care of an endocrinologist or other physician knowledgeable regarding diabetes
management Outpatient and in-patient medical record(s) for the last 3 years or since date of diagnosis
(whichever is shorter) should be reviewed by the treating physician and provided to the police physician
4322 If the LEO has type 1 diabetes the individual has been on a basalbolus regimena or an insulin pump
using analogue insulins for the 6 months prior to evaluation2
4323 If the LEO has type 2 diabetes on insulin the individual has been on a stable medication regimenb
for the 3 months prior to evaluation3 If on oral agents alone the LEO has been on a stable medication regimen
for the month prior to evaluationc
ACOEM Guidance for the Medical Evaluation of Law Enforcement Officers 1
43 ndash DIABETES MELLITUS
aA basalbolus insulin regimen consists of the use of a basal insulin (Glargine NPH) in a once or twice daily regimen to provide between-
meal insulin combined with the use of a short acting insulin (Regular Lispro Aspart or Glulisine) at mealtimes Insulin pumps are small
(beeper sized) battery powered devices that deliver small amounts of short-acting insulin in a constant infusion to meet basal insulin
requirements The wearer selects an additional mealtime bolus to be infused at the time of meals For more information on pumps visit
the manufacturerrsquos web sites ndash wwwMinimedcom wwwcozmorecom wwwanimascorpcom wwwdisetroniccom
bA stable insulin regimen is defined as maintaining the same types of insulin (long acting intermediate acting short or rapid acting)
Changes in insulin dose are part of the appropriate self-management of diabetes and do not disqualify an applicant or incumbent under
this section
cChanges in dose within the evaluation period will be allowed but addition of a new class of medications or insulin should result in a new
period of observation
one month for addition of a sulfonylurea or metformin
two months for the addition of a thiazolidinedione to insulin or a sulfonylurea or
three months for the addition of insulin
20
4324 If the LEO uses an insulin pump documentation is needed as follows
proper understanding and education in the use of the insulin pump
start date for the use of the pump
history of insulin site infectionsd
history of pump cessation and pump malfunction
backup plan for pump malfunction including use of injectable insulin and
frequency of infusion set changes
4325 The LEO has been educated in diabetes and its management and thoroughly informed of and under-
stands the procedures that must be followed to monitor and manage hisher diabetes and what procedures
should be followed if complications arise3
433 ndash QUANTITATIVE GLUCOSE MONITORING
4331 The LEO has documentation of ongoing self-monitoring of blood glucose
4332 This must be done with a glucose meter that stores every reading records date and time of reading
and from which data can be downloaded (Most meters now have this capability)
4333 Monitoring logs must be available covering the time period (1 3 or 6 months) as described in
Sections 4322 and 4323 The frequency of glucose monitoring must follow a schedule acceptable to the
police physician in consultation with the treating physician
Testing schedules are individual What follows is a common pattern but individual patterns may differ
2 ACOEM Guidance for the Medical Evaluation of Law Enforcement Officers
43 ndash DIABETES MELLITUS
dIndividual has not had more than one pump-site infection that caused him or her to miss work or usual daily activities in the preceding 6
months
THERAPEUTIC REGIMEN GLUCOSE TESTING SCHEDULE
Diet alone Once or twice a week
Metformin Thiazolidinediones or Alpha
Glucosidase inhibitors alone or in
combination
Once or twice a week
Sulfonylureas meglitanides nateglinide ndash
alone or in combination with the above group
Twice a day ndash AM and at supper with any
suspected hypoglycemic episodes
Insulin ndash one shot in combination with orals Twice a day ndash AM and at supper with any
suspected hypoglycemic episodes
2 to 3 times AM once a week
Insulin ndash two or more shots Insulin pump 3 to 4 times a day ndash at meals and bedtime
2 to 3 times AM once a week with any
suspected hypoglycemic episodes
21
4334 The LEO has had hemoglobin A1C measured at least 4 times a year (intervals of 2 to 3 months) over
the last 12 months prior to evaluation if diagnosis has been present for more than a year4 If hemoglobin A1C is
gt8 this may signal a problem with the LEOrsquos diabetes management that warrants further assessment5
434 ndash INCAPACITATING EVENTS
4341 The LEO has not had any incapacitating episodes within the past 1 year and no more than 2 episodes
in the past 3 years or since diagnosis of diabetes (whichever is shorter) of
43411 Severe hypoglycemia (loss of consciousness seizures or coma requiring assistance of others or
needing urgent treatment [glucagon injectionIV glucose]) or
43412 Blood sugar lt60 mgdl with unawareness demonstrated in current glucose logs6
435 ndash CHRONIC COMPLICATION SCREENING
4351 Chronic complications of diabetes are associated with increased risk for severe hypoglycemic
episodes and warrant further assessmente
4352 The components of screening for chronic complications are
43521 A complete eye exam by a qualified ophthalmologist or optometrist including a dilated retinal
exam demonstrating no more than mild background diabetic retinopathyf7
43522 Normal vibratory testing with a 128 Hz tuning forkg normal testing with 10 gram Semmes-
Weinstein monofilamentg and normal orthostatic blood pressureh and pulse testing89
ACOEM Guidance for the Medical Evaluation of Law Enforcement Officers 3
43 ndash DIABETES MELLITUS
ePresence of chronic complications of diabetes in and of themselves may not require the implementation of work restrictions
fNo more than one dot blot or flame-shaped hemorrhages or microaneurysm in all four fundus quadrants
gThe Michigan Diabetes Research and Training Center of the University of Michigan Health System recommends the following guidance
(see wwwmedumichedumdrtcprofsdocumentssviMNSI_howtopdf) for conducting vibratory and monofilament testing8
Vibration Sensation Vibration sensation should be performed with the great toe unsupported Vibration sensation will be tested bi-
laterally using a 128 Hz tuning fork placed over the dorsum of the great toe on the boney prominence of the DIP joint Patients whose
eyes are closed will be asked to indicate when they can no longer sense the vibration from the vibrating tuning fork In general the
examiner should be able to feel vibration from the hand-held tuning fork for 5 seconds longer on his distal forefinger than a normal subject
can at the great toe (eg examiners DIP joint of the first finger versus patients toe) If the examiner feels vibration for 10 or more seconds
on his or her finger then vibration is considered decreased A trial should be given when the tuning fork is not vibrating to be certain that
the patient is responding to vibration and not pressure or some other clue Vibration is scored as 1) present if the examiner senses the
vibration on his or her finger for lt10 seconds 2) reduced if sensed for 10 seconds or 3) absent (no vibration detection)
Monofilament Testing For this examination it is important that the patients foot be supported (ie allow the sole of the foot to rest on
a flat warm surface) The filament should initially be pre-stressed (4-6 perpendicular applications to the dorsum of the examiner s first
finger) The filament is then applied to the dorsum of the great toe midway between the nail fold and the DIP joint Do not hold the toe
directly The filament is applied perpendicularly and briefly (lt1 second) with an even pressure When the filament bends the force of
10 grams has been applied The patient whose eyes are closed is asked to respond yes if heshe feels the filament Eight correct responses
out of 10 applications is considered normal 1 to 7 correct responses indicates reduced sensation and no correct answers translates into
absent sensation
hOrthostatic hypotension is a physical finding defined by the American Autonomic Society and the American Academy of Neurology as a
systolic blood pressure decrease of at least 20 mm Hg or a diastolic blood pressure decrease of at least 10 mm Hg within 3 minutes of
standing
22
43523 Normal cardiac physical exam Cardiac stress testing to at least 12 METS is recommended and
should begin based on either the criteria of the American Heart AssociationAmerican College of
Cardiologyi10 or those of the American Diabetes Associationj11
Diabetics who have a normal cardiac stress test will be retested every one to three years based on
individual clinical assessment This assessment should consider
the age of the individual
the number and persistence of coronary artery disease (CAD) risk factors
the severity of CAD risk factors
43524 Microalbumincreatinine ratio 301 measured or calculatedk creatinine clearance
gt60 mlmin12
436 ndash ONGOING EVALUATION AND REQUIREMENTS
4361 Should have medical records and glucose meter logs reviewed periodically Because of the nature of
diabetes it is important that regular medical follow up be provided to the LEO The frequency and content of
the evaluation should be determined on an individual basis by the police physician in consultation with the
treating physicianl
4362 Must advise police physician of any change in type of medication
4363 Must advise police physician of any episodes of significant hypoglycemia or hyperglycemia
Urine microalbumincreatinine ratio _________________
III Treating Physician Statement
The above named individual meets all of the criteria provided on this form
Yes No ndash not recommended for position
No but IS recommended for position (letter of explanation attached)
It is my opinion that the above named individual is well-educated and well-motivated in diabetes self-management and has
achieved a level of diabetes management to be capable of safe and effective job performance as a law enforcement officer
I have reached this opinion after careful review of the above criteria
___________________________________________________________ ___________________________Signature of Physician Date
______________________________________________________________ ___________________________Printed or Typed Name of Physician Telephone Number
10 ACOEM Guidance for the Medical Evaluation of Law Enforcement Officers
43 ndash DIABETES MELLITUS
29
439 ndash REFERENCES
1 American Diabetes Association Diagnosis and classification of diabetes mellitus Diabetes Care 200427 Suppl
1S5-S10 See httpcarediabetesjournalsorgcgicontentfull27suppl_1s5
2 American Diabetes Association Continuous subcutaneous insulin infusion Diabetes Care 200427 Suppl 1S110
See httpcarediabetesjournalsorgcgicontentfull27suppl_1s110
3 Mensing C Boucher J Cypress M et al National standards for diabetes self-management education Diabetes
Care 200528 Suppl 1S72-9 See httpcarediabetesjournalsorgcgicontentfull28suppl_1s72
4 Goldstein DE Little RR Lorenz RA Malone JI Nathan DM Peterson CM American Diabetes Association Tests
of glycemia in diabetes Diabetes Care 200427 Suppl 1S91-3
See httpcarediabetesjournalsorgcgicontentfull27suppl_1s91
5 The Diabetes Control and Complications Trial Research Group Hypoglycemia in the Diabetes Control and
Complications Trial Diabetes 199746(2)271-86 See wwwncbinlmnihgovpubmed9000705 for abstract
6 American Diabetes Association Hypoglycemia and employmentlicensure Diabetes Care 200528 Suppl 1S61
See httpcarediabetesjournalsorgcgicontentfull28suppl_1s61
7 Viswanath K McGavin DD Diabetic Retinopathy Clinical Findings and Management J Comm Eye Health
200316(46)21-4 See wwwcehjournalorg0953-683316jceh_16_46_021html
8 Michigan Diabetes Research and Training Center University of Michigan Health System How to use the Michigan
Neuropathy Screening Instrument See wwwmedumichedumdrtcprofsdocumentssviMNSI_howtopdf
9 Bradley JG Davis KA Orthostatic hypotension Am Fam Physician 200368(12)2393-8
See wwwaafporgafp200312152393html
10 Gibbons RJ Balady GJ Bricker JT et al ACCAHA 2002 guideline update for exercise testing a report of the
American College of CardiologyAmerican Heart Association Task Force on Practice Guidelines (Committee on
Exercise Testing) J Am Coll Cardiol 200240(8)1531-40
See wwwaccorgqualityandscienceclinicalguidelinesexerciseexercise_cleanpdf
11 American Diabetes Association Standards of medical care in diabetes Diabetes Care 200528 Suppl 1S4-S36
Erratum in Diabetes Care 200528(4)990 See httpcarediabetesjournalsorgcgicontentfull28suppl_1s4
12 Molitch ME DeFronzo RA Franz MJ et al American Diabetes Association Nephropathy in diabetes Diabetes
Care 200427 Suppl 1S79-83 See httpcarediabetesjournalsorgcgicontentfull27suppl_1s79
13 Kitabchi AE Umpierrez GE Murphy MB et al American Diabetes Association Hyperglycemic crises in diabetes
Diabetes Care 200427 Suppl 1S94-102 See httpcarediabetesjournalsorgcgicontentfull27suppl_1s94
14 US Centers for Disease Control and Prevention National Diabetes Fact Sheet 2007
See wwwcdcgovdiabetespubspdfndfs_2007pdf
ACOEM Guidance for the Medical Evaluation of Law Enforcement Officers 11
43 ndash DIABETES MELLITUS
30
ATTACHMENT E
31
Typos A6921(2) 7th line down test should be plural 94201 Paragraph 2 target organ damage is used though end organ damage was defined earlier and in the appendix for that paragraph
A94201 Para A (1) d Id suggest deleting the phrases in brackets Im not sure either are predictably true or politically wise
a) tests for left ventricular hypertrophy Unfortunately use of the EKG to detect left ventricular hypertrophy is very insensitive (eg 5 sensitivity) The echocardiogram is the best test for diagnosing left ventricular hypertrophy but [it is relatively expensive and not readily available in small rural communities ] conducting echocardiograms on asymptomatic fire fighters with Stage 1 hypertension should be reserved only for those with long-standing hypertension
In addition
7761 A resting EKG shall be performed as part of the baseline medical evaluation and shall be obtained periodically thereafter
Changing from annually to periodically is noted has the language in the wellness-fitness initiative been changed as well Our previous decision was that we would support the W-F language since there was no compelling evidence to either support or refute it
Thanks
Sandy
32
NFPA 1582‐ HTN Draft 1
Reason for Revision
1) New classification of BP by the Joint National Commission [Chobanian et al 2002]
2) A high prevalence of FF have either HTN (~20) and Pre‐HTN (~20) [Soteriades et al 2003]
3) Among FF studies have shown a strong association between HTN and a number of adverse
cardiovascular events [Kales et al 2009]
4) A large percentage of on‐duty FF fatalities were found to have left ventricular hypertrophy a
complication of HTN at autopsy
Language in 2007 Edition with draft revisions in Red (Track changes)
611 The medical evaluation of a candidate shall include a medical history examination and any laboratory tests required to detect physical or medical condition(s) that could adversely affect hisher ability to safely perform the essential job tasks outlined in 511 A611 The medical history should include the candidates known health problems such as major illnesses surgeries medication use and allergies Symptom review is also important for detecting early signs of illness A medical history should also include a personal health history a family health history a health habit history an immunization history and a reproductive history
An occupational history should also be obtained to collect information about the persons past occupational and environmental exposures
(a) BP should be measured according to the Joint National Commission (JNC) -7 recommendations BP should be measured with a properly calibrated and validated instrument Patients should be seated quietly for at least 5 minutes in a chair with feet on the floor and arm supported at heart level An appropriate-sized cuff (cuff bladder encircling at least 80 of the arm) should be used to ensure accuracy At least 2 measurements should be made Systolic BP is the point at which the first of 2 or more sounds is heard (phase 1) and diastolic BP is the point before the disappearance of sounds (phase 5) [Chobanian et al 2003]
(2) Head eyes ears nose and throat (HEENT)
Formatted Font (Default) Times New RomanFont color Black
33
692 Vascular System 6921 Category A medical conditions shall include the following
(1) Uncontrolled or poorly controlled hypertension
(2) Hypertension with evidence of end organ damage
or not controlled by approved medications
A6921(1) Uncontrolled or poorly controlled hHypertension increases the risk of a sudden cardiac event This sudden cardiac event would cause sudden incapacitation which that is uncontrolled poorly controlled or requires medication likely to interferes with the safe performance of essential job tasks Uncontrolled or poorly controlled hypertension can be defined as the presence of end organ damage (see below) or stage 2 hypertension (BP systolic gt160 mmHg or BP diastolic gt100 mmHg) is an illness that can lead to functional impairment and potential for sudden incapacitation Individuals with pre- stage 1 or stage 2 hypertension should be referred to their primary care physician for evaluation lifestyle modification and treatment [QUESTION FOR GROUP _- WHAT ABOUT HAVING CANDIDATE RETURN IN ONE MONTH UNDER TREATMENT WITH NORMAL BP]
A6921(2)
Chronic hypertension can damage the eye (retinopathy) the kidneys (nephropathy) the vascular system (stroke transient ischemic attack or peripheral artery disease) or the heart (left ventricular hypertrophy and heart failure) These hypertension complications are known as end organ damage The cardiac and vascular complications are associated with an increased risk of sudden incapacitation and sudden cardiac death (Koren et al 1991) Unfortunately the cardiac complications are frequently asymptomatic and valid screening tests are not fast and are not inexpensive Therefore determining who to screen for cardiac complications (such as echocardiogram for LVH or a measurement of left ventricular ejection fraction for heart failure) should be based on the severity and the duration of HTN
76 Physical Examination The annual physical examination shall include each of the following components
(a) BP shall be measured according to the Joint National Commission (JNC)-7 recommendations
A76(1)(a) BP should be measured with a properly calibrated and validated instrument Patients should be seated quietly for at least 5 minutes in a chair with feet on the floor and arm supported at heart level An appropriate-sized cuff (cuff bladder encircling at least 80 of the arm) should be used to ensure accuracy At least 2 measurements should be made Systolic BP is the point at which the first of 2 or more sounds is heard (phase 1) and diastolic BP is the point before the disappearance of sounds (phase 5) [Chobanian et al 2003]
(2) Head eyes ears nose and throat (HEENT)
34
9420 Uncontrolled Hypertension 94201 Physician Evaluation Severe uncontrolled hypertension [defined as systolic pressure greater than 180 mm Hg diastolic pressure greater than 100 mm Hg or mean systolic blood
pressure ( systolic + diastolic) greater than 120 mm Hg] or malignant hypertension (defined as hypertension with the presence of target organ damage) compromises the members ability to safely perform essential job tasks 1 5 7 9 and 13 and the physician shall report the applicable job limitations to the fire department
Members with Pre-hypertention (systolic 120-139 mmHg or diastolic 80-89 mmHg) Stage 1 hypertension (systolic 140-159 mmHg or diastolic 90-99 mmHg) or Stage 2 hypertension (systolic ge160 mmHg or diastolic ge100 mmHg) should be referred to their primary care physician for evaluation lifestyle modification and treatment
(1) Members with Stage I hypertension should be followed-up not only by their primary care physician but also by the FD physician every 3 to 6 months to ensure their blood pressure is under control and to determine whether screening tests for asymptomatic end organ damage are appropriate
(2) Members with Stage 2 hypertension or with end organ damage (retinopathy nephropathy vascular or cardiac complications) compromises the members ability to safely perform essential job tasks 1 5 7 9 and 130 and the physician shall report the applicable job limitations to the fire department
A94201 Severe uncontrolled hypertension is a significant risk factor for the development of coronary artery disease congestive heart failure and stroke Blood pressure increases as a normal response to exercise This response is further exaggerated by the emotional and physical stress of performing these critical tasks while operating in personal protective clothing at extremes of temperature This normal elevation of blood pressure under these response conditions can lead to life-threatening hypertensive emergencies if a members daily blood pressure is already elevated to high levels In addition hypertension is a progressive illness that when uncontrolled ultimately and inevitably leads to target organ damage Target organs that are sensitive to the effects of elevated blood pressure are the central nervous system vision heart major blood vessels and kidneys
Chronic hypertension can damage the eye (retinopathy) the kidneys (nephropathy) the vascular system (stroke transient ischemic attack or peripheral artery disease) or the heart (left ventricular hypertrophy and heart failure) These hypertension complications are known as end organ damage The cardiac and vascular complications are associated with an increased risk of sudden incapacitation and sudden cardiac death (Koren et al 1991) Fortunately with proper evaluation life style modification and treatment these complications can be avoided Life style modification includes weight reduction DASH eating plan reduction in dietary sodium an increase in aerobic physical activity and moderation in alcohol consumption [Chobanian 2003]
Formatted Font (Default) Times New Roman12 pt Font color Black
Formatted Font (Default) Times New Roman12 pt Font color Black
35
A94201 (1) Members with Stage I hypertension whose BP returns to either pre-hypertenion or normal with lifestyle modification andor treatment can return to an annual medical evaluation For members with long-standing Stage I hypertension whose BP has not been reduced additional evaluation for possible end organ damage should be considered This evaluation could include any or all of the following
a) a compete patient history for symptoms of heart failure (eg shortness of breath upon exertion) or transient ischemic attacks (TIAs)
b) dilated eye examination for retinopathy
c) blood creatinine measurement for nephropathy
d) tests for left ventricular hypertrophy Unfortunately use of the resting EKG to detect left ventricular hypertrophy is very insensitive (eg 5 sensitivity) The echocardiogram is the best test for diagnosing left ventricular hypertrophy
A 94201 (2) Due to the high risk of a sudden cardiovascular event members with Stage 2 hypertension should be restricted until their BP can be brought under control Once the BP is brought under control they should be followed in the same manner as a member with Stage I hypertension
Formatted Font (Default) Times New Roman12 pt
36
D22 Cardiology Gibbons R J GJ Balady J W Beasley et al 1997 ACCAHA guidelines for exercise testing a report of American College of CardiologyAmerican Heart Association Task Force on Practice Guidelines (Committee on Exercise Testing) J Am Coll Cardiol 30260ndash311
Gibbons RJ Balady GJ Bricker JT Chaitman BR Fletcher GF Froelicher VF Mark DB McCallister BD Mooss AN OrsquoReilly MG Winters WL Jr [2002] ACCAHA 2002 guideline update for exercise testing summary article a report of the ACCAHA Task Force on Practice Guidelines (Committee to Update the 1997 Exercise Testing guidelines) J Am Coll Cardiol 401531ndash 40
Chobanian AV Bakris GL Black HR Cushman WC Green LA Izzo JL Jr Jones DW Materson BJ Oparil S Wright JT Jr Roccella EJ the National High Blood Pressure Education Program Coordinating Committee [2003] The seventh report of the Joint National Committee [JNC-7] on Prevention Detection Evaluation and Treatment of High Blood Pressure JAMA 2892560ndash2571
Soteriades ES Kales SN Liarokapis D Christiani DC [2003] Prospective surveillance of hypertension in firefighters J Clin Hypertens 5315-320
Kales SN Tsismenakis AJ Zhang C Soteriades ES [2009] Blood pressure in fire fighters police officers and other emergency responders Am J Hypertens 2211-20
37
NFPA 1582‐ HTN Draft 1
Reason for Revision
1) New classification of BP by the Joint National Commission [Chobanian et al 2002]
2) A high prevalence of FF have either HTN (~20) and Pre‐HTN (~20) [Soteriades et al 2003]
3) Among FF studies have shown a strong association between HTN and a number of adverse
cardiovascular events [Kales et al 2009]
4) A large percentage of on‐duty FF fatalities were found to have left ventricular hypertrophy a
complication of HTN at autopsy
Language in 2007 Edition with draft revisions in Red (Track changes)
611 The medical evaluation of a candidate shall include a medical history examination and any laboratory tests required to detect physical or medical condition(s) that could adversely affect hisher ability to safely perform the essential job tasks outlined in 511 A611 The medical history should include the candidates known health problems such as major illnesses surgeries medication use and allergies Symptom review is also important for detecting early signs of illness A medical history should also include a personal health history a family health history a health habit history an immunization history and a reproductive history
An occupational history should also be obtained to collect information about the persons past occupational and environmental exposures
(a) BP should be measured according to the Joint National Commission (JNC) -7 recommendations BP should be measured with a properly calibrated and validated instrument Patients should be seated quietly for at least 5 minutes in a chair with feet on the floor and arm supported at heart level An appropriate-sized cuff (cuff bladder encircling at least 80 of the arm) should be used to ensure accuracy At least 2 measurements should be made Systolic BP is the point at which the first of 2 or more sounds is heard (phase 1) and diastolic BP is the point before the disappearance of sounds (phase 5) [Chobanian et al 2003]
(2) Head eyes ears nose and throat
38
692 Vascular System 6921 Category A medical conditions shall include the following
(1) Uncontrolled or poorly controlled hypertension
(2) Hypertension with evidence of end organ damage
A6921(1) Uncontrolled or poorly controlled hypertension increases the risk of a sudden cardiac event This sudden cardiac event would cause sudden incapacitation which interferes with the safe performance of essential job tasks Uncontrolled or poorly controlled hypertension can be defined as the presence of end organ damage (see below) or stage 2 hypertension (BP systolic gt160 mmHg or BP diastolic gt100 mmHg) Individuals with pre- stage 1 or stage 2 hypertension should be referred to their primary care physician for evaluation lifestyle modification and treatment [QUESTION FOR GROUP _- WHAT ABOUT HAVING CANDIDATE RETURN IN ONE MONTH UNDER TREATMENT WITH NORMAL BP]
A6921(2)Chronic hypertension can damage the eye (retinopathy) the kidneys (nephropathy) the vascular system (stroke transient ischemic attack or peripheral artery disease) or the heart (left ventricular hypertrophy and heart failure) These hypertension complications are known as end organ damage The cardiac and vascular complications are associated with an increased risk of sudden incapacitation and sudden cardiac death (Koren et al 1991) Unfortunately the cardiac complications are frequently asymptomatic and valid screening tests are not fast and are not inexpensive Therefore determining who to screen for cardiac complications (such as echocardiogram for LVH or a measurement of left ventricular ejection fraction for heart failure) should be based on the severity and the duration of HTN
76 Physical Examination The annual physical examination shall include each of the following components
(a) BP shall be measured according to the Joint National Commission (JNC)-7 recommendations
A76(1)(a) BP should be measured with a properly calibrated and validated instrument Patients should be seated quietly for at least 5 minutes in a chair with feet on the floor and arm supported at heart level An appropriate-sized cuff (cuff bladder encircling at least 80 of the arm) should be used to ensure accuracy At least 2 measurements should be made Systolic BP is the point at which the first of 2 or more sounds is heard (phase 1) and diastolic BP is the point before the disappearance of sounds (phase 5) [Chobanian et al 2003]
(2) Head eyes ears nose and throat9420 Hypertension 94201 Physician Evaluation Members with Pre-hypertention (systolic 120-139 mmHg or diastolic 80-89 mmHg) Stage 1 hypertension (systolic 140-159 mmHg or diastolic 90-99 mmHg) or Stage 2 hypertension (systolic ge160 mmHg or diastolic ge100 mmHg) should be referred to their primary care physician for evaluation lifestyle modification and treatment
39
(1) Members with Stage I hypertension should be followed-up not only by their primary care physician but also by the FD physician every 3 to 6 months to ensure their blood pressure is under control and to determine whether screening tests for asymptomatic end organ damage are appropriate
(2) Members with Stage 2 hypertension or with end organ damage (retinopathy nephropathy vascular or cardiac complications) compromises the members ability to safely perform essential job tasks 1 5 7 9 and 130 and the physician shall report the applicable job limitations to the fire department
A94201 Chronic hypertension can damage the eye (retinopathy) the kidneys (nephropathy) the vascular system (stroke transient ischemic attack or peripheral artery disease) or the heart (left ventricular hypertrophy and heart failure) These hypertension complications are known as end organ damage The cardiac and vascular complications are associated with an increased risk of sudden incapacitation and sudden cardiac death (Koren et al 1991) Fortunately with proper evaluation life style modification and treatment these complications can be avoided Life style modification includes weight reduction DASH eating plan reduction in dietary sodium an increase in aerobic physical activity and moderation in alcohol consumption [Chobanian 2003]
A94201 (1) Members with Stage I hypertension whose BP returns to either pre-hypertenion or normal with lifestyle modification andor treatment can return to an annual medical evaluation For members with long-standing Stage I hypertension whose BP has not been reduced additional evaluation for possible end organ damage should be considered This evaluation could include any or all of the following
a) a compete patient history for symptoms of heart failure (eg shortness of breath upon exertion) or transient ischemic attacks (TIAs)
b) dilated eye examination for retinopathy
c) blood creatinine measurement for nephropathy
d) tests for left ventricular hypertrophy Unfortunately use of the resting EKG to detect left ventricular hypertrophy is very insensitive (eg 5 sensitivity) The echocardiogram is the best test for diagnosing left ventricular hypertrophy
A 94201 (2) Due to the high risk of a sudden cardiovascular event members with Stage 2 hypertension should be restricted until their BP can be brought under control Once the BP is brought under control they should be followed in the same manner as a member with Stage I hypertension
D22 Cardiology
40
Hypertension
Gibbons RJ Balady GJ Bricker JT Chaitman BR Fletcher GF Froelicher VF Mark DB McCallister BD Mooss AN OrsquoReilly MG Winters WL Jr [2002] ACCAHA 2002 guideline update for exercise testing summary article a report of the ACCAHA Task Force on Practice Guidelines (Committee to Update the 1997 Exercise Testing guidelines) J Am Coll Cardiol 401531ndash 40
Chobanian AV Bakris GL Black HR Cushman WC Green LA Izzo JL Jr Jones DW Materson BJ Oparil S Wright JT Jr Roccella EJ the National High Blood Pressure Education Program Coordinating Committee [2003] The seventh report of the Joint National Committee [JNC-7] on Prevention Detection Evaluation and Treatment of High Blood Pressure JAMA 2892560ndash2571
Soteriades ES Kales SN Liarokapis D Christiani DC [2003] Prospective surveillance of hypertension in firefighters J Clin Hypertens 5315-320
Kales SN Tsismenakis AJ Zhang C Soteriades ES [2009] Blood pressure in fire fighters police officers and other emergency responders Am J Hypertens 2211-20
41
NFPA 1582‐ Draft Revisions for CVDHTN
EKG and stress tests
Reason for Revision
1) Change requirement for annual resting EKG to periodically to be more consistent with ACCAHA
recommendation (Schlant et al 1992)
2) Add language to clarify what constitutes a positive ST
3) Make criteria for conducting diagnostic ST in asymptomatic patients consistent with the
ACCAHA
Language in 2007 Edition with draft revisions in Red (Track changes)
776 Electrocardiograms (EKG)) and Stress Tests 7761 A resting EKG shall be performed as part of the baseline medical evaluation and shall be obtained periodically (every 1 to 5 years) annually thereafter
A7761 A baseline resting EKGs shall be conducted Follow-up resting EKGs should be conducted as clinically indicated but at a minimum of every 1 to 5 years The frequency of these follow-up resting EKGs should increase as a members age increases or with increasing number andor severity of coronary heart disease risk factors Members above the age of 40 should have annual resting EKGs (Schlant et al 1992)
7762 The fire department physician or other qualified medical evaluator shall compare EKGs obtained during yearly evaluations with baseline and subsequent EKGs
7763 Stress testing EKG with or without echocardiography or radionuclide scanning shall be performed as clinically indicated by history or symptoms
A7761 Baseline electrocardiography should be conducted (Periodic resting electrocardiograms have not been shown to be useful but can be reasonable as a members agefactors increase)
A7763 No firm guidelines for stress testingelectrocardiography in asymptomatic individuals have been developed Stress testingelectrocardiography as a screening tool is used as part of an evaluation of aerobic capacity during the annual occupational fitness evaluation Submaximal stress testingelectrocardiography testing to 85 percent is commonly used as part of this screening
Submaximal stress electrocardiography testing should not be used for diagnostic purposes Cardiology evaluation with maximal stress testingelectrocardiography together with imaging techniques (eg echocardiography technetium Tc99m sestamibi study andor coronary angiography) is necessary for diagnosticprognostic purposes for the following
42
(1) Fire fighters with positive or questionably positive changes on screening submaximal stress tests
(2) Fire fighters with new onset chest pain or other symptoms suggestive of coronary artery disease (CAD)
(3) Fire fighters with diabetes mellitus who
(a) are gt35 years old or
(b) have type I diabetes for more than 15 years or
(c) have type II diabetes for more than 10 years or
(d) have any other CHD risk factor (see below) or
(e) have the presence of microvascular disease (proliferative retinopathy)
(4) Fire fighters over the age of 45 (for men) and 55 (for women) with onetwo or more risk factors for CAD Risk factors for CAD include hypercholesterolemia (total cholesterol greater than 240 mgdL) hypertension (systolic gt140 mmHg or diastolic gt90 mmHg) smoking or family history of premature CAD (heart attack or sudden cardiac death in a first degree relative less than 60 years of age)
as defined below if stress electrocardiography with imaging is negative then repeat as clinically indicated or at least every 5 years
(5) Fire fighters with a Framingham Risk Score gt10 Risk calculator is available at [httphp2010nhlbihinnetatpiiicalculatorasp]
(6) Fire fighters identified in 9431
Negative stress tests should be repeated as clinically indicated or at least every 2 to 5 years
Interpreting stress tests as ldquopositiverdquo or ldquonegativerdquo is beyond the scope of this document However factors that should be taken into consideration should include the individualrsquos exercise capacity symptoms blood pressure response heart rate response EKG changes and the presence of arrhythmias (Gibbon et al 2002)
Risk factors for CAD include hypercholesterolemia (total cholesterol greater than 240 mgdL) hypertension (systolic greater than 140 andor diastolic greater than 90) smoking diabetes mellitus or family history of premature CAD (heart attack or sudden cardiac death in a first degree relative less than 60 years of age)
There are other non-invasive tests to screen for coronary artery disease One of the most promising appears to be coronary artery calcium (CAD) scoring by computed tomography In 2007 an expert committee published an update to their original guidance document The committeersquos consensus was that ldquoit may be reasonable to consider use of CAC measurement in such patients [between 10 and 20 10-year risk of estimated coronary event]helliprdquo The committee did not recommend CAC measurement in low risk patients [lt10 10-year risk of estimated coronary event] or in high risk patients [gt20 10-year risk of estimate coronary event] (Greenland et al 2007]
43
D22 Cardiology
Chobanian AV Bakris GL Black HR Cushman WC Green LA Izzo JL Jr Jones DW Materson BJ Oparil S Wright JT Jr Roccella EJ the National High Blood Pressure Education Program Coordinating Committee [2003] The seventh report of the Joint National Committee [JNC-7] on Prevention Detection Evaluation and Treatment of High Blood Pressure JAMA 2892560ndash2571
Gibbons RJ Balady GJ Bricker JT Chaitman BR Fletcher GF Froelicher VF Mark DB McCallister BD Mooss AN OrsquoReilly MG Winters WL Jr [2002] ACCAHA 2002 guideline update for exercise testing summary article a report of the ACCAHA Task Force on Practice Guidelines (Committee to Update the 1997 Exercise Testing guidelines) J Am Coll Cardiol 401531ndash 1540
Greenland et al [2007] ACCFAHA 2007 Clinical Expert Consensus Document on Coronary Artery Calcium Scoring By Computed Tomography in Global Cardiovascular Risk Assessment and in Evaluation of Patients With Chest Pain A Report of the American College of Cardiology Foundation Clinical Expert Consensus Task Force (ACCFAHA Writing Committee to Update the 2000 Expert Consensus Document on Electron Beam Computed Tomography) J Am Coll Cardiol 49378-402
Kales SN Tsismenakis AJ Zhang C Soteriades ES [2009] Blood pressure in fire fighters police officers and other emergency responders Am J Hypertens 2211-20
Schlant RC Adolph RJ DiMarco JP Dreifus LS Dunn MI Fisch C Garson A Jr Haywood LJ Levine HJ Murray JA Noble RJ Ronan JA Jr [1992] Guidelines for electrocardiography A report of the American College of CardiologyAmerican Heart Association Task Force on Assessment of Diagnostic and Therapeutic Cardiovascular Procedures (Committee on Electrocardiography) Circulation 85(3)1221-1228
Soteriades ES Kales SN Liarokapis D Christiani DC [2003] Prospective surveillance of hypertension in firefighters J Clin Hypertens 5315-320
Formatted Font Italic
Formatted Line spacing single
Formatted Font Italic
Formatted Font Italic
44
NFPA 1582‐ Draft Revisions for CVDHTN
EKG and stress tests
Reason for Revision
1) Change requirement for annual resting EKG to periodically to be more consistent with ACCAHA
recommendation (Schlant et al 1992)
2) Add language to clarify what constitutes a positive ST
3) Make criteria for conducting diagnostic ST in asymptomatic patients consistent with the
ACCAHA
Language in 2007 Edition with draft revisions in Red (Track changes)
776 Electrocardiograms (EKG) and Stress Tests 7761 A resting EKG shall be performed as part of the baseline medical evaluation and shall be obtained periodically (every 1 to 5 years) thereafter
A7761 A baseline resting EKGs shall be conducted Follow-up resting EKGs should be conducted as clinically indicated but at a minimum of every 1 to 5 years The frequency of these follow-up resting EKGs should increase as a members age increases or with increasing number andor severity of coronary heart disease risk factors Members above the age of 40 should have annual resting EKGs (Schlant et al 1992)
7762 The fire department physician or other qualified medical evaluator shall compare baseline and subsequent EKGs
7763 Stress testing with or without echocardiography or radionuclide scanning shall be performed as clinically indicated by history or symptoms
A7763 No firm guidelines for stress testing in asymptomatic individuals have been developed Stress testing as a screening tool is used as part of an evaluation of aerobic capacity during the annual occupational fitness evaluation Submaximal stress testing testing to 85 percent is commonly used as part of this screening
Submaximal stress testing should not be used for diagnostic purposes Cardiology evaluation with maximal stress testing together with imaging techniques (eg echocardiography technetium Tc99m sestamibi study) is necessary for diagnosticprognostic purposes for the following
(1) Fire fighters with positive or questionably positive changes on screening submaximal stress tests
(2) Fire fighters with new onset chest pain or other symptoms suggestive of coronary artery disease (CAD)
45
(3) Fire fighters with diabetes mellitus who
(a) are gt35 years old or
(b) have type I diabetes for more than 15 years or
(c) have type II diabetes for more than 10 years or
(d) have any other CHD risk factor (see below) or
(e) have the presence of microvascular disease (proliferative retinopathy)
(4) Fire fighters over the age of 45 (for men) and 55 (for women) with one or more risk factors for CAD Risk factors for CAD include hypercholesterolemia (total cholesterol greater than 240 mgdL) hypertension (systolic gt140 mmHg or diastolic gt90 mmHg) smoking or family history of premature CAD (heart attack or sudden cardiac death in a first degree relative less than 60 years of age)
(5) Fire fighters with a Framingham Risk Score gt10 Risk calculator is available at [httphp2010nhlbihinnetatpiiicalculatorasp]
(6) Fire fighters identified in 9431
Negative stress tests should be repeated as clinically indicated or at least every 2 to 5 years
Interpreting stress tests as ldquopositiverdquo or ldquonegativerdquo is beyond the scope of this document However factors that should be taken into consideration should include the individualrsquos exercise capacity symptoms blood pressure response heart rate response EKG changes and the presence of arrhythmias (Gibbon et al 2002)
There are other non-invasive tests to screen for coronary artery disease One of the most promising appears to be coronary artery calcium (CAD) scoring by computed tomography In 2007 an expert committee published an update to their original guidance document The committeersquos consensus was that ldquoit may be reasonable to consider use of CAC measurement in such patients [between 10 and 20 10-year risk of estimated coronary event]helliprdquo The committee did not recommend CAC measurement in low risk patients [lt10 10-year risk of estimated coronary event] or in high risk patients [gt20 10-year risk of estimate coronary event] (Greenland et al 2007]
D22 Cardiology
Resting EKG and Stress Tests
46
Chobanian AV Bakris GL Black HR Cushman WC Green LA Izzo JL Jr Jones DW Materson BJ Oparil S Wright JT Jr Roccella EJ the National High Blood Pressure Education Program Coordinating Committee [2003] The seventh report of the Joint National Committee [JNC-7] on Prevention Detection Evaluation and Treatment of High Blood Pressure JAMA 2892560ndash2571
Gibbons RJ Balady GJ Bricker JT Chaitman BR Fletcher GF Froelicher VF Mark DB McCallister BD Mooss AN OrsquoReilly MG Winters WL Jr [2002] ACCAHA 2002 guideline update for exercise testing summary article a report of the ACCAHA Task Force on Practice Guidelines (Committee to Update the 1997 Exercise Testing guidelines) J Am Coll Cardiol 401531ndash 1540
Greenland et al [2007] ACCFAHA 2007 Clinical Expert Consensus Document on Coronary Artery Calcium Scoring By Computed Tomography in Global Cardiovascular Risk Assessment and in Evaluation of Patients With Chest Pain A Report of the American College of Cardiology Foundation Clinical Expert Consensus Task Force (ACCFAHA Writing Committee to Update the 2000 Expert Consensus Document on Electron Beam Computed Tomography) J Am Coll Cardiol 49378-402
Kales SN Tsismenakis AJ Zhang C Soteriades ES [2009] Blood pressure in fire fighters police officers and other emergency responders Am J Hypertens 2211-20
Schlant RC Adolph RJ DiMarco JP Dreifus LS Dunn MI Fisch C Garson A Jr Haywood LJ Levine HJ Murray JA Noble RJ Ronan JA Jr [1992] Guidelines for electrocardiography A report of the American College of CardiologyAmerican Heart Association Task Force on Assessment of Diagnostic and Therapeutic Cardiovascular Procedures (Committee on Electrocardiography) Circulation 85(3)1221-1228
Soteriades ES Kales SN Liarokapis D Christiani DC [2003] Prospective surveillance of hypertension in firefighters J Clin Hypertens 5315-320
47
ATTACHMENT F
48
1
Current 1582 (2007) language in reference to pregnancy 43 (4) Report to the fire department physician any medical condition that could interfere with the ability of the individual to safely perform essential job tasks such as illness or injury use of prescription or nonprescription drugs and pregnancy 6112 Category B medical conditions shall include the following (1) Pregnancy for its duration A7792 (e) If HIV prophylaxis is to be given the following tests should be done i CBC ii Glucose renal and hepatic chemical function iii Pregnancy test for females B121 Pregnancy and Reproduction Federal regulations as well as many court decisions including the US Supreme Courtrsquos decision in International Union et al v Johnson Controls Inc [499 US 187 111 S Ct 1196 (1991)] have interpreted the requirements of Title VII with respect to pregnancy and reproduction The AHJ should seek the advice of counsel in resolving specific questions concerning these requirements as well as other requirements that can be imposed by state or local laws C211 (4) Review health status with the individual being evaluated Contraindications for evaluations shall be reviewed addressing any changes in the individualrsquos health status since their last medical evaluation that would warrant deferring the evaluation including (g) Pregnancy Recommendations to language enhancement
A female employee who is assigned to regular fire line duty shall report a pregnancy immediately to their respective Supervisor and the fire department physician The employee will then be given the option of a non-hazardous alternative duty position for the duration of her pregnancy (can we say this or is it even appropriate) Any pregnant employee wishing to remain on regular line duty shall be informed of the possible risks and consequences to herself and her fetus that are associated with continued line fire fighting duty Among those risk factors are exposure to teratogens known to have negative effects on the developing fetus such as smoke diesel fumes hazardous chemicals and extreme heat
49
Page 2
appendix It is recommended that the pregnant employee complete a release of liability form signed by herself and her health care provider utilizing NFPArsquos 13 critical tasks as a reference This will inform the health care provider of specific job-related tasks that will need to be performed in order to continue regular line duty These tasks are basic physical standards that any entry level firefighter would have to be able to complete competently The employeersquos health condition will be kept confidential by the department in accordance with HIPAA standards Employees are allowed to remain on active regular duty until they are no longer able to perform their duties in a reasonable manner andor their protective gear no longer fits correctly It is the responsibility of the health care provider to evaluate the pregnant employee If at any time the health care provider feels the pregnant employee can no longer perform the job related tasks this should be reported to the employer by the employee immediately
50
ATTACHMENT G
51
From GLENN BENARICKTo Sawyer SteveSubject RE RE 7743Date Monday August 30 2010 21633 PM
Yes thats my understanding
Glenn P Benarick 211 Winged Elm CircleAiken SC 29803803-644-7093gbenarprodigynet
--- On Mon 83010 Sawyer Steve ltssawyerNFPAorggt wrote
From Sawyer Steve ltssawyerNFPAorggtSubject RE RE 7743To GLENN BENARICK ltgbenarprodigynetgtDate Monday August 30 2010 212 PM
So it should be ldquoorrdquo instead of ldquoandrdquo for now
Steven F Sawyer
Senior Fire Service Specialist
Executive Secretary IFMAFire Service Section
NFPA
1 Batterymarch Park
Quincy MA 02169
6179847423
Fax 6179847056
ssawyernfpaorg
From GLENN BENARICK [mailtogbenarprodigynet] Sent Monday August 30 2010 1202 PMTo Sawyer SteveSubject Fw RE 7743
52
Steve a couple of our docs agree with April Boyer
Glenn P Benarick 211 Winged Elm Circle
Aiken SC 29803
803-644-7093
gbenarprodigynet
--- On Mon 83010 David Prezant ltprezandfdnynycgovgt wrote
From David Prezant ltprezandfdnynycgovgtSubject RE 7743To Thomas R (CDCNIOSHDSHEFS) Hales lttrh1cdcgovgt GLENNBENARICK ltgbenarprodigynetgtCc Sandy Bogucki ltsandyboguckiyaleedugtDate Monday August 30 2010 1004 AM
agree
we should change this to NHANES III rather than Knudson we should alsomodify this to allow not only for predicted cutoffs but all for use of thelower limit of normal cutoff This is important to prevent false-classificationof spirometry as abnormal in older groups and in taller grps The latter ofparticular import to firefighter occupational health surveillance
thanks
David Prezant MDChief Medical Officer Office of Medical AffairsCo-Director WTC Medical Monitoring amp Treatment ProgramsNew York City Fire Department9 Metrotech Center - Rm 4W-1Brooklyn NY 11201Phone 718-999-2696Fax 718-999-0665
Life is full of twists and turns
53
This email may contain confidential information If you are the unintendedrecipient of this email please send it back and delete from your directory
gtgtgt Hales Thomas R (CDCNIOSHDSHEFS) lttrh1cdcgovgt 8302010955 AM gtgtgt
Glen
This seems like a very reasonable comment and illustrates the importance of having clinicians providefeedback on the std Im not familiar with the software program of the various spirometers (NHANES IIIvs KnudsonATS vs both) Given the large role both Dave Prezant and Sandy Bogucki had for thepulmonary section let me forward to them for clarification
Tom
From GLENN BENARICK [mailtogbenarprodigynet] Sent Sunday August 29 2010 456 PMTo Hales Thomas R (CDCNIOSHDSHEFS)Subject FW 7743
Tom is April Boyer correct
Glenn P Benarick 211 Winged Elm Circle
Aiken SC 29803
803-644-7093
gbenarprodigynet
--- On Thu 82610 Sawyer Steve ltssawyerNFPAorggt wrote
From Sawyer Steve ltssawyerNFPAorggtSubject FW 7743To GLENN BENARICK ltgbenarprodigynetgtDate Thursday August 26 2010 925 PM
FYI Do you have any answer She is write
Steven
54
Steven F Sawyer
Senior Fire Service Specialist
Executive Secretary IFMAFire Service Section
NFPA
1 Batterymarch Park
Quincy MA 02169
6179847423
Fax 6179847056
ssawyernfpaorg
From April Boyer [mailtoaboyerbicclinicorg] Sent Thursday August 26 2010 232 PMTo Sawyer SteveCc RobinMWebbmilstateorusSubject 7743
Steven
The spirometry tests cannot be corrected according to both references as the NFPA states because thereferences are contradictory The first part of 7743 states to follow the ATS guidelines and use theKnudsen (we at Basin Immediate Care use the Nhanes III) The second part states to follow the ACOEMguidelines and use the Nhanes III in the occupational setting if available with your unit (which is availableon ours) 7743 does not use the word OR regarding both requirements it uses the word AND whenreferring to the first and second parts thence making 7743 contradictory I realize the NFPA 1582 hasnot been updated since 2007 unless I have just not received an updated version
Our question to you is which part of 7743 do you want us to follow the first or the second part Anyfacility that has an updated computerized spirometry system (as we do) will not be able to follow bothrequired parts for obvious reasons We can either follow the first part of 7743 and use an oldercorrected version of the Knudson by going into our system and changing out of the Nhanes III conversionOR we can follow the second part of 7743 and use the newer corrected version of Nhanes III which ourunit offers too
If you have any questions you may contact me at anytime and I also have many references in regards toboth parts of 7743 if you would like to see them
55
Thank you~
April
Confidentiality NoticeThis message may contain information that isconfidential or privileged
If you are not the intended recipientPlease advise the sender immediately and delete this message
56
ATTACHMENT H
57
NFPA 1582 771(7) Proposed revisions
Why
Preliminary results of two prospective randomized trials on the PSA test were published in 2009 These studies resulted in medical organizations that previously providing guidance to modify their recommendations
Current language
771 Blood Tests Blood tests shall be performed annually and shall include the following
(7) Prostate specific antigen (PSA) after age 40 for positive family history if African American or if otherwise clinically indicated after age 50 for all other male member
Suggested Revision
771 Blood Tests Blood tests shall be performed annually and shall include the following
(7) Prostate specific antigen (PSA) after age 40 for positive family history if African American or if otherwise clinically indicated after age 50 for all other male member
772 Prostate-Specific Antigen (PSA) test At age 50 fire fighters shall have an opportunity to make an informed decision with either the Fire Department physician or their health care provider concerning the PSA test For fire fighters at increased risk of prostate cancer (African-Americans or those with a first degree relative diagnosed with prostate cancer before age 65) shall have the opportunity for this informed decision at age 40
A772 The PSA as a screening test for prostate cancer in asymptomatic men is controversial controversial for two reasons First there is no consensus that PSA screening actually saves lives For example the PSA test may detect small cancers that would never become life threatening Second it is unclear that the benefits of PSA screening outweigh the risks of follow-up diagnostic tests and cancer treatments For example the prostate biopsy used to diagnose prostate cancer may cause bleeding and infection And prostate cancer treatments such as surgery and radiation therapy may cause incontinence (inability to control urine flow) erectile dysfunction (erections inadequate for intercourse) and other complications For these reasons it is important that the benefits and risks of prostate diagnostic procedures and treatment be taken into account when considering the PSA screening test These considerations can be taken account during discussions with the fire department physician or onersquos health care provider
D211 Cancer Screening
Smith R A C J Mettlin K J Davis and H Eyre 2000 ldquoAmerican Cancer Society guidelines for the early detection of cancerrdquo CA J Clin 50(1)34ndash49
Added references
58
Carroll P Albertsen PC Greene K et al [2010] Prostate-specific antigen best practice statement 2009 update Am Urological Assoc Available at httpwwwauanetorgcontentguidelines-and-quality-careclinical-guidelinesmain-reportspsa09pdf Date accessed September 2010
Ferrini R Woolf SH [2009] Screening for prostate cancer in American men American College of Preventive Medicine Practice Policy Statement Available at httpwwwacpmorgprostatehtm Date accessed September 2010
National Cancer Institute [2009] Prostate-specific antigen test National Cancer Institute Fact Sheet Available at httpwwwcancergovcancertopicsfactsheetDetectionPSA Date accessed September 2010
Wolf AMD Wender RC Etzioni RB et al [2010] American Cancer Society guideline for the early detection of prostate cancer Update 2010 Available at httpcaonlineamcancersocorgcgicontentfullcaac20066v1 Date accessed September 2010
59
Hypoglycemia (incapacitating ndash defined differently between the two documents (434)
NFPA ndash 0 episodes in past year le1 in past 5 yrs
ACOEM Police ndash 0 episodes in past year le2 in past 3 yrs
Given Dan Samorsquos and Richard Millerrsquos work with the ADALoeber it would be helpful to get their opinions on whether any of the changes requested by Loeber are appropriate for FF with DM
Tom
Thomas Hales MD MPH
Senior Medical Epidemiologist
NIOSH CDC
4676 Columbia Pkwy R-9
Cincinnati OH 45241
(513) 841-4583
trh1cdcgov
19
43 ndash DIABETES MELLITUS
431 ndash INTRODUCTION
The educated and motivated law enforcement officer (LEO) with well-managed diabetes mellitus can be capable of
safe and effective job performance1 However diabetes mellitus may place LEOs at risk for sudden incapacitation
thus jeopardizing their ability to perform critical job functions (These job functions include those listed in Sections
32 333 351 352 36 and 37 and discussed in Appendix A)
Therefore an individualized assessment of the LEOrsquos diabetes should be performed using the following evaluative
criteria to determine whether the individuals condition permits safe and effective job performance Such evaluation
must include the following key elements which are discussed in detail below
history of blood glucose control
knowledge of diabetes and its management
current stability of blood glucose
risk for significant hypoglycemia or hyperglycemia and
presence of diabetic complications
432 ndash OVERVIEW OF MEDICAL EVALUATION
The treating endocrinologist or other physician knowledgeable regarding diabetes management should provide
a narrative report certifying whether the LEO has or has not met the criteria set out in Sections 4321 through
4354 below In addition the physician should include supporting data (see Appendix B for the Physician Evalu-
ation Form)
4321 The LEO is under the care of an endocrinologist or other physician knowledgeable regarding diabetes
management Outpatient and in-patient medical record(s) for the last 3 years or since date of diagnosis
(whichever is shorter) should be reviewed by the treating physician and provided to the police physician
4322 If the LEO has type 1 diabetes the individual has been on a basalbolus regimena or an insulin pump
using analogue insulins for the 6 months prior to evaluation2
4323 If the LEO has type 2 diabetes on insulin the individual has been on a stable medication regimenb
for the 3 months prior to evaluation3 If on oral agents alone the LEO has been on a stable medication regimen
for the month prior to evaluationc
ACOEM Guidance for the Medical Evaluation of Law Enforcement Officers 1
43 ndash DIABETES MELLITUS
aA basalbolus insulin regimen consists of the use of a basal insulin (Glargine NPH) in a once or twice daily regimen to provide between-
meal insulin combined with the use of a short acting insulin (Regular Lispro Aspart or Glulisine) at mealtimes Insulin pumps are small
(beeper sized) battery powered devices that deliver small amounts of short-acting insulin in a constant infusion to meet basal insulin
requirements The wearer selects an additional mealtime bolus to be infused at the time of meals For more information on pumps visit
the manufacturerrsquos web sites ndash wwwMinimedcom wwwcozmorecom wwwanimascorpcom wwwdisetroniccom
bA stable insulin regimen is defined as maintaining the same types of insulin (long acting intermediate acting short or rapid acting)
Changes in insulin dose are part of the appropriate self-management of diabetes and do not disqualify an applicant or incumbent under
this section
cChanges in dose within the evaluation period will be allowed but addition of a new class of medications or insulin should result in a new
period of observation
one month for addition of a sulfonylurea or metformin
two months for the addition of a thiazolidinedione to insulin or a sulfonylurea or
three months for the addition of insulin
20
4324 If the LEO uses an insulin pump documentation is needed as follows
proper understanding and education in the use of the insulin pump
start date for the use of the pump
history of insulin site infectionsd
history of pump cessation and pump malfunction
backup plan for pump malfunction including use of injectable insulin and
frequency of infusion set changes
4325 The LEO has been educated in diabetes and its management and thoroughly informed of and under-
stands the procedures that must be followed to monitor and manage hisher diabetes and what procedures
should be followed if complications arise3
433 ndash QUANTITATIVE GLUCOSE MONITORING
4331 The LEO has documentation of ongoing self-monitoring of blood glucose
4332 This must be done with a glucose meter that stores every reading records date and time of reading
and from which data can be downloaded (Most meters now have this capability)
4333 Monitoring logs must be available covering the time period (1 3 or 6 months) as described in
Sections 4322 and 4323 The frequency of glucose monitoring must follow a schedule acceptable to the
police physician in consultation with the treating physician
Testing schedules are individual What follows is a common pattern but individual patterns may differ
2 ACOEM Guidance for the Medical Evaluation of Law Enforcement Officers
43 ndash DIABETES MELLITUS
dIndividual has not had more than one pump-site infection that caused him or her to miss work or usual daily activities in the preceding 6
months
THERAPEUTIC REGIMEN GLUCOSE TESTING SCHEDULE
Diet alone Once or twice a week
Metformin Thiazolidinediones or Alpha
Glucosidase inhibitors alone or in
combination
Once or twice a week
Sulfonylureas meglitanides nateglinide ndash
alone or in combination with the above group
Twice a day ndash AM and at supper with any
suspected hypoglycemic episodes
Insulin ndash one shot in combination with orals Twice a day ndash AM and at supper with any
suspected hypoglycemic episodes
2 to 3 times AM once a week
Insulin ndash two or more shots Insulin pump 3 to 4 times a day ndash at meals and bedtime
2 to 3 times AM once a week with any
suspected hypoglycemic episodes
21
4334 The LEO has had hemoglobin A1C measured at least 4 times a year (intervals of 2 to 3 months) over
the last 12 months prior to evaluation if diagnosis has been present for more than a year4 If hemoglobin A1C is
gt8 this may signal a problem with the LEOrsquos diabetes management that warrants further assessment5
434 ndash INCAPACITATING EVENTS
4341 The LEO has not had any incapacitating episodes within the past 1 year and no more than 2 episodes
in the past 3 years or since diagnosis of diabetes (whichever is shorter) of
43411 Severe hypoglycemia (loss of consciousness seizures or coma requiring assistance of others or
needing urgent treatment [glucagon injectionIV glucose]) or
43412 Blood sugar lt60 mgdl with unawareness demonstrated in current glucose logs6
435 ndash CHRONIC COMPLICATION SCREENING
4351 Chronic complications of diabetes are associated with increased risk for severe hypoglycemic
episodes and warrant further assessmente
4352 The components of screening for chronic complications are
43521 A complete eye exam by a qualified ophthalmologist or optometrist including a dilated retinal
exam demonstrating no more than mild background diabetic retinopathyf7
43522 Normal vibratory testing with a 128 Hz tuning forkg normal testing with 10 gram Semmes-
Weinstein monofilamentg and normal orthostatic blood pressureh and pulse testing89
ACOEM Guidance for the Medical Evaluation of Law Enforcement Officers 3
43 ndash DIABETES MELLITUS
ePresence of chronic complications of diabetes in and of themselves may not require the implementation of work restrictions
fNo more than one dot blot or flame-shaped hemorrhages or microaneurysm in all four fundus quadrants
gThe Michigan Diabetes Research and Training Center of the University of Michigan Health System recommends the following guidance
(see wwwmedumichedumdrtcprofsdocumentssviMNSI_howtopdf) for conducting vibratory and monofilament testing8
Vibration Sensation Vibration sensation should be performed with the great toe unsupported Vibration sensation will be tested bi-
laterally using a 128 Hz tuning fork placed over the dorsum of the great toe on the boney prominence of the DIP joint Patients whose
eyes are closed will be asked to indicate when they can no longer sense the vibration from the vibrating tuning fork In general the
examiner should be able to feel vibration from the hand-held tuning fork for 5 seconds longer on his distal forefinger than a normal subject
can at the great toe (eg examiners DIP joint of the first finger versus patients toe) If the examiner feels vibration for 10 or more seconds
on his or her finger then vibration is considered decreased A trial should be given when the tuning fork is not vibrating to be certain that
the patient is responding to vibration and not pressure or some other clue Vibration is scored as 1) present if the examiner senses the
vibration on his or her finger for lt10 seconds 2) reduced if sensed for 10 seconds or 3) absent (no vibration detection)
Monofilament Testing For this examination it is important that the patients foot be supported (ie allow the sole of the foot to rest on
a flat warm surface) The filament should initially be pre-stressed (4-6 perpendicular applications to the dorsum of the examiner s first
finger) The filament is then applied to the dorsum of the great toe midway between the nail fold and the DIP joint Do not hold the toe
directly The filament is applied perpendicularly and briefly (lt1 second) with an even pressure When the filament bends the force of
10 grams has been applied The patient whose eyes are closed is asked to respond yes if heshe feels the filament Eight correct responses
out of 10 applications is considered normal 1 to 7 correct responses indicates reduced sensation and no correct answers translates into
absent sensation
hOrthostatic hypotension is a physical finding defined by the American Autonomic Society and the American Academy of Neurology as a
systolic blood pressure decrease of at least 20 mm Hg or a diastolic blood pressure decrease of at least 10 mm Hg within 3 minutes of
standing
22
43523 Normal cardiac physical exam Cardiac stress testing to at least 12 METS is recommended and
should begin based on either the criteria of the American Heart AssociationAmerican College of
Cardiologyi10 or those of the American Diabetes Associationj11
Diabetics who have a normal cardiac stress test will be retested every one to three years based on
individual clinical assessment This assessment should consider
the age of the individual
the number and persistence of coronary artery disease (CAD) risk factors
the severity of CAD risk factors
43524 Microalbumincreatinine ratio 301 measured or calculatedk creatinine clearance
gt60 mlmin12
436 ndash ONGOING EVALUATION AND REQUIREMENTS
4361 Should have medical records and glucose meter logs reviewed periodically Because of the nature of
diabetes it is important that regular medical follow up be provided to the LEO The frequency and content of
the evaluation should be determined on an individual basis by the police physician in consultation with the
treating physicianl
4362 Must advise police physician of any change in type of medication
4363 Must advise police physician of any episodes of significant hypoglycemia or hyperglycemia
Urine microalbumincreatinine ratio _________________
III Treating Physician Statement
The above named individual meets all of the criteria provided on this form
Yes No ndash not recommended for position
No but IS recommended for position (letter of explanation attached)
It is my opinion that the above named individual is well-educated and well-motivated in diabetes self-management and has
achieved a level of diabetes management to be capable of safe and effective job performance as a law enforcement officer
I have reached this opinion after careful review of the above criteria
___________________________________________________________ ___________________________Signature of Physician Date
______________________________________________________________ ___________________________Printed or Typed Name of Physician Telephone Number
10 ACOEM Guidance for the Medical Evaluation of Law Enforcement Officers
43 ndash DIABETES MELLITUS
29
439 ndash REFERENCES
1 American Diabetes Association Diagnosis and classification of diabetes mellitus Diabetes Care 200427 Suppl
1S5-S10 See httpcarediabetesjournalsorgcgicontentfull27suppl_1s5
2 American Diabetes Association Continuous subcutaneous insulin infusion Diabetes Care 200427 Suppl 1S110
See httpcarediabetesjournalsorgcgicontentfull27suppl_1s110
3 Mensing C Boucher J Cypress M et al National standards for diabetes self-management education Diabetes
Care 200528 Suppl 1S72-9 See httpcarediabetesjournalsorgcgicontentfull28suppl_1s72
4 Goldstein DE Little RR Lorenz RA Malone JI Nathan DM Peterson CM American Diabetes Association Tests
of glycemia in diabetes Diabetes Care 200427 Suppl 1S91-3
See httpcarediabetesjournalsorgcgicontentfull27suppl_1s91
5 The Diabetes Control and Complications Trial Research Group Hypoglycemia in the Diabetes Control and
Complications Trial Diabetes 199746(2)271-86 See wwwncbinlmnihgovpubmed9000705 for abstract
6 American Diabetes Association Hypoglycemia and employmentlicensure Diabetes Care 200528 Suppl 1S61
See httpcarediabetesjournalsorgcgicontentfull28suppl_1s61
7 Viswanath K McGavin DD Diabetic Retinopathy Clinical Findings and Management J Comm Eye Health
200316(46)21-4 See wwwcehjournalorg0953-683316jceh_16_46_021html
8 Michigan Diabetes Research and Training Center University of Michigan Health System How to use the Michigan
Neuropathy Screening Instrument See wwwmedumichedumdrtcprofsdocumentssviMNSI_howtopdf
9 Bradley JG Davis KA Orthostatic hypotension Am Fam Physician 200368(12)2393-8
See wwwaafporgafp200312152393html
10 Gibbons RJ Balady GJ Bricker JT et al ACCAHA 2002 guideline update for exercise testing a report of the
American College of CardiologyAmerican Heart Association Task Force on Practice Guidelines (Committee on
Exercise Testing) J Am Coll Cardiol 200240(8)1531-40
See wwwaccorgqualityandscienceclinicalguidelinesexerciseexercise_cleanpdf
11 American Diabetes Association Standards of medical care in diabetes Diabetes Care 200528 Suppl 1S4-S36
Erratum in Diabetes Care 200528(4)990 See httpcarediabetesjournalsorgcgicontentfull28suppl_1s4
12 Molitch ME DeFronzo RA Franz MJ et al American Diabetes Association Nephropathy in diabetes Diabetes
Care 200427 Suppl 1S79-83 See httpcarediabetesjournalsorgcgicontentfull27suppl_1s79
13 Kitabchi AE Umpierrez GE Murphy MB et al American Diabetes Association Hyperglycemic crises in diabetes
Diabetes Care 200427 Suppl 1S94-102 See httpcarediabetesjournalsorgcgicontentfull27suppl_1s94
14 US Centers for Disease Control and Prevention National Diabetes Fact Sheet 2007
See wwwcdcgovdiabetespubspdfndfs_2007pdf
ACOEM Guidance for the Medical Evaluation of Law Enforcement Officers 11
43 ndash DIABETES MELLITUS
30
ATTACHMENT E
31
Typos A6921(2) 7th line down test should be plural 94201 Paragraph 2 target organ damage is used though end organ damage was defined earlier and in the appendix for that paragraph
A94201 Para A (1) d Id suggest deleting the phrases in brackets Im not sure either are predictably true or politically wise
a) tests for left ventricular hypertrophy Unfortunately use of the EKG to detect left ventricular hypertrophy is very insensitive (eg 5 sensitivity) The echocardiogram is the best test for diagnosing left ventricular hypertrophy but [it is relatively expensive and not readily available in small rural communities ] conducting echocardiograms on asymptomatic fire fighters with Stage 1 hypertension should be reserved only for those with long-standing hypertension
In addition
7761 A resting EKG shall be performed as part of the baseline medical evaluation and shall be obtained periodically thereafter
Changing from annually to periodically is noted has the language in the wellness-fitness initiative been changed as well Our previous decision was that we would support the W-F language since there was no compelling evidence to either support or refute it
Thanks
Sandy
32
NFPA 1582‐ HTN Draft 1
Reason for Revision
1) New classification of BP by the Joint National Commission [Chobanian et al 2002]
2) A high prevalence of FF have either HTN (~20) and Pre‐HTN (~20) [Soteriades et al 2003]
3) Among FF studies have shown a strong association between HTN and a number of adverse
cardiovascular events [Kales et al 2009]
4) A large percentage of on‐duty FF fatalities were found to have left ventricular hypertrophy a
complication of HTN at autopsy
Language in 2007 Edition with draft revisions in Red (Track changes)
611 The medical evaluation of a candidate shall include a medical history examination and any laboratory tests required to detect physical or medical condition(s) that could adversely affect hisher ability to safely perform the essential job tasks outlined in 511 A611 The medical history should include the candidates known health problems such as major illnesses surgeries medication use and allergies Symptom review is also important for detecting early signs of illness A medical history should also include a personal health history a family health history a health habit history an immunization history and a reproductive history
An occupational history should also be obtained to collect information about the persons past occupational and environmental exposures
(a) BP should be measured according to the Joint National Commission (JNC) -7 recommendations BP should be measured with a properly calibrated and validated instrument Patients should be seated quietly for at least 5 minutes in a chair with feet on the floor and arm supported at heart level An appropriate-sized cuff (cuff bladder encircling at least 80 of the arm) should be used to ensure accuracy At least 2 measurements should be made Systolic BP is the point at which the first of 2 or more sounds is heard (phase 1) and diastolic BP is the point before the disappearance of sounds (phase 5) [Chobanian et al 2003]
(2) Head eyes ears nose and throat (HEENT)
Formatted Font (Default) Times New RomanFont color Black
33
692 Vascular System 6921 Category A medical conditions shall include the following
(1) Uncontrolled or poorly controlled hypertension
(2) Hypertension with evidence of end organ damage
or not controlled by approved medications
A6921(1) Uncontrolled or poorly controlled hHypertension increases the risk of a sudden cardiac event This sudden cardiac event would cause sudden incapacitation which that is uncontrolled poorly controlled or requires medication likely to interferes with the safe performance of essential job tasks Uncontrolled or poorly controlled hypertension can be defined as the presence of end organ damage (see below) or stage 2 hypertension (BP systolic gt160 mmHg or BP diastolic gt100 mmHg) is an illness that can lead to functional impairment and potential for sudden incapacitation Individuals with pre- stage 1 or stage 2 hypertension should be referred to their primary care physician for evaluation lifestyle modification and treatment [QUESTION FOR GROUP _- WHAT ABOUT HAVING CANDIDATE RETURN IN ONE MONTH UNDER TREATMENT WITH NORMAL BP]
A6921(2)
Chronic hypertension can damage the eye (retinopathy) the kidneys (nephropathy) the vascular system (stroke transient ischemic attack or peripheral artery disease) or the heart (left ventricular hypertrophy and heart failure) These hypertension complications are known as end organ damage The cardiac and vascular complications are associated with an increased risk of sudden incapacitation and sudden cardiac death (Koren et al 1991) Unfortunately the cardiac complications are frequently asymptomatic and valid screening tests are not fast and are not inexpensive Therefore determining who to screen for cardiac complications (such as echocardiogram for LVH or a measurement of left ventricular ejection fraction for heart failure) should be based on the severity and the duration of HTN
76 Physical Examination The annual physical examination shall include each of the following components
(a) BP shall be measured according to the Joint National Commission (JNC)-7 recommendations
A76(1)(a) BP should be measured with a properly calibrated and validated instrument Patients should be seated quietly for at least 5 minutes in a chair with feet on the floor and arm supported at heart level An appropriate-sized cuff (cuff bladder encircling at least 80 of the arm) should be used to ensure accuracy At least 2 measurements should be made Systolic BP is the point at which the first of 2 or more sounds is heard (phase 1) and diastolic BP is the point before the disappearance of sounds (phase 5) [Chobanian et al 2003]
(2) Head eyes ears nose and throat (HEENT)
34
9420 Uncontrolled Hypertension 94201 Physician Evaluation Severe uncontrolled hypertension [defined as systolic pressure greater than 180 mm Hg diastolic pressure greater than 100 mm Hg or mean systolic blood
pressure ( systolic + diastolic) greater than 120 mm Hg] or malignant hypertension (defined as hypertension with the presence of target organ damage) compromises the members ability to safely perform essential job tasks 1 5 7 9 and 13 and the physician shall report the applicable job limitations to the fire department
Members with Pre-hypertention (systolic 120-139 mmHg or diastolic 80-89 mmHg) Stage 1 hypertension (systolic 140-159 mmHg or diastolic 90-99 mmHg) or Stage 2 hypertension (systolic ge160 mmHg or diastolic ge100 mmHg) should be referred to their primary care physician for evaluation lifestyle modification and treatment
(1) Members with Stage I hypertension should be followed-up not only by their primary care physician but also by the FD physician every 3 to 6 months to ensure their blood pressure is under control and to determine whether screening tests for asymptomatic end organ damage are appropriate
(2) Members with Stage 2 hypertension or with end organ damage (retinopathy nephropathy vascular or cardiac complications) compromises the members ability to safely perform essential job tasks 1 5 7 9 and 130 and the physician shall report the applicable job limitations to the fire department
A94201 Severe uncontrolled hypertension is a significant risk factor for the development of coronary artery disease congestive heart failure and stroke Blood pressure increases as a normal response to exercise This response is further exaggerated by the emotional and physical stress of performing these critical tasks while operating in personal protective clothing at extremes of temperature This normal elevation of blood pressure under these response conditions can lead to life-threatening hypertensive emergencies if a members daily blood pressure is already elevated to high levels In addition hypertension is a progressive illness that when uncontrolled ultimately and inevitably leads to target organ damage Target organs that are sensitive to the effects of elevated blood pressure are the central nervous system vision heart major blood vessels and kidneys
Chronic hypertension can damage the eye (retinopathy) the kidneys (nephropathy) the vascular system (stroke transient ischemic attack or peripheral artery disease) or the heart (left ventricular hypertrophy and heart failure) These hypertension complications are known as end organ damage The cardiac and vascular complications are associated with an increased risk of sudden incapacitation and sudden cardiac death (Koren et al 1991) Fortunately with proper evaluation life style modification and treatment these complications can be avoided Life style modification includes weight reduction DASH eating plan reduction in dietary sodium an increase in aerobic physical activity and moderation in alcohol consumption [Chobanian 2003]
Formatted Font (Default) Times New Roman12 pt Font color Black
Formatted Font (Default) Times New Roman12 pt Font color Black
35
A94201 (1) Members with Stage I hypertension whose BP returns to either pre-hypertenion or normal with lifestyle modification andor treatment can return to an annual medical evaluation For members with long-standing Stage I hypertension whose BP has not been reduced additional evaluation for possible end organ damage should be considered This evaluation could include any or all of the following
a) a compete patient history for symptoms of heart failure (eg shortness of breath upon exertion) or transient ischemic attacks (TIAs)
b) dilated eye examination for retinopathy
c) blood creatinine measurement for nephropathy
d) tests for left ventricular hypertrophy Unfortunately use of the resting EKG to detect left ventricular hypertrophy is very insensitive (eg 5 sensitivity) The echocardiogram is the best test for diagnosing left ventricular hypertrophy
A 94201 (2) Due to the high risk of a sudden cardiovascular event members with Stage 2 hypertension should be restricted until their BP can be brought under control Once the BP is brought under control they should be followed in the same manner as a member with Stage I hypertension
Formatted Font (Default) Times New Roman12 pt
36
D22 Cardiology Gibbons R J GJ Balady J W Beasley et al 1997 ACCAHA guidelines for exercise testing a report of American College of CardiologyAmerican Heart Association Task Force on Practice Guidelines (Committee on Exercise Testing) J Am Coll Cardiol 30260ndash311
Gibbons RJ Balady GJ Bricker JT Chaitman BR Fletcher GF Froelicher VF Mark DB McCallister BD Mooss AN OrsquoReilly MG Winters WL Jr [2002] ACCAHA 2002 guideline update for exercise testing summary article a report of the ACCAHA Task Force on Practice Guidelines (Committee to Update the 1997 Exercise Testing guidelines) J Am Coll Cardiol 401531ndash 40
Chobanian AV Bakris GL Black HR Cushman WC Green LA Izzo JL Jr Jones DW Materson BJ Oparil S Wright JT Jr Roccella EJ the National High Blood Pressure Education Program Coordinating Committee [2003] The seventh report of the Joint National Committee [JNC-7] on Prevention Detection Evaluation and Treatment of High Blood Pressure JAMA 2892560ndash2571
Soteriades ES Kales SN Liarokapis D Christiani DC [2003] Prospective surveillance of hypertension in firefighters J Clin Hypertens 5315-320
Kales SN Tsismenakis AJ Zhang C Soteriades ES [2009] Blood pressure in fire fighters police officers and other emergency responders Am J Hypertens 2211-20
37
NFPA 1582‐ HTN Draft 1
Reason for Revision
1) New classification of BP by the Joint National Commission [Chobanian et al 2002]
2) A high prevalence of FF have either HTN (~20) and Pre‐HTN (~20) [Soteriades et al 2003]
3) Among FF studies have shown a strong association between HTN and a number of adverse
cardiovascular events [Kales et al 2009]
4) A large percentage of on‐duty FF fatalities were found to have left ventricular hypertrophy a
complication of HTN at autopsy
Language in 2007 Edition with draft revisions in Red (Track changes)
611 The medical evaluation of a candidate shall include a medical history examination and any laboratory tests required to detect physical or medical condition(s) that could adversely affect hisher ability to safely perform the essential job tasks outlined in 511 A611 The medical history should include the candidates known health problems such as major illnesses surgeries medication use and allergies Symptom review is also important for detecting early signs of illness A medical history should also include a personal health history a family health history a health habit history an immunization history and a reproductive history
An occupational history should also be obtained to collect information about the persons past occupational and environmental exposures
(a) BP should be measured according to the Joint National Commission (JNC) -7 recommendations BP should be measured with a properly calibrated and validated instrument Patients should be seated quietly for at least 5 minutes in a chair with feet on the floor and arm supported at heart level An appropriate-sized cuff (cuff bladder encircling at least 80 of the arm) should be used to ensure accuracy At least 2 measurements should be made Systolic BP is the point at which the first of 2 or more sounds is heard (phase 1) and diastolic BP is the point before the disappearance of sounds (phase 5) [Chobanian et al 2003]
(2) Head eyes ears nose and throat
38
692 Vascular System 6921 Category A medical conditions shall include the following
(1) Uncontrolled or poorly controlled hypertension
(2) Hypertension with evidence of end organ damage
A6921(1) Uncontrolled or poorly controlled hypertension increases the risk of a sudden cardiac event This sudden cardiac event would cause sudden incapacitation which interferes with the safe performance of essential job tasks Uncontrolled or poorly controlled hypertension can be defined as the presence of end organ damage (see below) or stage 2 hypertension (BP systolic gt160 mmHg or BP diastolic gt100 mmHg) Individuals with pre- stage 1 or stage 2 hypertension should be referred to their primary care physician for evaluation lifestyle modification and treatment [QUESTION FOR GROUP _- WHAT ABOUT HAVING CANDIDATE RETURN IN ONE MONTH UNDER TREATMENT WITH NORMAL BP]
A6921(2)Chronic hypertension can damage the eye (retinopathy) the kidneys (nephropathy) the vascular system (stroke transient ischemic attack or peripheral artery disease) or the heart (left ventricular hypertrophy and heart failure) These hypertension complications are known as end organ damage The cardiac and vascular complications are associated with an increased risk of sudden incapacitation and sudden cardiac death (Koren et al 1991) Unfortunately the cardiac complications are frequently asymptomatic and valid screening tests are not fast and are not inexpensive Therefore determining who to screen for cardiac complications (such as echocardiogram for LVH or a measurement of left ventricular ejection fraction for heart failure) should be based on the severity and the duration of HTN
76 Physical Examination The annual physical examination shall include each of the following components
(a) BP shall be measured according to the Joint National Commission (JNC)-7 recommendations
A76(1)(a) BP should be measured with a properly calibrated and validated instrument Patients should be seated quietly for at least 5 minutes in a chair with feet on the floor and arm supported at heart level An appropriate-sized cuff (cuff bladder encircling at least 80 of the arm) should be used to ensure accuracy At least 2 measurements should be made Systolic BP is the point at which the first of 2 or more sounds is heard (phase 1) and diastolic BP is the point before the disappearance of sounds (phase 5) [Chobanian et al 2003]
(2) Head eyes ears nose and throat9420 Hypertension 94201 Physician Evaluation Members with Pre-hypertention (systolic 120-139 mmHg or diastolic 80-89 mmHg) Stage 1 hypertension (systolic 140-159 mmHg or diastolic 90-99 mmHg) or Stage 2 hypertension (systolic ge160 mmHg or diastolic ge100 mmHg) should be referred to their primary care physician for evaluation lifestyle modification and treatment
39
(1) Members with Stage I hypertension should be followed-up not only by their primary care physician but also by the FD physician every 3 to 6 months to ensure their blood pressure is under control and to determine whether screening tests for asymptomatic end organ damage are appropriate
(2) Members with Stage 2 hypertension or with end organ damage (retinopathy nephropathy vascular or cardiac complications) compromises the members ability to safely perform essential job tasks 1 5 7 9 and 130 and the physician shall report the applicable job limitations to the fire department
A94201 Chronic hypertension can damage the eye (retinopathy) the kidneys (nephropathy) the vascular system (stroke transient ischemic attack or peripheral artery disease) or the heart (left ventricular hypertrophy and heart failure) These hypertension complications are known as end organ damage The cardiac and vascular complications are associated with an increased risk of sudden incapacitation and sudden cardiac death (Koren et al 1991) Fortunately with proper evaluation life style modification and treatment these complications can be avoided Life style modification includes weight reduction DASH eating plan reduction in dietary sodium an increase in aerobic physical activity and moderation in alcohol consumption [Chobanian 2003]
A94201 (1) Members with Stage I hypertension whose BP returns to either pre-hypertenion or normal with lifestyle modification andor treatment can return to an annual medical evaluation For members with long-standing Stage I hypertension whose BP has not been reduced additional evaluation for possible end organ damage should be considered This evaluation could include any or all of the following
a) a compete patient history for symptoms of heart failure (eg shortness of breath upon exertion) or transient ischemic attacks (TIAs)
b) dilated eye examination for retinopathy
c) blood creatinine measurement for nephropathy
d) tests for left ventricular hypertrophy Unfortunately use of the resting EKG to detect left ventricular hypertrophy is very insensitive (eg 5 sensitivity) The echocardiogram is the best test for diagnosing left ventricular hypertrophy
A 94201 (2) Due to the high risk of a sudden cardiovascular event members with Stage 2 hypertension should be restricted until their BP can be brought under control Once the BP is brought under control they should be followed in the same manner as a member with Stage I hypertension
D22 Cardiology
40
Hypertension
Gibbons RJ Balady GJ Bricker JT Chaitman BR Fletcher GF Froelicher VF Mark DB McCallister BD Mooss AN OrsquoReilly MG Winters WL Jr [2002] ACCAHA 2002 guideline update for exercise testing summary article a report of the ACCAHA Task Force on Practice Guidelines (Committee to Update the 1997 Exercise Testing guidelines) J Am Coll Cardiol 401531ndash 40
Chobanian AV Bakris GL Black HR Cushman WC Green LA Izzo JL Jr Jones DW Materson BJ Oparil S Wright JT Jr Roccella EJ the National High Blood Pressure Education Program Coordinating Committee [2003] The seventh report of the Joint National Committee [JNC-7] on Prevention Detection Evaluation and Treatment of High Blood Pressure JAMA 2892560ndash2571
Soteriades ES Kales SN Liarokapis D Christiani DC [2003] Prospective surveillance of hypertension in firefighters J Clin Hypertens 5315-320
Kales SN Tsismenakis AJ Zhang C Soteriades ES [2009] Blood pressure in fire fighters police officers and other emergency responders Am J Hypertens 2211-20
41
NFPA 1582‐ Draft Revisions for CVDHTN
EKG and stress tests
Reason for Revision
1) Change requirement for annual resting EKG to periodically to be more consistent with ACCAHA
recommendation (Schlant et al 1992)
2) Add language to clarify what constitutes a positive ST
3) Make criteria for conducting diagnostic ST in asymptomatic patients consistent with the
ACCAHA
Language in 2007 Edition with draft revisions in Red (Track changes)
776 Electrocardiograms (EKG)) and Stress Tests 7761 A resting EKG shall be performed as part of the baseline medical evaluation and shall be obtained periodically (every 1 to 5 years) annually thereafter
A7761 A baseline resting EKGs shall be conducted Follow-up resting EKGs should be conducted as clinically indicated but at a minimum of every 1 to 5 years The frequency of these follow-up resting EKGs should increase as a members age increases or with increasing number andor severity of coronary heart disease risk factors Members above the age of 40 should have annual resting EKGs (Schlant et al 1992)
7762 The fire department physician or other qualified medical evaluator shall compare EKGs obtained during yearly evaluations with baseline and subsequent EKGs
7763 Stress testing EKG with or without echocardiography or radionuclide scanning shall be performed as clinically indicated by history or symptoms
A7761 Baseline electrocardiography should be conducted (Periodic resting electrocardiograms have not been shown to be useful but can be reasonable as a members agefactors increase)
A7763 No firm guidelines for stress testingelectrocardiography in asymptomatic individuals have been developed Stress testingelectrocardiography as a screening tool is used as part of an evaluation of aerobic capacity during the annual occupational fitness evaluation Submaximal stress testingelectrocardiography testing to 85 percent is commonly used as part of this screening
Submaximal stress electrocardiography testing should not be used for diagnostic purposes Cardiology evaluation with maximal stress testingelectrocardiography together with imaging techniques (eg echocardiography technetium Tc99m sestamibi study andor coronary angiography) is necessary for diagnosticprognostic purposes for the following
42
(1) Fire fighters with positive or questionably positive changes on screening submaximal stress tests
(2) Fire fighters with new onset chest pain or other symptoms suggestive of coronary artery disease (CAD)
(3) Fire fighters with diabetes mellitus who
(a) are gt35 years old or
(b) have type I diabetes for more than 15 years or
(c) have type II diabetes for more than 10 years or
(d) have any other CHD risk factor (see below) or
(e) have the presence of microvascular disease (proliferative retinopathy)
(4) Fire fighters over the age of 45 (for men) and 55 (for women) with onetwo or more risk factors for CAD Risk factors for CAD include hypercholesterolemia (total cholesterol greater than 240 mgdL) hypertension (systolic gt140 mmHg or diastolic gt90 mmHg) smoking or family history of premature CAD (heart attack or sudden cardiac death in a first degree relative less than 60 years of age)
as defined below if stress electrocardiography with imaging is negative then repeat as clinically indicated or at least every 5 years
(5) Fire fighters with a Framingham Risk Score gt10 Risk calculator is available at [httphp2010nhlbihinnetatpiiicalculatorasp]
(6) Fire fighters identified in 9431
Negative stress tests should be repeated as clinically indicated or at least every 2 to 5 years
Interpreting stress tests as ldquopositiverdquo or ldquonegativerdquo is beyond the scope of this document However factors that should be taken into consideration should include the individualrsquos exercise capacity symptoms blood pressure response heart rate response EKG changes and the presence of arrhythmias (Gibbon et al 2002)
Risk factors for CAD include hypercholesterolemia (total cholesterol greater than 240 mgdL) hypertension (systolic greater than 140 andor diastolic greater than 90) smoking diabetes mellitus or family history of premature CAD (heart attack or sudden cardiac death in a first degree relative less than 60 years of age)
There are other non-invasive tests to screen for coronary artery disease One of the most promising appears to be coronary artery calcium (CAD) scoring by computed tomography In 2007 an expert committee published an update to their original guidance document The committeersquos consensus was that ldquoit may be reasonable to consider use of CAC measurement in such patients [between 10 and 20 10-year risk of estimated coronary event]helliprdquo The committee did not recommend CAC measurement in low risk patients [lt10 10-year risk of estimated coronary event] or in high risk patients [gt20 10-year risk of estimate coronary event] (Greenland et al 2007]
43
D22 Cardiology
Chobanian AV Bakris GL Black HR Cushman WC Green LA Izzo JL Jr Jones DW Materson BJ Oparil S Wright JT Jr Roccella EJ the National High Blood Pressure Education Program Coordinating Committee [2003] The seventh report of the Joint National Committee [JNC-7] on Prevention Detection Evaluation and Treatment of High Blood Pressure JAMA 2892560ndash2571
Gibbons RJ Balady GJ Bricker JT Chaitman BR Fletcher GF Froelicher VF Mark DB McCallister BD Mooss AN OrsquoReilly MG Winters WL Jr [2002] ACCAHA 2002 guideline update for exercise testing summary article a report of the ACCAHA Task Force on Practice Guidelines (Committee to Update the 1997 Exercise Testing guidelines) J Am Coll Cardiol 401531ndash 1540
Greenland et al [2007] ACCFAHA 2007 Clinical Expert Consensus Document on Coronary Artery Calcium Scoring By Computed Tomography in Global Cardiovascular Risk Assessment and in Evaluation of Patients With Chest Pain A Report of the American College of Cardiology Foundation Clinical Expert Consensus Task Force (ACCFAHA Writing Committee to Update the 2000 Expert Consensus Document on Electron Beam Computed Tomography) J Am Coll Cardiol 49378-402
Kales SN Tsismenakis AJ Zhang C Soteriades ES [2009] Blood pressure in fire fighters police officers and other emergency responders Am J Hypertens 2211-20
Schlant RC Adolph RJ DiMarco JP Dreifus LS Dunn MI Fisch C Garson A Jr Haywood LJ Levine HJ Murray JA Noble RJ Ronan JA Jr [1992] Guidelines for electrocardiography A report of the American College of CardiologyAmerican Heart Association Task Force on Assessment of Diagnostic and Therapeutic Cardiovascular Procedures (Committee on Electrocardiography) Circulation 85(3)1221-1228
Soteriades ES Kales SN Liarokapis D Christiani DC [2003] Prospective surveillance of hypertension in firefighters J Clin Hypertens 5315-320
Formatted Font Italic
Formatted Line spacing single
Formatted Font Italic
Formatted Font Italic
44
NFPA 1582‐ Draft Revisions for CVDHTN
EKG and stress tests
Reason for Revision
1) Change requirement for annual resting EKG to periodically to be more consistent with ACCAHA
recommendation (Schlant et al 1992)
2) Add language to clarify what constitutes a positive ST
3) Make criteria for conducting diagnostic ST in asymptomatic patients consistent with the
ACCAHA
Language in 2007 Edition with draft revisions in Red (Track changes)
776 Electrocardiograms (EKG) and Stress Tests 7761 A resting EKG shall be performed as part of the baseline medical evaluation and shall be obtained periodically (every 1 to 5 years) thereafter
A7761 A baseline resting EKGs shall be conducted Follow-up resting EKGs should be conducted as clinically indicated but at a minimum of every 1 to 5 years The frequency of these follow-up resting EKGs should increase as a members age increases or with increasing number andor severity of coronary heart disease risk factors Members above the age of 40 should have annual resting EKGs (Schlant et al 1992)
7762 The fire department physician or other qualified medical evaluator shall compare baseline and subsequent EKGs
7763 Stress testing with or without echocardiography or radionuclide scanning shall be performed as clinically indicated by history or symptoms
A7763 No firm guidelines for stress testing in asymptomatic individuals have been developed Stress testing as a screening tool is used as part of an evaluation of aerobic capacity during the annual occupational fitness evaluation Submaximal stress testing testing to 85 percent is commonly used as part of this screening
Submaximal stress testing should not be used for diagnostic purposes Cardiology evaluation with maximal stress testing together with imaging techniques (eg echocardiography technetium Tc99m sestamibi study) is necessary for diagnosticprognostic purposes for the following
(1) Fire fighters with positive or questionably positive changes on screening submaximal stress tests
(2) Fire fighters with new onset chest pain or other symptoms suggestive of coronary artery disease (CAD)
45
(3) Fire fighters with diabetes mellitus who
(a) are gt35 years old or
(b) have type I diabetes for more than 15 years or
(c) have type II diabetes for more than 10 years or
(d) have any other CHD risk factor (see below) or
(e) have the presence of microvascular disease (proliferative retinopathy)
(4) Fire fighters over the age of 45 (for men) and 55 (for women) with one or more risk factors for CAD Risk factors for CAD include hypercholesterolemia (total cholesterol greater than 240 mgdL) hypertension (systolic gt140 mmHg or diastolic gt90 mmHg) smoking or family history of premature CAD (heart attack or sudden cardiac death in a first degree relative less than 60 years of age)
(5) Fire fighters with a Framingham Risk Score gt10 Risk calculator is available at [httphp2010nhlbihinnetatpiiicalculatorasp]
(6) Fire fighters identified in 9431
Negative stress tests should be repeated as clinically indicated or at least every 2 to 5 years
Interpreting stress tests as ldquopositiverdquo or ldquonegativerdquo is beyond the scope of this document However factors that should be taken into consideration should include the individualrsquos exercise capacity symptoms blood pressure response heart rate response EKG changes and the presence of arrhythmias (Gibbon et al 2002)
There are other non-invasive tests to screen for coronary artery disease One of the most promising appears to be coronary artery calcium (CAD) scoring by computed tomography In 2007 an expert committee published an update to their original guidance document The committeersquos consensus was that ldquoit may be reasonable to consider use of CAC measurement in such patients [between 10 and 20 10-year risk of estimated coronary event]helliprdquo The committee did not recommend CAC measurement in low risk patients [lt10 10-year risk of estimated coronary event] or in high risk patients [gt20 10-year risk of estimate coronary event] (Greenland et al 2007]
D22 Cardiology
Resting EKG and Stress Tests
46
Chobanian AV Bakris GL Black HR Cushman WC Green LA Izzo JL Jr Jones DW Materson BJ Oparil S Wright JT Jr Roccella EJ the National High Blood Pressure Education Program Coordinating Committee [2003] The seventh report of the Joint National Committee [JNC-7] on Prevention Detection Evaluation and Treatment of High Blood Pressure JAMA 2892560ndash2571
Gibbons RJ Balady GJ Bricker JT Chaitman BR Fletcher GF Froelicher VF Mark DB McCallister BD Mooss AN OrsquoReilly MG Winters WL Jr [2002] ACCAHA 2002 guideline update for exercise testing summary article a report of the ACCAHA Task Force on Practice Guidelines (Committee to Update the 1997 Exercise Testing guidelines) J Am Coll Cardiol 401531ndash 1540
Greenland et al [2007] ACCFAHA 2007 Clinical Expert Consensus Document on Coronary Artery Calcium Scoring By Computed Tomography in Global Cardiovascular Risk Assessment and in Evaluation of Patients With Chest Pain A Report of the American College of Cardiology Foundation Clinical Expert Consensus Task Force (ACCFAHA Writing Committee to Update the 2000 Expert Consensus Document on Electron Beam Computed Tomography) J Am Coll Cardiol 49378-402
Kales SN Tsismenakis AJ Zhang C Soteriades ES [2009] Blood pressure in fire fighters police officers and other emergency responders Am J Hypertens 2211-20
Schlant RC Adolph RJ DiMarco JP Dreifus LS Dunn MI Fisch C Garson A Jr Haywood LJ Levine HJ Murray JA Noble RJ Ronan JA Jr [1992] Guidelines for electrocardiography A report of the American College of CardiologyAmerican Heart Association Task Force on Assessment of Diagnostic and Therapeutic Cardiovascular Procedures (Committee on Electrocardiography) Circulation 85(3)1221-1228
Soteriades ES Kales SN Liarokapis D Christiani DC [2003] Prospective surveillance of hypertension in firefighters J Clin Hypertens 5315-320
47
ATTACHMENT F
48
1
Current 1582 (2007) language in reference to pregnancy 43 (4) Report to the fire department physician any medical condition that could interfere with the ability of the individual to safely perform essential job tasks such as illness or injury use of prescription or nonprescription drugs and pregnancy 6112 Category B medical conditions shall include the following (1) Pregnancy for its duration A7792 (e) If HIV prophylaxis is to be given the following tests should be done i CBC ii Glucose renal and hepatic chemical function iii Pregnancy test for females B121 Pregnancy and Reproduction Federal regulations as well as many court decisions including the US Supreme Courtrsquos decision in International Union et al v Johnson Controls Inc [499 US 187 111 S Ct 1196 (1991)] have interpreted the requirements of Title VII with respect to pregnancy and reproduction The AHJ should seek the advice of counsel in resolving specific questions concerning these requirements as well as other requirements that can be imposed by state or local laws C211 (4) Review health status with the individual being evaluated Contraindications for evaluations shall be reviewed addressing any changes in the individualrsquos health status since their last medical evaluation that would warrant deferring the evaluation including (g) Pregnancy Recommendations to language enhancement
A female employee who is assigned to regular fire line duty shall report a pregnancy immediately to their respective Supervisor and the fire department physician The employee will then be given the option of a non-hazardous alternative duty position for the duration of her pregnancy (can we say this or is it even appropriate) Any pregnant employee wishing to remain on regular line duty shall be informed of the possible risks and consequences to herself and her fetus that are associated with continued line fire fighting duty Among those risk factors are exposure to teratogens known to have negative effects on the developing fetus such as smoke diesel fumes hazardous chemicals and extreme heat
49
Page 2
appendix It is recommended that the pregnant employee complete a release of liability form signed by herself and her health care provider utilizing NFPArsquos 13 critical tasks as a reference This will inform the health care provider of specific job-related tasks that will need to be performed in order to continue regular line duty These tasks are basic physical standards that any entry level firefighter would have to be able to complete competently The employeersquos health condition will be kept confidential by the department in accordance with HIPAA standards Employees are allowed to remain on active regular duty until they are no longer able to perform their duties in a reasonable manner andor their protective gear no longer fits correctly It is the responsibility of the health care provider to evaluate the pregnant employee If at any time the health care provider feels the pregnant employee can no longer perform the job related tasks this should be reported to the employer by the employee immediately
50
ATTACHMENT G
51
From GLENN BENARICKTo Sawyer SteveSubject RE RE 7743Date Monday August 30 2010 21633 PM
Yes thats my understanding
Glenn P Benarick 211 Winged Elm CircleAiken SC 29803803-644-7093gbenarprodigynet
--- On Mon 83010 Sawyer Steve ltssawyerNFPAorggt wrote
From Sawyer Steve ltssawyerNFPAorggtSubject RE RE 7743To GLENN BENARICK ltgbenarprodigynetgtDate Monday August 30 2010 212 PM
So it should be ldquoorrdquo instead of ldquoandrdquo for now
Steven F Sawyer
Senior Fire Service Specialist
Executive Secretary IFMAFire Service Section
NFPA
1 Batterymarch Park
Quincy MA 02169
6179847423
Fax 6179847056
ssawyernfpaorg
From GLENN BENARICK [mailtogbenarprodigynet] Sent Monday August 30 2010 1202 PMTo Sawyer SteveSubject Fw RE 7743
52
Steve a couple of our docs agree with April Boyer
Glenn P Benarick 211 Winged Elm Circle
Aiken SC 29803
803-644-7093
gbenarprodigynet
--- On Mon 83010 David Prezant ltprezandfdnynycgovgt wrote
From David Prezant ltprezandfdnynycgovgtSubject RE 7743To Thomas R (CDCNIOSHDSHEFS) Hales lttrh1cdcgovgt GLENNBENARICK ltgbenarprodigynetgtCc Sandy Bogucki ltsandyboguckiyaleedugtDate Monday August 30 2010 1004 AM
agree
we should change this to NHANES III rather than Knudson we should alsomodify this to allow not only for predicted cutoffs but all for use of thelower limit of normal cutoff This is important to prevent false-classificationof spirometry as abnormal in older groups and in taller grps The latter ofparticular import to firefighter occupational health surveillance
thanks
David Prezant MDChief Medical Officer Office of Medical AffairsCo-Director WTC Medical Monitoring amp Treatment ProgramsNew York City Fire Department9 Metrotech Center - Rm 4W-1Brooklyn NY 11201Phone 718-999-2696Fax 718-999-0665
Life is full of twists and turns
53
This email may contain confidential information If you are the unintendedrecipient of this email please send it back and delete from your directory
gtgtgt Hales Thomas R (CDCNIOSHDSHEFS) lttrh1cdcgovgt 8302010955 AM gtgtgt
Glen
This seems like a very reasonable comment and illustrates the importance of having clinicians providefeedback on the std Im not familiar with the software program of the various spirometers (NHANES IIIvs KnudsonATS vs both) Given the large role both Dave Prezant and Sandy Bogucki had for thepulmonary section let me forward to them for clarification
Tom
From GLENN BENARICK [mailtogbenarprodigynet] Sent Sunday August 29 2010 456 PMTo Hales Thomas R (CDCNIOSHDSHEFS)Subject FW 7743
Tom is April Boyer correct
Glenn P Benarick 211 Winged Elm Circle
Aiken SC 29803
803-644-7093
gbenarprodigynet
--- On Thu 82610 Sawyer Steve ltssawyerNFPAorggt wrote
From Sawyer Steve ltssawyerNFPAorggtSubject FW 7743To GLENN BENARICK ltgbenarprodigynetgtDate Thursday August 26 2010 925 PM
FYI Do you have any answer She is write
Steven
54
Steven F Sawyer
Senior Fire Service Specialist
Executive Secretary IFMAFire Service Section
NFPA
1 Batterymarch Park
Quincy MA 02169
6179847423
Fax 6179847056
ssawyernfpaorg
From April Boyer [mailtoaboyerbicclinicorg] Sent Thursday August 26 2010 232 PMTo Sawyer SteveCc RobinMWebbmilstateorusSubject 7743
Steven
The spirometry tests cannot be corrected according to both references as the NFPA states because thereferences are contradictory The first part of 7743 states to follow the ATS guidelines and use theKnudsen (we at Basin Immediate Care use the Nhanes III) The second part states to follow the ACOEMguidelines and use the Nhanes III in the occupational setting if available with your unit (which is availableon ours) 7743 does not use the word OR regarding both requirements it uses the word AND whenreferring to the first and second parts thence making 7743 contradictory I realize the NFPA 1582 hasnot been updated since 2007 unless I have just not received an updated version
Our question to you is which part of 7743 do you want us to follow the first or the second part Anyfacility that has an updated computerized spirometry system (as we do) will not be able to follow bothrequired parts for obvious reasons We can either follow the first part of 7743 and use an oldercorrected version of the Knudson by going into our system and changing out of the Nhanes III conversionOR we can follow the second part of 7743 and use the newer corrected version of Nhanes III which ourunit offers too
If you have any questions you may contact me at anytime and I also have many references in regards toboth parts of 7743 if you would like to see them
55
Thank you~
April
Confidentiality NoticeThis message may contain information that isconfidential or privileged
If you are not the intended recipientPlease advise the sender immediately and delete this message
56
ATTACHMENT H
57
NFPA 1582 771(7) Proposed revisions
Why
Preliminary results of two prospective randomized trials on the PSA test were published in 2009 These studies resulted in medical organizations that previously providing guidance to modify their recommendations
Current language
771 Blood Tests Blood tests shall be performed annually and shall include the following
(7) Prostate specific antigen (PSA) after age 40 for positive family history if African American or if otherwise clinically indicated after age 50 for all other male member
Suggested Revision
771 Blood Tests Blood tests shall be performed annually and shall include the following
(7) Prostate specific antigen (PSA) after age 40 for positive family history if African American or if otherwise clinically indicated after age 50 for all other male member
772 Prostate-Specific Antigen (PSA) test At age 50 fire fighters shall have an opportunity to make an informed decision with either the Fire Department physician or their health care provider concerning the PSA test For fire fighters at increased risk of prostate cancer (African-Americans or those with a first degree relative diagnosed with prostate cancer before age 65) shall have the opportunity for this informed decision at age 40
A772 The PSA as a screening test for prostate cancer in asymptomatic men is controversial controversial for two reasons First there is no consensus that PSA screening actually saves lives For example the PSA test may detect small cancers that would never become life threatening Second it is unclear that the benefits of PSA screening outweigh the risks of follow-up diagnostic tests and cancer treatments For example the prostate biopsy used to diagnose prostate cancer may cause bleeding and infection And prostate cancer treatments such as surgery and radiation therapy may cause incontinence (inability to control urine flow) erectile dysfunction (erections inadequate for intercourse) and other complications For these reasons it is important that the benefits and risks of prostate diagnostic procedures and treatment be taken into account when considering the PSA screening test These considerations can be taken account during discussions with the fire department physician or onersquos health care provider
D211 Cancer Screening
Smith R A C J Mettlin K J Davis and H Eyre 2000 ldquoAmerican Cancer Society guidelines for the early detection of cancerrdquo CA J Clin 50(1)34ndash49
Added references
58
Carroll P Albertsen PC Greene K et al [2010] Prostate-specific antigen best practice statement 2009 update Am Urological Assoc Available at httpwwwauanetorgcontentguidelines-and-quality-careclinical-guidelinesmain-reportspsa09pdf Date accessed September 2010
Ferrini R Woolf SH [2009] Screening for prostate cancer in American men American College of Preventive Medicine Practice Policy Statement Available at httpwwwacpmorgprostatehtm Date accessed September 2010
National Cancer Institute [2009] Prostate-specific antigen test National Cancer Institute Fact Sheet Available at httpwwwcancergovcancertopicsfactsheetDetectionPSA Date accessed September 2010
Wolf AMD Wender RC Etzioni RB et al [2010] American Cancer Society guideline for the early detection of prostate cancer Update 2010 Available at httpcaonlineamcancersocorgcgicontentfullcaac20066v1 Date accessed September 2010
59
43 ndash DIABETES MELLITUS
431 ndash INTRODUCTION
The educated and motivated law enforcement officer (LEO) with well-managed diabetes mellitus can be capable of
safe and effective job performance1 However diabetes mellitus may place LEOs at risk for sudden incapacitation
thus jeopardizing their ability to perform critical job functions (These job functions include those listed in Sections
32 333 351 352 36 and 37 and discussed in Appendix A)
Therefore an individualized assessment of the LEOrsquos diabetes should be performed using the following evaluative
criteria to determine whether the individuals condition permits safe and effective job performance Such evaluation
must include the following key elements which are discussed in detail below
history of blood glucose control
knowledge of diabetes and its management
current stability of blood glucose
risk for significant hypoglycemia or hyperglycemia and
presence of diabetic complications
432 ndash OVERVIEW OF MEDICAL EVALUATION
The treating endocrinologist or other physician knowledgeable regarding diabetes management should provide
a narrative report certifying whether the LEO has or has not met the criteria set out in Sections 4321 through
4354 below In addition the physician should include supporting data (see Appendix B for the Physician Evalu-
ation Form)
4321 The LEO is under the care of an endocrinologist or other physician knowledgeable regarding diabetes
management Outpatient and in-patient medical record(s) for the last 3 years or since date of diagnosis
(whichever is shorter) should be reviewed by the treating physician and provided to the police physician
4322 If the LEO has type 1 diabetes the individual has been on a basalbolus regimena or an insulin pump
using analogue insulins for the 6 months prior to evaluation2
4323 If the LEO has type 2 diabetes on insulin the individual has been on a stable medication regimenb
for the 3 months prior to evaluation3 If on oral agents alone the LEO has been on a stable medication regimen
for the month prior to evaluationc
ACOEM Guidance for the Medical Evaluation of Law Enforcement Officers 1
43 ndash DIABETES MELLITUS
aA basalbolus insulin regimen consists of the use of a basal insulin (Glargine NPH) in a once or twice daily regimen to provide between-
meal insulin combined with the use of a short acting insulin (Regular Lispro Aspart or Glulisine) at mealtimes Insulin pumps are small
(beeper sized) battery powered devices that deliver small amounts of short-acting insulin in a constant infusion to meet basal insulin
requirements The wearer selects an additional mealtime bolus to be infused at the time of meals For more information on pumps visit
the manufacturerrsquos web sites ndash wwwMinimedcom wwwcozmorecom wwwanimascorpcom wwwdisetroniccom
bA stable insulin regimen is defined as maintaining the same types of insulin (long acting intermediate acting short or rapid acting)
Changes in insulin dose are part of the appropriate self-management of diabetes and do not disqualify an applicant or incumbent under
this section
cChanges in dose within the evaluation period will be allowed but addition of a new class of medications or insulin should result in a new
period of observation
one month for addition of a sulfonylurea or metformin
two months for the addition of a thiazolidinedione to insulin or a sulfonylurea or
three months for the addition of insulin
20
4324 If the LEO uses an insulin pump documentation is needed as follows
proper understanding and education in the use of the insulin pump
start date for the use of the pump
history of insulin site infectionsd
history of pump cessation and pump malfunction
backup plan for pump malfunction including use of injectable insulin and
frequency of infusion set changes
4325 The LEO has been educated in diabetes and its management and thoroughly informed of and under-
stands the procedures that must be followed to monitor and manage hisher diabetes and what procedures
should be followed if complications arise3
433 ndash QUANTITATIVE GLUCOSE MONITORING
4331 The LEO has documentation of ongoing self-monitoring of blood glucose
4332 This must be done with a glucose meter that stores every reading records date and time of reading
and from which data can be downloaded (Most meters now have this capability)
4333 Monitoring logs must be available covering the time period (1 3 or 6 months) as described in
Sections 4322 and 4323 The frequency of glucose monitoring must follow a schedule acceptable to the
police physician in consultation with the treating physician
Testing schedules are individual What follows is a common pattern but individual patterns may differ
2 ACOEM Guidance for the Medical Evaluation of Law Enforcement Officers
43 ndash DIABETES MELLITUS
dIndividual has not had more than one pump-site infection that caused him or her to miss work or usual daily activities in the preceding 6
months
THERAPEUTIC REGIMEN GLUCOSE TESTING SCHEDULE
Diet alone Once or twice a week
Metformin Thiazolidinediones or Alpha
Glucosidase inhibitors alone or in
combination
Once or twice a week
Sulfonylureas meglitanides nateglinide ndash
alone or in combination with the above group
Twice a day ndash AM and at supper with any
suspected hypoglycemic episodes
Insulin ndash one shot in combination with orals Twice a day ndash AM and at supper with any
suspected hypoglycemic episodes
2 to 3 times AM once a week
Insulin ndash two or more shots Insulin pump 3 to 4 times a day ndash at meals and bedtime
2 to 3 times AM once a week with any
suspected hypoglycemic episodes
21
4334 The LEO has had hemoglobin A1C measured at least 4 times a year (intervals of 2 to 3 months) over
the last 12 months prior to evaluation if diagnosis has been present for more than a year4 If hemoglobin A1C is
gt8 this may signal a problem with the LEOrsquos diabetes management that warrants further assessment5
434 ndash INCAPACITATING EVENTS
4341 The LEO has not had any incapacitating episodes within the past 1 year and no more than 2 episodes
in the past 3 years or since diagnosis of diabetes (whichever is shorter) of
43411 Severe hypoglycemia (loss of consciousness seizures or coma requiring assistance of others or
needing urgent treatment [glucagon injectionIV glucose]) or
43412 Blood sugar lt60 mgdl with unawareness demonstrated in current glucose logs6
435 ndash CHRONIC COMPLICATION SCREENING
4351 Chronic complications of diabetes are associated with increased risk for severe hypoglycemic
episodes and warrant further assessmente
4352 The components of screening for chronic complications are
43521 A complete eye exam by a qualified ophthalmologist or optometrist including a dilated retinal
exam demonstrating no more than mild background diabetic retinopathyf7
43522 Normal vibratory testing with a 128 Hz tuning forkg normal testing with 10 gram Semmes-
Weinstein monofilamentg and normal orthostatic blood pressureh and pulse testing89
ACOEM Guidance for the Medical Evaluation of Law Enforcement Officers 3
43 ndash DIABETES MELLITUS
ePresence of chronic complications of diabetes in and of themselves may not require the implementation of work restrictions
fNo more than one dot blot or flame-shaped hemorrhages or microaneurysm in all four fundus quadrants
gThe Michigan Diabetes Research and Training Center of the University of Michigan Health System recommends the following guidance
(see wwwmedumichedumdrtcprofsdocumentssviMNSI_howtopdf) for conducting vibratory and monofilament testing8
Vibration Sensation Vibration sensation should be performed with the great toe unsupported Vibration sensation will be tested bi-
laterally using a 128 Hz tuning fork placed over the dorsum of the great toe on the boney prominence of the DIP joint Patients whose
eyes are closed will be asked to indicate when they can no longer sense the vibration from the vibrating tuning fork In general the
examiner should be able to feel vibration from the hand-held tuning fork for 5 seconds longer on his distal forefinger than a normal subject
can at the great toe (eg examiners DIP joint of the first finger versus patients toe) If the examiner feels vibration for 10 or more seconds
on his or her finger then vibration is considered decreased A trial should be given when the tuning fork is not vibrating to be certain that
the patient is responding to vibration and not pressure or some other clue Vibration is scored as 1) present if the examiner senses the
vibration on his or her finger for lt10 seconds 2) reduced if sensed for 10 seconds or 3) absent (no vibration detection)
Monofilament Testing For this examination it is important that the patients foot be supported (ie allow the sole of the foot to rest on
a flat warm surface) The filament should initially be pre-stressed (4-6 perpendicular applications to the dorsum of the examiner s first
finger) The filament is then applied to the dorsum of the great toe midway between the nail fold and the DIP joint Do not hold the toe
directly The filament is applied perpendicularly and briefly (lt1 second) with an even pressure When the filament bends the force of
10 grams has been applied The patient whose eyes are closed is asked to respond yes if heshe feels the filament Eight correct responses
out of 10 applications is considered normal 1 to 7 correct responses indicates reduced sensation and no correct answers translates into
absent sensation
hOrthostatic hypotension is a physical finding defined by the American Autonomic Society and the American Academy of Neurology as a
systolic blood pressure decrease of at least 20 mm Hg or a diastolic blood pressure decrease of at least 10 mm Hg within 3 minutes of
standing
22
43523 Normal cardiac physical exam Cardiac stress testing to at least 12 METS is recommended and
should begin based on either the criteria of the American Heart AssociationAmerican College of
Cardiologyi10 or those of the American Diabetes Associationj11
Diabetics who have a normal cardiac stress test will be retested every one to three years based on
individual clinical assessment This assessment should consider
the age of the individual
the number and persistence of coronary artery disease (CAD) risk factors
the severity of CAD risk factors
43524 Microalbumincreatinine ratio 301 measured or calculatedk creatinine clearance
gt60 mlmin12
436 ndash ONGOING EVALUATION AND REQUIREMENTS
4361 Should have medical records and glucose meter logs reviewed periodically Because of the nature of
diabetes it is important that regular medical follow up be provided to the LEO The frequency and content of
the evaluation should be determined on an individual basis by the police physician in consultation with the
treating physicianl
4362 Must advise police physician of any change in type of medication
4363 Must advise police physician of any episodes of significant hypoglycemia or hyperglycemia
Urine microalbumincreatinine ratio _________________
III Treating Physician Statement
The above named individual meets all of the criteria provided on this form
Yes No ndash not recommended for position
No but IS recommended for position (letter of explanation attached)
It is my opinion that the above named individual is well-educated and well-motivated in diabetes self-management and has
achieved a level of diabetes management to be capable of safe and effective job performance as a law enforcement officer
I have reached this opinion after careful review of the above criteria
___________________________________________________________ ___________________________Signature of Physician Date
______________________________________________________________ ___________________________Printed or Typed Name of Physician Telephone Number
10 ACOEM Guidance for the Medical Evaluation of Law Enforcement Officers
43 ndash DIABETES MELLITUS
29
439 ndash REFERENCES
1 American Diabetes Association Diagnosis and classification of diabetes mellitus Diabetes Care 200427 Suppl
1S5-S10 See httpcarediabetesjournalsorgcgicontentfull27suppl_1s5
2 American Diabetes Association Continuous subcutaneous insulin infusion Diabetes Care 200427 Suppl 1S110
See httpcarediabetesjournalsorgcgicontentfull27suppl_1s110
3 Mensing C Boucher J Cypress M et al National standards for diabetes self-management education Diabetes
Care 200528 Suppl 1S72-9 See httpcarediabetesjournalsorgcgicontentfull28suppl_1s72
4 Goldstein DE Little RR Lorenz RA Malone JI Nathan DM Peterson CM American Diabetes Association Tests
of glycemia in diabetes Diabetes Care 200427 Suppl 1S91-3
See httpcarediabetesjournalsorgcgicontentfull27suppl_1s91
5 The Diabetes Control and Complications Trial Research Group Hypoglycemia in the Diabetes Control and
Complications Trial Diabetes 199746(2)271-86 See wwwncbinlmnihgovpubmed9000705 for abstract
6 American Diabetes Association Hypoglycemia and employmentlicensure Diabetes Care 200528 Suppl 1S61
See httpcarediabetesjournalsorgcgicontentfull28suppl_1s61
7 Viswanath K McGavin DD Diabetic Retinopathy Clinical Findings and Management J Comm Eye Health
200316(46)21-4 See wwwcehjournalorg0953-683316jceh_16_46_021html
8 Michigan Diabetes Research and Training Center University of Michigan Health System How to use the Michigan
Neuropathy Screening Instrument See wwwmedumichedumdrtcprofsdocumentssviMNSI_howtopdf
9 Bradley JG Davis KA Orthostatic hypotension Am Fam Physician 200368(12)2393-8
See wwwaafporgafp200312152393html
10 Gibbons RJ Balady GJ Bricker JT et al ACCAHA 2002 guideline update for exercise testing a report of the
American College of CardiologyAmerican Heart Association Task Force on Practice Guidelines (Committee on
Exercise Testing) J Am Coll Cardiol 200240(8)1531-40
See wwwaccorgqualityandscienceclinicalguidelinesexerciseexercise_cleanpdf
11 American Diabetes Association Standards of medical care in diabetes Diabetes Care 200528 Suppl 1S4-S36
Erratum in Diabetes Care 200528(4)990 See httpcarediabetesjournalsorgcgicontentfull28suppl_1s4
12 Molitch ME DeFronzo RA Franz MJ et al American Diabetes Association Nephropathy in diabetes Diabetes
Care 200427 Suppl 1S79-83 See httpcarediabetesjournalsorgcgicontentfull27suppl_1s79
13 Kitabchi AE Umpierrez GE Murphy MB et al American Diabetes Association Hyperglycemic crises in diabetes
Diabetes Care 200427 Suppl 1S94-102 See httpcarediabetesjournalsorgcgicontentfull27suppl_1s94
14 US Centers for Disease Control and Prevention National Diabetes Fact Sheet 2007
See wwwcdcgovdiabetespubspdfndfs_2007pdf
ACOEM Guidance for the Medical Evaluation of Law Enforcement Officers 11
43 ndash DIABETES MELLITUS
30
ATTACHMENT E
31
Typos A6921(2) 7th line down test should be plural 94201 Paragraph 2 target organ damage is used though end organ damage was defined earlier and in the appendix for that paragraph
A94201 Para A (1) d Id suggest deleting the phrases in brackets Im not sure either are predictably true or politically wise
a) tests for left ventricular hypertrophy Unfortunately use of the EKG to detect left ventricular hypertrophy is very insensitive (eg 5 sensitivity) The echocardiogram is the best test for diagnosing left ventricular hypertrophy but [it is relatively expensive and not readily available in small rural communities ] conducting echocardiograms on asymptomatic fire fighters with Stage 1 hypertension should be reserved only for those with long-standing hypertension
In addition
7761 A resting EKG shall be performed as part of the baseline medical evaluation and shall be obtained periodically thereafter
Changing from annually to periodically is noted has the language in the wellness-fitness initiative been changed as well Our previous decision was that we would support the W-F language since there was no compelling evidence to either support or refute it
Thanks
Sandy
32
NFPA 1582‐ HTN Draft 1
Reason for Revision
1) New classification of BP by the Joint National Commission [Chobanian et al 2002]
2) A high prevalence of FF have either HTN (~20) and Pre‐HTN (~20) [Soteriades et al 2003]
3) Among FF studies have shown a strong association between HTN and a number of adverse
cardiovascular events [Kales et al 2009]
4) A large percentage of on‐duty FF fatalities were found to have left ventricular hypertrophy a
complication of HTN at autopsy
Language in 2007 Edition with draft revisions in Red (Track changes)
611 The medical evaluation of a candidate shall include a medical history examination and any laboratory tests required to detect physical or medical condition(s) that could adversely affect hisher ability to safely perform the essential job tasks outlined in 511 A611 The medical history should include the candidates known health problems such as major illnesses surgeries medication use and allergies Symptom review is also important for detecting early signs of illness A medical history should also include a personal health history a family health history a health habit history an immunization history and a reproductive history
An occupational history should also be obtained to collect information about the persons past occupational and environmental exposures
(a) BP should be measured according to the Joint National Commission (JNC) -7 recommendations BP should be measured with a properly calibrated and validated instrument Patients should be seated quietly for at least 5 minutes in a chair with feet on the floor and arm supported at heart level An appropriate-sized cuff (cuff bladder encircling at least 80 of the arm) should be used to ensure accuracy At least 2 measurements should be made Systolic BP is the point at which the first of 2 or more sounds is heard (phase 1) and diastolic BP is the point before the disappearance of sounds (phase 5) [Chobanian et al 2003]
(2) Head eyes ears nose and throat (HEENT)
Formatted Font (Default) Times New RomanFont color Black
33
692 Vascular System 6921 Category A medical conditions shall include the following
(1) Uncontrolled or poorly controlled hypertension
(2) Hypertension with evidence of end organ damage
or not controlled by approved medications
A6921(1) Uncontrolled or poorly controlled hHypertension increases the risk of a sudden cardiac event This sudden cardiac event would cause sudden incapacitation which that is uncontrolled poorly controlled or requires medication likely to interferes with the safe performance of essential job tasks Uncontrolled or poorly controlled hypertension can be defined as the presence of end organ damage (see below) or stage 2 hypertension (BP systolic gt160 mmHg or BP diastolic gt100 mmHg) is an illness that can lead to functional impairment and potential for sudden incapacitation Individuals with pre- stage 1 or stage 2 hypertension should be referred to their primary care physician for evaluation lifestyle modification and treatment [QUESTION FOR GROUP _- WHAT ABOUT HAVING CANDIDATE RETURN IN ONE MONTH UNDER TREATMENT WITH NORMAL BP]
A6921(2)
Chronic hypertension can damage the eye (retinopathy) the kidneys (nephropathy) the vascular system (stroke transient ischemic attack or peripheral artery disease) or the heart (left ventricular hypertrophy and heart failure) These hypertension complications are known as end organ damage The cardiac and vascular complications are associated with an increased risk of sudden incapacitation and sudden cardiac death (Koren et al 1991) Unfortunately the cardiac complications are frequently asymptomatic and valid screening tests are not fast and are not inexpensive Therefore determining who to screen for cardiac complications (such as echocardiogram for LVH or a measurement of left ventricular ejection fraction for heart failure) should be based on the severity and the duration of HTN
76 Physical Examination The annual physical examination shall include each of the following components
(a) BP shall be measured according to the Joint National Commission (JNC)-7 recommendations
A76(1)(a) BP should be measured with a properly calibrated and validated instrument Patients should be seated quietly for at least 5 minutes in a chair with feet on the floor and arm supported at heart level An appropriate-sized cuff (cuff bladder encircling at least 80 of the arm) should be used to ensure accuracy At least 2 measurements should be made Systolic BP is the point at which the first of 2 or more sounds is heard (phase 1) and diastolic BP is the point before the disappearance of sounds (phase 5) [Chobanian et al 2003]
(2) Head eyes ears nose and throat (HEENT)
34
9420 Uncontrolled Hypertension 94201 Physician Evaluation Severe uncontrolled hypertension [defined as systolic pressure greater than 180 mm Hg diastolic pressure greater than 100 mm Hg or mean systolic blood
pressure ( systolic + diastolic) greater than 120 mm Hg] or malignant hypertension (defined as hypertension with the presence of target organ damage) compromises the members ability to safely perform essential job tasks 1 5 7 9 and 13 and the physician shall report the applicable job limitations to the fire department
Members with Pre-hypertention (systolic 120-139 mmHg or diastolic 80-89 mmHg) Stage 1 hypertension (systolic 140-159 mmHg or diastolic 90-99 mmHg) or Stage 2 hypertension (systolic ge160 mmHg or diastolic ge100 mmHg) should be referred to their primary care physician for evaluation lifestyle modification and treatment
(1) Members with Stage I hypertension should be followed-up not only by their primary care physician but also by the FD physician every 3 to 6 months to ensure their blood pressure is under control and to determine whether screening tests for asymptomatic end organ damage are appropriate
(2) Members with Stage 2 hypertension or with end organ damage (retinopathy nephropathy vascular or cardiac complications) compromises the members ability to safely perform essential job tasks 1 5 7 9 and 130 and the physician shall report the applicable job limitations to the fire department
A94201 Severe uncontrolled hypertension is a significant risk factor for the development of coronary artery disease congestive heart failure and stroke Blood pressure increases as a normal response to exercise This response is further exaggerated by the emotional and physical stress of performing these critical tasks while operating in personal protective clothing at extremes of temperature This normal elevation of blood pressure under these response conditions can lead to life-threatening hypertensive emergencies if a members daily blood pressure is already elevated to high levels In addition hypertension is a progressive illness that when uncontrolled ultimately and inevitably leads to target organ damage Target organs that are sensitive to the effects of elevated blood pressure are the central nervous system vision heart major blood vessels and kidneys
Chronic hypertension can damage the eye (retinopathy) the kidneys (nephropathy) the vascular system (stroke transient ischemic attack or peripheral artery disease) or the heart (left ventricular hypertrophy and heart failure) These hypertension complications are known as end organ damage The cardiac and vascular complications are associated with an increased risk of sudden incapacitation and sudden cardiac death (Koren et al 1991) Fortunately with proper evaluation life style modification and treatment these complications can be avoided Life style modification includes weight reduction DASH eating plan reduction in dietary sodium an increase in aerobic physical activity and moderation in alcohol consumption [Chobanian 2003]
Formatted Font (Default) Times New Roman12 pt Font color Black
Formatted Font (Default) Times New Roman12 pt Font color Black
35
A94201 (1) Members with Stage I hypertension whose BP returns to either pre-hypertenion or normal with lifestyle modification andor treatment can return to an annual medical evaluation For members with long-standing Stage I hypertension whose BP has not been reduced additional evaluation for possible end organ damage should be considered This evaluation could include any or all of the following
a) a compete patient history for symptoms of heart failure (eg shortness of breath upon exertion) or transient ischemic attacks (TIAs)
b) dilated eye examination for retinopathy
c) blood creatinine measurement for nephropathy
d) tests for left ventricular hypertrophy Unfortunately use of the resting EKG to detect left ventricular hypertrophy is very insensitive (eg 5 sensitivity) The echocardiogram is the best test for diagnosing left ventricular hypertrophy
A 94201 (2) Due to the high risk of a sudden cardiovascular event members with Stage 2 hypertension should be restricted until their BP can be brought under control Once the BP is brought under control they should be followed in the same manner as a member with Stage I hypertension
Formatted Font (Default) Times New Roman12 pt
36
D22 Cardiology Gibbons R J GJ Balady J W Beasley et al 1997 ACCAHA guidelines for exercise testing a report of American College of CardiologyAmerican Heart Association Task Force on Practice Guidelines (Committee on Exercise Testing) J Am Coll Cardiol 30260ndash311
Gibbons RJ Balady GJ Bricker JT Chaitman BR Fletcher GF Froelicher VF Mark DB McCallister BD Mooss AN OrsquoReilly MG Winters WL Jr [2002] ACCAHA 2002 guideline update for exercise testing summary article a report of the ACCAHA Task Force on Practice Guidelines (Committee to Update the 1997 Exercise Testing guidelines) J Am Coll Cardiol 401531ndash 40
Chobanian AV Bakris GL Black HR Cushman WC Green LA Izzo JL Jr Jones DW Materson BJ Oparil S Wright JT Jr Roccella EJ the National High Blood Pressure Education Program Coordinating Committee [2003] The seventh report of the Joint National Committee [JNC-7] on Prevention Detection Evaluation and Treatment of High Blood Pressure JAMA 2892560ndash2571
Soteriades ES Kales SN Liarokapis D Christiani DC [2003] Prospective surveillance of hypertension in firefighters J Clin Hypertens 5315-320
Kales SN Tsismenakis AJ Zhang C Soteriades ES [2009] Blood pressure in fire fighters police officers and other emergency responders Am J Hypertens 2211-20
37
NFPA 1582‐ HTN Draft 1
Reason for Revision
1) New classification of BP by the Joint National Commission [Chobanian et al 2002]
2) A high prevalence of FF have either HTN (~20) and Pre‐HTN (~20) [Soteriades et al 2003]
3) Among FF studies have shown a strong association between HTN and a number of adverse
cardiovascular events [Kales et al 2009]
4) A large percentage of on‐duty FF fatalities were found to have left ventricular hypertrophy a
complication of HTN at autopsy
Language in 2007 Edition with draft revisions in Red (Track changes)
611 The medical evaluation of a candidate shall include a medical history examination and any laboratory tests required to detect physical or medical condition(s) that could adversely affect hisher ability to safely perform the essential job tasks outlined in 511 A611 The medical history should include the candidates known health problems such as major illnesses surgeries medication use and allergies Symptom review is also important for detecting early signs of illness A medical history should also include a personal health history a family health history a health habit history an immunization history and a reproductive history
An occupational history should also be obtained to collect information about the persons past occupational and environmental exposures
(a) BP should be measured according to the Joint National Commission (JNC) -7 recommendations BP should be measured with a properly calibrated and validated instrument Patients should be seated quietly for at least 5 minutes in a chair with feet on the floor and arm supported at heart level An appropriate-sized cuff (cuff bladder encircling at least 80 of the arm) should be used to ensure accuracy At least 2 measurements should be made Systolic BP is the point at which the first of 2 or more sounds is heard (phase 1) and diastolic BP is the point before the disappearance of sounds (phase 5) [Chobanian et al 2003]
(2) Head eyes ears nose and throat
38
692 Vascular System 6921 Category A medical conditions shall include the following
(1) Uncontrolled or poorly controlled hypertension
(2) Hypertension with evidence of end organ damage
A6921(1) Uncontrolled or poorly controlled hypertension increases the risk of a sudden cardiac event This sudden cardiac event would cause sudden incapacitation which interferes with the safe performance of essential job tasks Uncontrolled or poorly controlled hypertension can be defined as the presence of end organ damage (see below) or stage 2 hypertension (BP systolic gt160 mmHg or BP diastolic gt100 mmHg) Individuals with pre- stage 1 or stage 2 hypertension should be referred to their primary care physician for evaluation lifestyle modification and treatment [QUESTION FOR GROUP _- WHAT ABOUT HAVING CANDIDATE RETURN IN ONE MONTH UNDER TREATMENT WITH NORMAL BP]
A6921(2)Chronic hypertension can damage the eye (retinopathy) the kidneys (nephropathy) the vascular system (stroke transient ischemic attack or peripheral artery disease) or the heart (left ventricular hypertrophy and heart failure) These hypertension complications are known as end organ damage The cardiac and vascular complications are associated with an increased risk of sudden incapacitation and sudden cardiac death (Koren et al 1991) Unfortunately the cardiac complications are frequently asymptomatic and valid screening tests are not fast and are not inexpensive Therefore determining who to screen for cardiac complications (such as echocardiogram for LVH or a measurement of left ventricular ejection fraction for heart failure) should be based on the severity and the duration of HTN
76 Physical Examination The annual physical examination shall include each of the following components
(a) BP shall be measured according to the Joint National Commission (JNC)-7 recommendations
A76(1)(a) BP should be measured with a properly calibrated and validated instrument Patients should be seated quietly for at least 5 minutes in a chair with feet on the floor and arm supported at heart level An appropriate-sized cuff (cuff bladder encircling at least 80 of the arm) should be used to ensure accuracy At least 2 measurements should be made Systolic BP is the point at which the first of 2 or more sounds is heard (phase 1) and diastolic BP is the point before the disappearance of sounds (phase 5) [Chobanian et al 2003]
(2) Head eyes ears nose and throat9420 Hypertension 94201 Physician Evaluation Members with Pre-hypertention (systolic 120-139 mmHg or diastolic 80-89 mmHg) Stage 1 hypertension (systolic 140-159 mmHg or diastolic 90-99 mmHg) or Stage 2 hypertension (systolic ge160 mmHg or diastolic ge100 mmHg) should be referred to their primary care physician for evaluation lifestyle modification and treatment
39
(1) Members with Stage I hypertension should be followed-up not only by their primary care physician but also by the FD physician every 3 to 6 months to ensure their blood pressure is under control and to determine whether screening tests for asymptomatic end organ damage are appropriate
(2) Members with Stage 2 hypertension or with end organ damage (retinopathy nephropathy vascular or cardiac complications) compromises the members ability to safely perform essential job tasks 1 5 7 9 and 130 and the physician shall report the applicable job limitations to the fire department
A94201 Chronic hypertension can damage the eye (retinopathy) the kidneys (nephropathy) the vascular system (stroke transient ischemic attack or peripheral artery disease) or the heart (left ventricular hypertrophy and heart failure) These hypertension complications are known as end organ damage The cardiac and vascular complications are associated with an increased risk of sudden incapacitation and sudden cardiac death (Koren et al 1991) Fortunately with proper evaluation life style modification and treatment these complications can be avoided Life style modification includes weight reduction DASH eating plan reduction in dietary sodium an increase in aerobic physical activity and moderation in alcohol consumption [Chobanian 2003]
A94201 (1) Members with Stage I hypertension whose BP returns to either pre-hypertenion or normal with lifestyle modification andor treatment can return to an annual medical evaluation For members with long-standing Stage I hypertension whose BP has not been reduced additional evaluation for possible end organ damage should be considered This evaluation could include any or all of the following
a) a compete patient history for symptoms of heart failure (eg shortness of breath upon exertion) or transient ischemic attacks (TIAs)
b) dilated eye examination for retinopathy
c) blood creatinine measurement for nephropathy
d) tests for left ventricular hypertrophy Unfortunately use of the resting EKG to detect left ventricular hypertrophy is very insensitive (eg 5 sensitivity) The echocardiogram is the best test for diagnosing left ventricular hypertrophy
A 94201 (2) Due to the high risk of a sudden cardiovascular event members with Stage 2 hypertension should be restricted until their BP can be brought under control Once the BP is brought under control they should be followed in the same manner as a member with Stage I hypertension
D22 Cardiology
40
Hypertension
Gibbons RJ Balady GJ Bricker JT Chaitman BR Fletcher GF Froelicher VF Mark DB McCallister BD Mooss AN OrsquoReilly MG Winters WL Jr [2002] ACCAHA 2002 guideline update for exercise testing summary article a report of the ACCAHA Task Force on Practice Guidelines (Committee to Update the 1997 Exercise Testing guidelines) J Am Coll Cardiol 401531ndash 40
Chobanian AV Bakris GL Black HR Cushman WC Green LA Izzo JL Jr Jones DW Materson BJ Oparil S Wright JT Jr Roccella EJ the National High Blood Pressure Education Program Coordinating Committee [2003] The seventh report of the Joint National Committee [JNC-7] on Prevention Detection Evaluation and Treatment of High Blood Pressure JAMA 2892560ndash2571
Soteriades ES Kales SN Liarokapis D Christiani DC [2003] Prospective surveillance of hypertension in firefighters J Clin Hypertens 5315-320
Kales SN Tsismenakis AJ Zhang C Soteriades ES [2009] Blood pressure in fire fighters police officers and other emergency responders Am J Hypertens 2211-20
41
NFPA 1582‐ Draft Revisions for CVDHTN
EKG and stress tests
Reason for Revision
1) Change requirement for annual resting EKG to periodically to be more consistent with ACCAHA
recommendation (Schlant et al 1992)
2) Add language to clarify what constitutes a positive ST
3) Make criteria for conducting diagnostic ST in asymptomatic patients consistent with the
ACCAHA
Language in 2007 Edition with draft revisions in Red (Track changes)
776 Electrocardiograms (EKG)) and Stress Tests 7761 A resting EKG shall be performed as part of the baseline medical evaluation and shall be obtained periodically (every 1 to 5 years) annually thereafter
A7761 A baseline resting EKGs shall be conducted Follow-up resting EKGs should be conducted as clinically indicated but at a minimum of every 1 to 5 years The frequency of these follow-up resting EKGs should increase as a members age increases or with increasing number andor severity of coronary heart disease risk factors Members above the age of 40 should have annual resting EKGs (Schlant et al 1992)
7762 The fire department physician or other qualified medical evaluator shall compare EKGs obtained during yearly evaluations with baseline and subsequent EKGs
7763 Stress testing EKG with or without echocardiography or radionuclide scanning shall be performed as clinically indicated by history or symptoms
A7761 Baseline electrocardiography should be conducted (Periodic resting electrocardiograms have not been shown to be useful but can be reasonable as a members agefactors increase)
A7763 No firm guidelines for stress testingelectrocardiography in asymptomatic individuals have been developed Stress testingelectrocardiography as a screening tool is used as part of an evaluation of aerobic capacity during the annual occupational fitness evaluation Submaximal stress testingelectrocardiography testing to 85 percent is commonly used as part of this screening
Submaximal stress electrocardiography testing should not be used for diagnostic purposes Cardiology evaluation with maximal stress testingelectrocardiography together with imaging techniques (eg echocardiography technetium Tc99m sestamibi study andor coronary angiography) is necessary for diagnosticprognostic purposes for the following
42
(1) Fire fighters with positive or questionably positive changes on screening submaximal stress tests
(2) Fire fighters with new onset chest pain or other symptoms suggestive of coronary artery disease (CAD)
(3) Fire fighters with diabetes mellitus who
(a) are gt35 years old or
(b) have type I diabetes for more than 15 years or
(c) have type II diabetes for more than 10 years or
(d) have any other CHD risk factor (see below) or
(e) have the presence of microvascular disease (proliferative retinopathy)
(4) Fire fighters over the age of 45 (for men) and 55 (for women) with onetwo or more risk factors for CAD Risk factors for CAD include hypercholesterolemia (total cholesterol greater than 240 mgdL) hypertension (systolic gt140 mmHg or diastolic gt90 mmHg) smoking or family history of premature CAD (heart attack or sudden cardiac death in a first degree relative less than 60 years of age)
as defined below if stress electrocardiography with imaging is negative then repeat as clinically indicated or at least every 5 years
(5) Fire fighters with a Framingham Risk Score gt10 Risk calculator is available at [httphp2010nhlbihinnetatpiiicalculatorasp]
(6) Fire fighters identified in 9431
Negative stress tests should be repeated as clinically indicated or at least every 2 to 5 years
Interpreting stress tests as ldquopositiverdquo or ldquonegativerdquo is beyond the scope of this document However factors that should be taken into consideration should include the individualrsquos exercise capacity symptoms blood pressure response heart rate response EKG changes and the presence of arrhythmias (Gibbon et al 2002)
Risk factors for CAD include hypercholesterolemia (total cholesterol greater than 240 mgdL) hypertension (systolic greater than 140 andor diastolic greater than 90) smoking diabetes mellitus or family history of premature CAD (heart attack or sudden cardiac death in a first degree relative less than 60 years of age)
There are other non-invasive tests to screen for coronary artery disease One of the most promising appears to be coronary artery calcium (CAD) scoring by computed tomography In 2007 an expert committee published an update to their original guidance document The committeersquos consensus was that ldquoit may be reasonable to consider use of CAC measurement in such patients [between 10 and 20 10-year risk of estimated coronary event]helliprdquo The committee did not recommend CAC measurement in low risk patients [lt10 10-year risk of estimated coronary event] or in high risk patients [gt20 10-year risk of estimate coronary event] (Greenland et al 2007]
43
D22 Cardiology
Chobanian AV Bakris GL Black HR Cushman WC Green LA Izzo JL Jr Jones DW Materson BJ Oparil S Wright JT Jr Roccella EJ the National High Blood Pressure Education Program Coordinating Committee [2003] The seventh report of the Joint National Committee [JNC-7] on Prevention Detection Evaluation and Treatment of High Blood Pressure JAMA 2892560ndash2571
Gibbons RJ Balady GJ Bricker JT Chaitman BR Fletcher GF Froelicher VF Mark DB McCallister BD Mooss AN OrsquoReilly MG Winters WL Jr [2002] ACCAHA 2002 guideline update for exercise testing summary article a report of the ACCAHA Task Force on Practice Guidelines (Committee to Update the 1997 Exercise Testing guidelines) J Am Coll Cardiol 401531ndash 1540
Greenland et al [2007] ACCFAHA 2007 Clinical Expert Consensus Document on Coronary Artery Calcium Scoring By Computed Tomography in Global Cardiovascular Risk Assessment and in Evaluation of Patients With Chest Pain A Report of the American College of Cardiology Foundation Clinical Expert Consensus Task Force (ACCFAHA Writing Committee to Update the 2000 Expert Consensus Document on Electron Beam Computed Tomography) J Am Coll Cardiol 49378-402
Kales SN Tsismenakis AJ Zhang C Soteriades ES [2009] Blood pressure in fire fighters police officers and other emergency responders Am J Hypertens 2211-20
Schlant RC Adolph RJ DiMarco JP Dreifus LS Dunn MI Fisch C Garson A Jr Haywood LJ Levine HJ Murray JA Noble RJ Ronan JA Jr [1992] Guidelines for electrocardiography A report of the American College of CardiologyAmerican Heart Association Task Force on Assessment of Diagnostic and Therapeutic Cardiovascular Procedures (Committee on Electrocardiography) Circulation 85(3)1221-1228
Soteriades ES Kales SN Liarokapis D Christiani DC [2003] Prospective surveillance of hypertension in firefighters J Clin Hypertens 5315-320
Formatted Font Italic
Formatted Line spacing single
Formatted Font Italic
Formatted Font Italic
44
NFPA 1582‐ Draft Revisions for CVDHTN
EKG and stress tests
Reason for Revision
1) Change requirement for annual resting EKG to periodically to be more consistent with ACCAHA
recommendation (Schlant et al 1992)
2) Add language to clarify what constitutes a positive ST
3) Make criteria for conducting diagnostic ST in asymptomatic patients consistent with the
ACCAHA
Language in 2007 Edition with draft revisions in Red (Track changes)
776 Electrocardiograms (EKG) and Stress Tests 7761 A resting EKG shall be performed as part of the baseline medical evaluation and shall be obtained periodically (every 1 to 5 years) thereafter
A7761 A baseline resting EKGs shall be conducted Follow-up resting EKGs should be conducted as clinically indicated but at a minimum of every 1 to 5 years The frequency of these follow-up resting EKGs should increase as a members age increases or with increasing number andor severity of coronary heart disease risk factors Members above the age of 40 should have annual resting EKGs (Schlant et al 1992)
7762 The fire department physician or other qualified medical evaluator shall compare baseline and subsequent EKGs
7763 Stress testing with or without echocardiography or radionuclide scanning shall be performed as clinically indicated by history or symptoms
A7763 No firm guidelines for stress testing in asymptomatic individuals have been developed Stress testing as a screening tool is used as part of an evaluation of aerobic capacity during the annual occupational fitness evaluation Submaximal stress testing testing to 85 percent is commonly used as part of this screening
Submaximal stress testing should not be used for diagnostic purposes Cardiology evaluation with maximal stress testing together with imaging techniques (eg echocardiography technetium Tc99m sestamibi study) is necessary for diagnosticprognostic purposes for the following
(1) Fire fighters with positive or questionably positive changes on screening submaximal stress tests
(2) Fire fighters with new onset chest pain or other symptoms suggestive of coronary artery disease (CAD)
45
(3) Fire fighters with diabetes mellitus who
(a) are gt35 years old or
(b) have type I diabetes for more than 15 years or
(c) have type II diabetes for more than 10 years or
(d) have any other CHD risk factor (see below) or
(e) have the presence of microvascular disease (proliferative retinopathy)
(4) Fire fighters over the age of 45 (for men) and 55 (for women) with one or more risk factors for CAD Risk factors for CAD include hypercholesterolemia (total cholesterol greater than 240 mgdL) hypertension (systolic gt140 mmHg or diastolic gt90 mmHg) smoking or family history of premature CAD (heart attack or sudden cardiac death in a first degree relative less than 60 years of age)
(5) Fire fighters with a Framingham Risk Score gt10 Risk calculator is available at [httphp2010nhlbihinnetatpiiicalculatorasp]
(6) Fire fighters identified in 9431
Negative stress tests should be repeated as clinically indicated or at least every 2 to 5 years
Interpreting stress tests as ldquopositiverdquo or ldquonegativerdquo is beyond the scope of this document However factors that should be taken into consideration should include the individualrsquos exercise capacity symptoms blood pressure response heart rate response EKG changes and the presence of arrhythmias (Gibbon et al 2002)
There are other non-invasive tests to screen for coronary artery disease One of the most promising appears to be coronary artery calcium (CAD) scoring by computed tomography In 2007 an expert committee published an update to their original guidance document The committeersquos consensus was that ldquoit may be reasonable to consider use of CAC measurement in such patients [between 10 and 20 10-year risk of estimated coronary event]helliprdquo The committee did not recommend CAC measurement in low risk patients [lt10 10-year risk of estimated coronary event] or in high risk patients [gt20 10-year risk of estimate coronary event] (Greenland et al 2007]
D22 Cardiology
Resting EKG and Stress Tests
46
Chobanian AV Bakris GL Black HR Cushman WC Green LA Izzo JL Jr Jones DW Materson BJ Oparil S Wright JT Jr Roccella EJ the National High Blood Pressure Education Program Coordinating Committee [2003] The seventh report of the Joint National Committee [JNC-7] on Prevention Detection Evaluation and Treatment of High Blood Pressure JAMA 2892560ndash2571
Gibbons RJ Balady GJ Bricker JT Chaitman BR Fletcher GF Froelicher VF Mark DB McCallister BD Mooss AN OrsquoReilly MG Winters WL Jr [2002] ACCAHA 2002 guideline update for exercise testing summary article a report of the ACCAHA Task Force on Practice Guidelines (Committee to Update the 1997 Exercise Testing guidelines) J Am Coll Cardiol 401531ndash 1540
Greenland et al [2007] ACCFAHA 2007 Clinical Expert Consensus Document on Coronary Artery Calcium Scoring By Computed Tomography in Global Cardiovascular Risk Assessment and in Evaluation of Patients With Chest Pain A Report of the American College of Cardiology Foundation Clinical Expert Consensus Task Force (ACCFAHA Writing Committee to Update the 2000 Expert Consensus Document on Electron Beam Computed Tomography) J Am Coll Cardiol 49378-402
Kales SN Tsismenakis AJ Zhang C Soteriades ES [2009] Blood pressure in fire fighters police officers and other emergency responders Am J Hypertens 2211-20
Schlant RC Adolph RJ DiMarco JP Dreifus LS Dunn MI Fisch C Garson A Jr Haywood LJ Levine HJ Murray JA Noble RJ Ronan JA Jr [1992] Guidelines for electrocardiography A report of the American College of CardiologyAmerican Heart Association Task Force on Assessment of Diagnostic and Therapeutic Cardiovascular Procedures (Committee on Electrocardiography) Circulation 85(3)1221-1228
Soteriades ES Kales SN Liarokapis D Christiani DC [2003] Prospective surveillance of hypertension in firefighters J Clin Hypertens 5315-320
47
ATTACHMENT F
48
1
Current 1582 (2007) language in reference to pregnancy 43 (4) Report to the fire department physician any medical condition that could interfere with the ability of the individual to safely perform essential job tasks such as illness or injury use of prescription or nonprescription drugs and pregnancy 6112 Category B medical conditions shall include the following (1) Pregnancy for its duration A7792 (e) If HIV prophylaxis is to be given the following tests should be done i CBC ii Glucose renal and hepatic chemical function iii Pregnancy test for females B121 Pregnancy and Reproduction Federal regulations as well as many court decisions including the US Supreme Courtrsquos decision in International Union et al v Johnson Controls Inc [499 US 187 111 S Ct 1196 (1991)] have interpreted the requirements of Title VII with respect to pregnancy and reproduction The AHJ should seek the advice of counsel in resolving specific questions concerning these requirements as well as other requirements that can be imposed by state or local laws C211 (4) Review health status with the individual being evaluated Contraindications for evaluations shall be reviewed addressing any changes in the individualrsquos health status since their last medical evaluation that would warrant deferring the evaluation including (g) Pregnancy Recommendations to language enhancement
A female employee who is assigned to regular fire line duty shall report a pregnancy immediately to their respective Supervisor and the fire department physician The employee will then be given the option of a non-hazardous alternative duty position for the duration of her pregnancy (can we say this or is it even appropriate) Any pregnant employee wishing to remain on regular line duty shall be informed of the possible risks and consequences to herself and her fetus that are associated with continued line fire fighting duty Among those risk factors are exposure to teratogens known to have negative effects on the developing fetus such as smoke diesel fumes hazardous chemicals and extreme heat
49
Page 2
appendix It is recommended that the pregnant employee complete a release of liability form signed by herself and her health care provider utilizing NFPArsquos 13 critical tasks as a reference This will inform the health care provider of specific job-related tasks that will need to be performed in order to continue regular line duty These tasks are basic physical standards that any entry level firefighter would have to be able to complete competently The employeersquos health condition will be kept confidential by the department in accordance with HIPAA standards Employees are allowed to remain on active regular duty until they are no longer able to perform their duties in a reasonable manner andor their protective gear no longer fits correctly It is the responsibility of the health care provider to evaluate the pregnant employee If at any time the health care provider feels the pregnant employee can no longer perform the job related tasks this should be reported to the employer by the employee immediately
50
ATTACHMENT G
51
From GLENN BENARICKTo Sawyer SteveSubject RE RE 7743Date Monday August 30 2010 21633 PM
Yes thats my understanding
Glenn P Benarick 211 Winged Elm CircleAiken SC 29803803-644-7093gbenarprodigynet
--- On Mon 83010 Sawyer Steve ltssawyerNFPAorggt wrote
From Sawyer Steve ltssawyerNFPAorggtSubject RE RE 7743To GLENN BENARICK ltgbenarprodigynetgtDate Monday August 30 2010 212 PM
So it should be ldquoorrdquo instead of ldquoandrdquo for now
Steven F Sawyer
Senior Fire Service Specialist
Executive Secretary IFMAFire Service Section
NFPA
1 Batterymarch Park
Quincy MA 02169
6179847423
Fax 6179847056
ssawyernfpaorg
From GLENN BENARICK [mailtogbenarprodigynet] Sent Monday August 30 2010 1202 PMTo Sawyer SteveSubject Fw RE 7743
52
Steve a couple of our docs agree with April Boyer
Glenn P Benarick 211 Winged Elm Circle
Aiken SC 29803
803-644-7093
gbenarprodigynet
--- On Mon 83010 David Prezant ltprezandfdnynycgovgt wrote
From David Prezant ltprezandfdnynycgovgtSubject RE 7743To Thomas R (CDCNIOSHDSHEFS) Hales lttrh1cdcgovgt GLENNBENARICK ltgbenarprodigynetgtCc Sandy Bogucki ltsandyboguckiyaleedugtDate Monday August 30 2010 1004 AM
agree
we should change this to NHANES III rather than Knudson we should alsomodify this to allow not only for predicted cutoffs but all for use of thelower limit of normal cutoff This is important to prevent false-classificationof spirometry as abnormal in older groups and in taller grps The latter ofparticular import to firefighter occupational health surveillance
thanks
David Prezant MDChief Medical Officer Office of Medical AffairsCo-Director WTC Medical Monitoring amp Treatment ProgramsNew York City Fire Department9 Metrotech Center - Rm 4W-1Brooklyn NY 11201Phone 718-999-2696Fax 718-999-0665
Life is full of twists and turns
53
This email may contain confidential information If you are the unintendedrecipient of this email please send it back and delete from your directory
gtgtgt Hales Thomas R (CDCNIOSHDSHEFS) lttrh1cdcgovgt 8302010955 AM gtgtgt
Glen
This seems like a very reasonable comment and illustrates the importance of having clinicians providefeedback on the std Im not familiar with the software program of the various spirometers (NHANES IIIvs KnudsonATS vs both) Given the large role both Dave Prezant and Sandy Bogucki had for thepulmonary section let me forward to them for clarification
Tom
From GLENN BENARICK [mailtogbenarprodigynet] Sent Sunday August 29 2010 456 PMTo Hales Thomas R (CDCNIOSHDSHEFS)Subject FW 7743
Tom is April Boyer correct
Glenn P Benarick 211 Winged Elm Circle
Aiken SC 29803
803-644-7093
gbenarprodigynet
--- On Thu 82610 Sawyer Steve ltssawyerNFPAorggt wrote
From Sawyer Steve ltssawyerNFPAorggtSubject FW 7743To GLENN BENARICK ltgbenarprodigynetgtDate Thursday August 26 2010 925 PM
FYI Do you have any answer She is write
Steven
54
Steven F Sawyer
Senior Fire Service Specialist
Executive Secretary IFMAFire Service Section
NFPA
1 Batterymarch Park
Quincy MA 02169
6179847423
Fax 6179847056
ssawyernfpaorg
From April Boyer [mailtoaboyerbicclinicorg] Sent Thursday August 26 2010 232 PMTo Sawyer SteveCc RobinMWebbmilstateorusSubject 7743
Steven
The spirometry tests cannot be corrected according to both references as the NFPA states because thereferences are contradictory The first part of 7743 states to follow the ATS guidelines and use theKnudsen (we at Basin Immediate Care use the Nhanes III) The second part states to follow the ACOEMguidelines and use the Nhanes III in the occupational setting if available with your unit (which is availableon ours) 7743 does not use the word OR regarding both requirements it uses the word AND whenreferring to the first and second parts thence making 7743 contradictory I realize the NFPA 1582 hasnot been updated since 2007 unless I have just not received an updated version
Our question to you is which part of 7743 do you want us to follow the first or the second part Anyfacility that has an updated computerized spirometry system (as we do) will not be able to follow bothrequired parts for obvious reasons We can either follow the first part of 7743 and use an oldercorrected version of the Knudson by going into our system and changing out of the Nhanes III conversionOR we can follow the second part of 7743 and use the newer corrected version of Nhanes III which ourunit offers too
If you have any questions you may contact me at anytime and I also have many references in regards toboth parts of 7743 if you would like to see them
55
Thank you~
April
Confidentiality NoticeThis message may contain information that isconfidential or privileged
If you are not the intended recipientPlease advise the sender immediately and delete this message
56
ATTACHMENT H
57
NFPA 1582 771(7) Proposed revisions
Why
Preliminary results of two prospective randomized trials on the PSA test were published in 2009 These studies resulted in medical organizations that previously providing guidance to modify their recommendations
Current language
771 Blood Tests Blood tests shall be performed annually and shall include the following
(7) Prostate specific antigen (PSA) after age 40 for positive family history if African American or if otherwise clinically indicated after age 50 for all other male member
Suggested Revision
771 Blood Tests Blood tests shall be performed annually and shall include the following
(7) Prostate specific antigen (PSA) after age 40 for positive family history if African American or if otherwise clinically indicated after age 50 for all other male member
772 Prostate-Specific Antigen (PSA) test At age 50 fire fighters shall have an opportunity to make an informed decision with either the Fire Department physician or their health care provider concerning the PSA test For fire fighters at increased risk of prostate cancer (African-Americans or those with a first degree relative diagnosed with prostate cancer before age 65) shall have the opportunity for this informed decision at age 40
A772 The PSA as a screening test for prostate cancer in asymptomatic men is controversial controversial for two reasons First there is no consensus that PSA screening actually saves lives For example the PSA test may detect small cancers that would never become life threatening Second it is unclear that the benefits of PSA screening outweigh the risks of follow-up diagnostic tests and cancer treatments For example the prostate biopsy used to diagnose prostate cancer may cause bleeding and infection And prostate cancer treatments such as surgery and radiation therapy may cause incontinence (inability to control urine flow) erectile dysfunction (erections inadequate for intercourse) and other complications For these reasons it is important that the benefits and risks of prostate diagnostic procedures and treatment be taken into account when considering the PSA screening test These considerations can be taken account during discussions with the fire department physician or onersquos health care provider
D211 Cancer Screening
Smith R A C J Mettlin K J Davis and H Eyre 2000 ldquoAmerican Cancer Society guidelines for the early detection of cancerrdquo CA J Clin 50(1)34ndash49
Added references
58
Carroll P Albertsen PC Greene K et al [2010] Prostate-specific antigen best practice statement 2009 update Am Urological Assoc Available at httpwwwauanetorgcontentguidelines-and-quality-careclinical-guidelinesmain-reportspsa09pdf Date accessed September 2010
Ferrini R Woolf SH [2009] Screening for prostate cancer in American men American College of Preventive Medicine Practice Policy Statement Available at httpwwwacpmorgprostatehtm Date accessed September 2010
National Cancer Institute [2009] Prostate-specific antigen test National Cancer Institute Fact Sheet Available at httpwwwcancergovcancertopicsfactsheetDetectionPSA Date accessed September 2010
Wolf AMD Wender RC Etzioni RB et al [2010] American Cancer Society guideline for the early detection of prostate cancer Update 2010 Available at httpcaonlineamcancersocorgcgicontentfullcaac20066v1 Date accessed September 2010
59
4324 If the LEO uses an insulin pump documentation is needed as follows
proper understanding and education in the use of the insulin pump
start date for the use of the pump
history of insulin site infectionsd
history of pump cessation and pump malfunction
backup plan for pump malfunction including use of injectable insulin and
frequency of infusion set changes
4325 The LEO has been educated in diabetes and its management and thoroughly informed of and under-
stands the procedures that must be followed to monitor and manage hisher diabetes and what procedures
should be followed if complications arise3
433 ndash QUANTITATIVE GLUCOSE MONITORING
4331 The LEO has documentation of ongoing self-monitoring of blood glucose
4332 This must be done with a glucose meter that stores every reading records date and time of reading
and from which data can be downloaded (Most meters now have this capability)
4333 Monitoring logs must be available covering the time period (1 3 or 6 months) as described in
Sections 4322 and 4323 The frequency of glucose monitoring must follow a schedule acceptable to the
police physician in consultation with the treating physician
Testing schedules are individual What follows is a common pattern but individual patterns may differ
2 ACOEM Guidance for the Medical Evaluation of Law Enforcement Officers
43 ndash DIABETES MELLITUS
dIndividual has not had more than one pump-site infection that caused him or her to miss work or usual daily activities in the preceding 6
months
THERAPEUTIC REGIMEN GLUCOSE TESTING SCHEDULE
Diet alone Once or twice a week
Metformin Thiazolidinediones or Alpha
Glucosidase inhibitors alone or in
combination
Once or twice a week
Sulfonylureas meglitanides nateglinide ndash
alone or in combination with the above group
Twice a day ndash AM and at supper with any
suspected hypoglycemic episodes
Insulin ndash one shot in combination with orals Twice a day ndash AM and at supper with any
suspected hypoglycemic episodes
2 to 3 times AM once a week
Insulin ndash two or more shots Insulin pump 3 to 4 times a day ndash at meals and bedtime
2 to 3 times AM once a week with any
suspected hypoglycemic episodes
21
4334 The LEO has had hemoglobin A1C measured at least 4 times a year (intervals of 2 to 3 months) over
the last 12 months prior to evaluation if diagnosis has been present for more than a year4 If hemoglobin A1C is
gt8 this may signal a problem with the LEOrsquos diabetes management that warrants further assessment5
434 ndash INCAPACITATING EVENTS
4341 The LEO has not had any incapacitating episodes within the past 1 year and no more than 2 episodes
in the past 3 years or since diagnosis of diabetes (whichever is shorter) of
43411 Severe hypoglycemia (loss of consciousness seizures or coma requiring assistance of others or
needing urgent treatment [glucagon injectionIV glucose]) or
43412 Blood sugar lt60 mgdl with unawareness demonstrated in current glucose logs6
435 ndash CHRONIC COMPLICATION SCREENING
4351 Chronic complications of diabetes are associated with increased risk for severe hypoglycemic
episodes and warrant further assessmente
4352 The components of screening for chronic complications are
43521 A complete eye exam by a qualified ophthalmologist or optometrist including a dilated retinal
exam demonstrating no more than mild background diabetic retinopathyf7
43522 Normal vibratory testing with a 128 Hz tuning forkg normal testing with 10 gram Semmes-
Weinstein monofilamentg and normal orthostatic blood pressureh and pulse testing89
ACOEM Guidance for the Medical Evaluation of Law Enforcement Officers 3
43 ndash DIABETES MELLITUS
ePresence of chronic complications of diabetes in and of themselves may not require the implementation of work restrictions
fNo more than one dot blot or flame-shaped hemorrhages or microaneurysm in all four fundus quadrants
gThe Michigan Diabetes Research and Training Center of the University of Michigan Health System recommends the following guidance
(see wwwmedumichedumdrtcprofsdocumentssviMNSI_howtopdf) for conducting vibratory and monofilament testing8
Vibration Sensation Vibration sensation should be performed with the great toe unsupported Vibration sensation will be tested bi-
laterally using a 128 Hz tuning fork placed over the dorsum of the great toe on the boney prominence of the DIP joint Patients whose
eyes are closed will be asked to indicate when they can no longer sense the vibration from the vibrating tuning fork In general the
examiner should be able to feel vibration from the hand-held tuning fork for 5 seconds longer on his distal forefinger than a normal subject
can at the great toe (eg examiners DIP joint of the first finger versus patients toe) If the examiner feels vibration for 10 or more seconds
on his or her finger then vibration is considered decreased A trial should be given when the tuning fork is not vibrating to be certain that
the patient is responding to vibration and not pressure or some other clue Vibration is scored as 1) present if the examiner senses the
vibration on his or her finger for lt10 seconds 2) reduced if sensed for 10 seconds or 3) absent (no vibration detection)
Monofilament Testing For this examination it is important that the patients foot be supported (ie allow the sole of the foot to rest on
a flat warm surface) The filament should initially be pre-stressed (4-6 perpendicular applications to the dorsum of the examiner s first
finger) The filament is then applied to the dorsum of the great toe midway between the nail fold and the DIP joint Do not hold the toe
directly The filament is applied perpendicularly and briefly (lt1 second) with an even pressure When the filament bends the force of
10 grams has been applied The patient whose eyes are closed is asked to respond yes if heshe feels the filament Eight correct responses
out of 10 applications is considered normal 1 to 7 correct responses indicates reduced sensation and no correct answers translates into
absent sensation
hOrthostatic hypotension is a physical finding defined by the American Autonomic Society and the American Academy of Neurology as a
systolic blood pressure decrease of at least 20 mm Hg or a diastolic blood pressure decrease of at least 10 mm Hg within 3 minutes of
standing
22
43523 Normal cardiac physical exam Cardiac stress testing to at least 12 METS is recommended and
should begin based on either the criteria of the American Heart AssociationAmerican College of
Cardiologyi10 or those of the American Diabetes Associationj11
Diabetics who have a normal cardiac stress test will be retested every one to three years based on
individual clinical assessment This assessment should consider
the age of the individual
the number and persistence of coronary artery disease (CAD) risk factors
the severity of CAD risk factors
43524 Microalbumincreatinine ratio 301 measured or calculatedk creatinine clearance
gt60 mlmin12
436 ndash ONGOING EVALUATION AND REQUIREMENTS
4361 Should have medical records and glucose meter logs reviewed periodically Because of the nature of
diabetes it is important that regular medical follow up be provided to the LEO The frequency and content of
the evaluation should be determined on an individual basis by the police physician in consultation with the
treating physicianl
4362 Must advise police physician of any change in type of medication
4363 Must advise police physician of any episodes of significant hypoglycemia or hyperglycemia
Urine microalbumincreatinine ratio _________________
III Treating Physician Statement
The above named individual meets all of the criteria provided on this form
Yes No ndash not recommended for position
No but IS recommended for position (letter of explanation attached)
It is my opinion that the above named individual is well-educated and well-motivated in diabetes self-management and has
achieved a level of diabetes management to be capable of safe and effective job performance as a law enforcement officer
I have reached this opinion after careful review of the above criteria
___________________________________________________________ ___________________________Signature of Physician Date
______________________________________________________________ ___________________________Printed or Typed Name of Physician Telephone Number
10 ACOEM Guidance for the Medical Evaluation of Law Enforcement Officers
43 ndash DIABETES MELLITUS
29
439 ndash REFERENCES
1 American Diabetes Association Diagnosis and classification of diabetes mellitus Diabetes Care 200427 Suppl
1S5-S10 See httpcarediabetesjournalsorgcgicontentfull27suppl_1s5
2 American Diabetes Association Continuous subcutaneous insulin infusion Diabetes Care 200427 Suppl 1S110
See httpcarediabetesjournalsorgcgicontentfull27suppl_1s110
3 Mensing C Boucher J Cypress M et al National standards for diabetes self-management education Diabetes
Care 200528 Suppl 1S72-9 See httpcarediabetesjournalsorgcgicontentfull28suppl_1s72
4 Goldstein DE Little RR Lorenz RA Malone JI Nathan DM Peterson CM American Diabetes Association Tests
of glycemia in diabetes Diabetes Care 200427 Suppl 1S91-3
See httpcarediabetesjournalsorgcgicontentfull27suppl_1s91
5 The Diabetes Control and Complications Trial Research Group Hypoglycemia in the Diabetes Control and
Complications Trial Diabetes 199746(2)271-86 See wwwncbinlmnihgovpubmed9000705 for abstract
6 American Diabetes Association Hypoglycemia and employmentlicensure Diabetes Care 200528 Suppl 1S61
See httpcarediabetesjournalsorgcgicontentfull28suppl_1s61
7 Viswanath K McGavin DD Diabetic Retinopathy Clinical Findings and Management J Comm Eye Health
200316(46)21-4 See wwwcehjournalorg0953-683316jceh_16_46_021html
8 Michigan Diabetes Research and Training Center University of Michigan Health System How to use the Michigan
Neuropathy Screening Instrument See wwwmedumichedumdrtcprofsdocumentssviMNSI_howtopdf
9 Bradley JG Davis KA Orthostatic hypotension Am Fam Physician 200368(12)2393-8
See wwwaafporgafp200312152393html
10 Gibbons RJ Balady GJ Bricker JT et al ACCAHA 2002 guideline update for exercise testing a report of the
American College of CardiologyAmerican Heart Association Task Force on Practice Guidelines (Committee on
Exercise Testing) J Am Coll Cardiol 200240(8)1531-40
See wwwaccorgqualityandscienceclinicalguidelinesexerciseexercise_cleanpdf
11 American Diabetes Association Standards of medical care in diabetes Diabetes Care 200528 Suppl 1S4-S36
Erratum in Diabetes Care 200528(4)990 See httpcarediabetesjournalsorgcgicontentfull28suppl_1s4
12 Molitch ME DeFronzo RA Franz MJ et al American Diabetes Association Nephropathy in diabetes Diabetes
Care 200427 Suppl 1S79-83 See httpcarediabetesjournalsorgcgicontentfull27suppl_1s79
13 Kitabchi AE Umpierrez GE Murphy MB et al American Diabetes Association Hyperglycemic crises in diabetes
Diabetes Care 200427 Suppl 1S94-102 See httpcarediabetesjournalsorgcgicontentfull27suppl_1s94
14 US Centers for Disease Control and Prevention National Diabetes Fact Sheet 2007
See wwwcdcgovdiabetespubspdfndfs_2007pdf
ACOEM Guidance for the Medical Evaluation of Law Enforcement Officers 11
43 ndash DIABETES MELLITUS
30
ATTACHMENT E
31
Typos A6921(2) 7th line down test should be plural 94201 Paragraph 2 target organ damage is used though end organ damage was defined earlier and in the appendix for that paragraph
A94201 Para A (1) d Id suggest deleting the phrases in brackets Im not sure either are predictably true or politically wise
a) tests for left ventricular hypertrophy Unfortunately use of the EKG to detect left ventricular hypertrophy is very insensitive (eg 5 sensitivity) The echocardiogram is the best test for diagnosing left ventricular hypertrophy but [it is relatively expensive and not readily available in small rural communities ] conducting echocardiograms on asymptomatic fire fighters with Stage 1 hypertension should be reserved only for those with long-standing hypertension
In addition
7761 A resting EKG shall be performed as part of the baseline medical evaluation and shall be obtained periodically thereafter
Changing from annually to periodically is noted has the language in the wellness-fitness initiative been changed as well Our previous decision was that we would support the W-F language since there was no compelling evidence to either support or refute it
Thanks
Sandy
32
NFPA 1582‐ HTN Draft 1
Reason for Revision
1) New classification of BP by the Joint National Commission [Chobanian et al 2002]
2) A high prevalence of FF have either HTN (~20) and Pre‐HTN (~20) [Soteriades et al 2003]
3) Among FF studies have shown a strong association between HTN and a number of adverse
cardiovascular events [Kales et al 2009]
4) A large percentage of on‐duty FF fatalities were found to have left ventricular hypertrophy a
complication of HTN at autopsy
Language in 2007 Edition with draft revisions in Red (Track changes)
611 The medical evaluation of a candidate shall include a medical history examination and any laboratory tests required to detect physical or medical condition(s) that could adversely affect hisher ability to safely perform the essential job tasks outlined in 511 A611 The medical history should include the candidates known health problems such as major illnesses surgeries medication use and allergies Symptom review is also important for detecting early signs of illness A medical history should also include a personal health history a family health history a health habit history an immunization history and a reproductive history
An occupational history should also be obtained to collect information about the persons past occupational and environmental exposures
(a) BP should be measured according to the Joint National Commission (JNC) -7 recommendations BP should be measured with a properly calibrated and validated instrument Patients should be seated quietly for at least 5 minutes in a chair with feet on the floor and arm supported at heart level An appropriate-sized cuff (cuff bladder encircling at least 80 of the arm) should be used to ensure accuracy At least 2 measurements should be made Systolic BP is the point at which the first of 2 or more sounds is heard (phase 1) and diastolic BP is the point before the disappearance of sounds (phase 5) [Chobanian et al 2003]
(2) Head eyes ears nose and throat (HEENT)
Formatted Font (Default) Times New RomanFont color Black
33
692 Vascular System 6921 Category A medical conditions shall include the following
(1) Uncontrolled or poorly controlled hypertension
(2) Hypertension with evidence of end organ damage
or not controlled by approved medications
A6921(1) Uncontrolled or poorly controlled hHypertension increases the risk of a sudden cardiac event This sudden cardiac event would cause sudden incapacitation which that is uncontrolled poorly controlled or requires medication likely to interferes with the safe performance of essential job tasks Uncontrolled or poorly controlled hypertension can be defined as the presence of end organ damage (see below) or stage 2 hypertension (BP systolic gt160 mmHg or BP diastolic gt100 mmHg) is an illness that can lead to functional impairment and potential for sudden incapacitation Individuals with pre- stage 1 or stage 2 hypertension should be referred to their primary care physician for evaluation lifestyle modification and treatment [QUESTION FOR GROUP _- WHAT ABOUT HAVING CANDIDATE RETURN IN ONE MONTH UNDER TREATMENT WITH NORMAL BP]
A6921(2)
Chronic hypertension can damage the eye (retinopathy) the kidneys (nephropathy) the vascular system (stroke transient ischemic attack or peripheral artery disease) or the heart (left ventricular hypertrophy and heart failure) These hypertension complications are known as end organ damage The cardiac and vascular complications are associated with an increased risk of sudden incapacitation and sudden cardiac death (Koren et al 1991) Unfortunately the cardiac complications are frequently asymptomatic and valid screening tests are not fast and are not inexpensive Therefore determining who to screen for cardiac complications (such as echocardiogram for LVH or a measurement of left ventricular ejection fraction for heart failure) should be based on the severity and the duration of HTN
76 Physical Examination The annual physical examination shall include each of the following components
(a) BP shall be measured according to the Joint National Commission (JNC)-7 recommendations
A76(1)(a) BP should be measured with a properly calibrated and validated instrument Patients should be seated quietly for at least 5 minutes in a chair with feet on the floor and arm supported at heart level An appropriate-sized cuff (cuff bladder encircling at least 80 of the arm) should be used to ensure accuracy At least 2 measurements should be made Systolic BP is the point at which the first of 2 or more sounds is heard (phase 1) and diastolic BP is the point before the disappearance of sounds (phase 5) [Chobanian et al 2003]
(2) Head eyes ears nose and throat (HEENT)
34
9420 Uncontrolled Hypertension 94201 Physician Evaluation Severe uncontrolled hypertension [defined as systolic pressure greater than 180 mm Hg diastolic pressure greater than 100 mm Hg or mean systolic blood
pressure ( systolic + diastolic) greater than 120 mm Hg] or malignant hypertension (defined as hypertension with the presence of target organ damage) compromises the members ability to safely perform essential job tasks 1 5 7 9 and 13 and the physician shall report the applicable job limitations to the fire department
Members with Pre-hypertention (systolic 120-139 mmHg or diastolic 80-89 mmHg) Stage 1 hypertension (systolic 140-159 mmHg or diastolic 90-99 mmHg) or Stage 2 hypertension (systolic ge160 mmHg or diastolic ge100 mmHg) should be referred to their primary care physician for evaluation lifestyle modification and treatment
(1) Members with Stage I hypertension should be followed-up not only by their primary care physician but also by the FD physician every 3 to 6 months to ensure their blood pressure is under control and to determine whether screening tests for asymptomatic end organ damage are appropriate
(2) Members with Stage 2 hypertension or with end organ damage (retinopathy nephropathy vascular or cardiac complications) compromises the members ability to safely perform essential job tasks 1 5 7 9 and 130 and the physician shall report the applicable job limitations to the fire department
A94201 Severe uncontrolled hypertension is a significant risk factor for the development of coronary artery disease congestive heart failure and stroke Blood pressure increases as a normal response to exercise This response is further exaggerated by the emotional and physical stress of performing these critical tasks while operating in personal protective clothing at extremes of temperature This normal elevation of blood pressure under these response conditions can lead to life-threatening hypertensive emergencies if a members daily blood pressure is already elevated to high levels In addition hypertension is a progressive illness that when uncontrolled ultimately and inevitably leads to target organ damage Target organs that are sensitive to the effects of elevated blood pressure are the central nervous system vision heart major blood vessels and kidneys
Chronic hypertension can damage the eye (retinopathy) the kidneys (nephropathy) the vascular system (stroke transient ischemic attack or peripheral artery disease) or the heart (left ventricular hypertrophy and heart failure) These hypertension complications are known as end organ damage The cardiac and vascular complications are associated with an increased risk of sudden incapacitation and sudden cardiac death (Koren et al 1991) Fortunately with proper evaluation life style modification and treatment these complications can be avoided Life style modification includes weight reduction DASH eating plan reduction in dietary sodium an increase in aerobic physical activity and moderation in alcohol consumption [Chobanian 2003]
Formatted Font (Default) Times New Roman12 pt Font color Black
Formatted Font (Default) Times New Roman12 pt Font color Black
35
A94201 (1) Members with Stage I hypertension whose BP returns to either pre-hypertenion or normal with lifestyle modification andor treatment can return to an annual medical evaluation For members with long-standing Stage I hypertension whose BP has not been reduced additional evaluation for possible end organ damage should be considered This evaluation could include any or all of the following
a) a compete patient history for symptoms of heart failure (eg shortness of breath upon exertion) or transient ischemic attacks (TIAs)
b) dilated eye examination for retinopathy
c) blood creatinine measurement for nephropathy
d) tests for left ventricular hypertrophy Unfortunately use of the resting EKG to detect left ventricular hypertrophy is very insensitive (eg 5 sensitivity) The echocardiogram is the best test for diagnosing left ventricular hypertrophy
A 94201 (2) Due to the high risk of a sudden cardiovascular event members with Stage 2 hypertension should be restricted until their BP can be brought under control Once the BP is brought under control they should be followed in the same manner as a member with Stage I hypertension
Formatted Font (Default) Times New Roman12 pt
36
D22 Cardiology Gibbons R J GJ Balady J W Beasley et al 1997 ACCAHA guidelines for exercise testing a report of American College of CardiologyAmerican Heart Association Task Force on Practice Guidelines (Committee on Exercise Testing) J Am Coll Cardiol 30260ndash311
Gibbons RJ Balady GJ Bricker JT Chaitman BR Fletcher GF Froelicher VF Mark DB McCallister BD Mooss AN OrsquoReilly MG Winters WL Jr [2002] ACCAHA 2002 guideline update for exercise testing summary article a report of the ACCAHA Task Force on Practice Guidelines (Committee to Update the 1997 Exercise Testing guidelines) J Am Coll Cardiol 401531ndash 40
Chobanian AV Bakris GL Black HR Cushman WC Green LA Izzo JL Jr Jones DW Materson BJ Oparil S Wright JT Jr Roccella EJ the National High Blood Pressure Education Program Coordinating Committee [2003] The seventh report of the Joint National Committee [JNC-7] on Prevention Detection Evaluation and Treatment of High Blood Pressure JAMA 2892560ndash2571
Soteriades ES Kales SN Liarokapis D Christiani DC [2003] Prospective surveillance of hypertension in firefighters J Clin Hypertens 5315-320
Kales SN Tsismenakis AJ Zhang C Soteriades ES [2009] Blood pressure in fire fighters police officers and other emergency responders Am J Hypertens 2211-20
37
NFPA 1582‐ HTN Draft 1
Reason for Revision
1) New classification of BP by the Joint National Commission [Chobanian et al 2002]
2) A high prevalence of FF have either HTN (~20) and Pre‐HTN (~20) [Soteriades et al 2003]
3) Among FF studies have shown a strong association between HTN and a number of adverse
cardiovascular events [Kales et al 2009]
4) A large percentage of on‐duty FF fatalities were found to have left ventricular hypertrophy a
complication of HTN at autopsy
Language in 2007 Edition with draft revisions in Red (Track changes)
611 The medical evaluation of a candidate shall include a medical history examination and any laboratory tests required to detect physical or medical condition(s) that could adversely affect hisher ability to safely perform the essential job tasks outlined in 511 A611 The medical history should include the candidates known health problems such as major illnesses surgeries medication use and allergies Symptom review is also important for detecting early signs of illness A medical history should also include a personal health history a family health history a health habit history an immunization history and a reproductive history
An occupational history should also be obtained to collect information about the persons past occupational and environmental exposures
(a) BP should be measured according to the Joint National Commission (JNC) -7 recommendations BP should be measured with a properly calibrated and validated instrument Patients should be seated quietly for at least 5 minutes in a chair with feet on the floor and arm supported at heart level An appropriate-sized cuff (cuff bladder encircling at least 80 of the arm) should be used to ensure accuracy At least 2 measurements should be made Systolic BP is the point at which the first of 2 or more sounds is heard (phase 1) and diastolic BP is the point before the disappearance of sounds (phase 5) [Chobanian et al 2003]
(2) Head eyes ears nose and throat
38
692 Vascular System 6921 Category A medical conditions shall include the following
(1) Uncontrolled or poorly controlled hypertension
(2) Hypertension with evidence of end organ damage
A6921(1) Uncontrolled or poorly controlled hypertension increases the risk of a sudden cardiac event This sudden cardiac event would cause sudden incapacitation which interferes with the safe performance of essential job tasks Uncontrolled or poorly controlled hypertension can be defined as the presence of end organ damage (see below) or stage 2 hypertension (BP systolic gt160 mmHg or BP diastolic gt100 mmHg) Individuals with pre- stage 1 or stage 2 hypertension should be referred to their primary care physician for evaluation lifestyle modification and treatment [QUESTION FOR GROUP _- WHAT ABOUT HAVING CANDIDATE RETURN IN ONE MONTH UNDER TREATMENT WITH NORMAL BP]
A6921(2)Chronic hypertension can damage the eye (retinopathy) the kidneys (nephropathy) the vascular system (stroke transient ischemic attack or peripheral artery disease) or the heart (left ventricular hypertrophy and heart failure) These hypertension complications are known as end organ damage The cardiac and vascular complications are associated with an increased risk of sudden incapacitation and sudden cardiac death (Koren et al 1991) Unfortunately the cardiac complications are frequently asymptomatic and valid screening tests are not fast and are not inexpensive Therefore determining who to screen for cardiac complications (such as echocardiogram for LVH or a measurement of left ventricular ejection fraction for heart failure) should be based on the severity and the duration of HTN
76 Physical Examination The annual physical examination shall include each of the following components
(a) BP shall be measured according to the Joint National Commission (JNC)-7 recommendations
A76(1)(a) BP should be measured with a properly calibrated and validated instrument Patients should be seated quietly for at least 5 minutes in a chair with feet on the floor and arm supported at heart level An appropriate-sized cuff (cuff bladder encircling at least 80 of the arm) should be used to ensure accuracy At least 2 measurements should be made Systolic BP is the point at which the first of 2 or more sounds is heard (phase 1) and diastolic BP is the point before the disappearance of sounds (phase 5) [Chobanian et al 2003]
(2) Head eyes ears nose and throat9420 Hypertension 94201 Physician Evaluation Members with Pre-hypertention (systolic 120-139 mmHg or diastolic 80-89 mmHg) Stage 1 hypertension (systolic 140-159 mmHg or diastolic 90-99 mmHg) or Stage 2 hypertension (systolic ge160 mmHg or diastolic ge100 mmHg) should be referred to their primary care physician for evaluation lifestyle modification and treatment
39
(1) Members with Stage I hypertension should be followed-up not only by their primary care physician but also by the FD physician every 3 to 6 months to ensure their blood pressure is under control and to determine whether screening tests for asymptomatic end organ damage are appropriate
(2) Members with Stage 2 hypertension or with end organ damage (retinopathy nephropathy vascular or cardiac complications) compromises the members ability to safely perform essential job tasks 1 5 7 9 and 130 and the physician shall report the applicable job limitations to the fire department
A94201 Chronic hypertension can damage the eye (retinopathy) the kidneys (nephropathy) the vascular system (stroke transient ischemic attack or peripheral artery disease) or the heart (left ventricular hypertrophy and heart failure) These hypertension complications are known as end organ damage The cardiac and vascular complications are associated with an increased risk of sudden incapacitation and sudden cardiac death (Koren et al 1991) Fortunately with proper evaluation life style modification and treatment these complications can be avoided Life style modification includes weight reduction DASH eating plan reduction in dietary sodium an increase in aerobic physical activity and moderation in alcohol consumption [Chobanian 2003]
A94201 (1) Members with Stage I hypertension whose BP returns to either pre-hypertenion or normal with lifestyle modification andor treatment can return to an annual medical evaluation For members with long-standing Stage I hypertension whose BP has not been reduced additional evaluation for possible end organ damage should be considered This evaluation could include any or all of the following
a) a compete patient history for symptoms of heart failure (eg shortness of breath upon exertion) or transient ischemic attacks (TIAs)
b) dilated eye examination for retinopathy
c) blood creatinine measurement for nephropathy
d) tests for left ventricular hypertrophy Unfortunately use of the resting EKG to detect left ventricular hypertrophy is very insensitive (eg 5 sensitivity) The echocardiogram is the best test for diagnosing left ventricular hypertrophy
A 94201 (2) Due to the high risk of a sudden cardiovascular event members with Stage 2 hypertension should be restricted until their BP can be brought under control Once the BP is brought under control they should be followed in the same manner as a member with Stage I hypertension
D22 Cardiology
40
Hypertension
Gibbons RJ Balady GJ Bricker JT Chaitman BR Fletcher GF Froelicher VF Mark DB McCallister BD Mooss AN OrsquoReilly MG Winters WL Jr [2002] ACCAHA 2002 guideline update for exercise testing summary article a report of the ACCAHA Task Force on Practice Guidelines (Committee to Update the 1997 Exercise Testing guidelines) J Am Coll Cardiol 401531ndash 40
Chobanian AV Bakris GL Black HR Cushman WC Green LA Izzo JL Jr Jones DW Materson BJ Oparil S Wright JT Jr Roccella EJ the National High Blood Pressure Education Program Coordinating Committee [2003] The seventh report of the Joint National Committee [JNC-7] on Prevention Detection Evaluation and Treatment of High Blood Pressure JAMA 2892560ndash2571
Soteriades ES Kales SN Liarokapis D Christiani DC [2003] Prospective surveillance of hypertension in firefighters J Clin Hypertens 5315-320
Kales SN Tsismenakis AJ Zhang C Soteriades ES [2009] Blood pressure in fire fighters police officers and other emergency responders Am J Hypertens 2211-20
41
NFPA 1582‐ Draft Revisions for CVDHTN
EKG and stress tests
Reason for Revision
1) Change requirement for annual resting EKG to periodically to be more consistent with ACCAHA
recommendation (Schlant et al 1992)
2) Add language to clarify what constitutes a positive ST
3) Make criteria for conducting diagnostic ST in asymptomatic patients consistent with the
ACCAHA
Language in 2007 Edition with draft revisions in Red (Track changes)
776 Electrocardiograms (EKG)) and Stress Tests 7761 A resting EKG shall be performed as part of the baseline medical evaluation and shall be obtained periodically (every 1 to 5 years) annually thereafter
A7761 A baseline resting EKGs shall be conducted Follow-up resting EKGs should be conducted as clinically indicated but at a minimum of every 1 to 5 years The frequency of these follow-up resting EKGs should increase as a members age increases or with increasing number andor severity of coronary heart disease risk factors Members above the age of 40 should have annual resting EKGs (Schlant et al 1992)
7762 The fire department physician or other qualified medical evaluator shall compare EKGs obtained during yearly evaluations with baseline and subsequent EKGs
7763 Stress testing EKG with or without echocardiography or radionuclide scanning shall be performed as clinically indicated by history or symptoms
A7761 Baseline electrocardiography should be conducted (Periodic resting electrocardiograms have not been shown to be useful but can be reasonable as a members agefactors increase)
A7763 No firm guidelines for stress testingelectrocardiography in asymptomatic individuals have been developed Stress testingelectrocardiography as a screening tool is used as part of an evaluation of aerobic capacity during the annual occupational fitness evaluation Submaximal stress testingelectrocardiography testing to 85 percent is commonly used as part of this screening
Submaximal stress electrocardiography testing should not be used for diagnostic purposes Cardiology evaluation with maximal stress testingelectrocardiography together with imaging techniques (eg echocardiography technetium Tc99m sestamibi study andor coronary angiography) is necessary for diagnosticprognostic purposes for the following
42
(1) Fire fighters with positive or questionably positive changes on screening submaximal stress tests
(2) Fire fighters with new onset chest pain or other symptoms suggestive of coronary artery disease (CAD)
(3) Fire fighters with diabetes mellitus who
(a) are gt35 years old or
(b) have type I diabetes for more than 15 years or
(c) have type II diabetes for more than 10 years or
(d) have any other CHD risk factor (see below) or
(e) have the presence of microvascular disease (proliferative retinopathy)
(4) Fire fighters over the age of 45 (for men) and 55 (for women) with onetwo or more risk factors for CAD Risk factors for CAD include hypercholesterolemia (total cholesterol greater than 240 mgdL) hypertension (systolic gt140 mmHg or diastolic gt90 mmHg) smoking or family history of premature CAD (heart attack or sudden cardiac death in a first degree relative less than 60 years of age)
as defined below if stress electrocardiography with imaging is negative then repeat as clinically indicated or at least every 5 years
(5) Fire fighters with a Framingham Risk Score gt10 Risk calculator is available at [httphp2010nhlbihinnetatpiiicalculatorasp]
(6) Fire fighters identified in 9431
Negative stress tests should be repeated as clinically indicated or at least every 2 to 5 years
Interpreting stress tests as ldquopositiverdquo or ldquonegativerdquo is beyond the scope of this document However factors that should be taken into consideration should include the individualrsquos exercise capacity symptoms blood pressure response heart rate response EKG changes and the presence of arrhythmias (Gibbon et al 2002)
Risk factors for CAD include hypercholesterolemia (total cholesterol greater than 240 mgdL) hypertension (systolic greater than 140 andor diastolic greater than 90) smoking diabetes mellitus or family history of premature CAD (heart attack or sudden cardiac death in a first degree relative less than 60 years of age)
There are other non-invasive tests to screen for coronary artery disease One of the most promising appears to be coronary artery calcium (CAD) scoring by computed tomography In 2007 an expert committee published an update to their original guidance document The committeersquos consensus was that ldquoit may be reasonable to consider use of CAC measurement in such patients [between 10 and 20 10-year risk of estimated coronary event]helliprdquo The committee did not recommend CAC measurement in low risk patients [lt10 10-year risk of estimated coronary event] or in high risk patients [gt20 10-year risk of estimate coronary event] (Greenland et al 2007]
43
D22 Cardiology
Chobanian AV Bakris GL Black HR Cushman WC Green LA Izzo JL Jr Jones DW Materson BJ Oparil S Wright JT Jr Roccella EJ the National High Blood Pressure Education Program Coordinating Committee [2003] The seventh report of the Joint National Committee [JNC-7] on Prevention Detection Evaluation and Treatment of High Blood Pressure JAMA 2892560ndash2571
Gibbons RJ Balady GJ Bricker JT Chaitman BR Fletcher GF Froelicher VF Mark DB McCallister BD Mooss AN OrsquoReilly MG Winters WL Jr [2002] ACCAHA 2002 guideline update for exercise testing summary article a report of the ACCAHA Task Force on Practice Guidelines (Committee to Update the 1997 Exercise Testing guidelines) J Am Coll Cardiol 401531ndash 1540
Greenland et al [2007] ACCFAHA 2007 Clinical Expert Consensus Document on Coronary Artery Calcium Scoring By Computed Tomography in Global Cardiovascular Risk Assessment and in Evaluation of Patients With Chest Pain A Report of the American College of Cardiology Foundation Clinical Expert Consensus Task Force (ACCFAHA Writing Committee to Update the 2000 Expert Consensus Document on Electron Beam Computed Tomography) J Am Coll Cardiol 49378-402
Kales SN Tsismenakis AJ Zhang C Soteriades ES [2009] Blood pressure in fire fighters police officers and other emergency responders Am J Hypertens 2211-20
Schlant RC Adolph RJ DiMarco JP Dreifus LS Dunn MI Fisch C Garson A Jr Haywood LJ Levine HJ Murray JA Noble RJ Ronan JA Jr [1992] Guidelines for electrocardiography A report of the American College of CardiologyAmerican Heart Association Task Force on Assessment of Diagnostic and Therapeutic Cardiovascular Procedures (Committee on Electrocardiography) Circulation 85(3)1221-1228
Soteriades ES Kales SN Liarokapis D Christiani DC [2003] Prospective surveillance of hypertension in firefighters J Clin Hypertens 5315-320
Formatted Font Italic
Formatted Line spacing single
Formatted Font Italic
Formatted Font Italic
44
NFPA 1582‐ Draft Revisions for CVDHTN
EKG and stress tests
Reason for Revision
1) Change requirement for annual resting EKG to periodically to be more consistent with ACCAHA
recommendation (Schlant et al 1992)
2) Add language to clarify what constitutes a positive ST
3) Make criteria for conducting diagnostic ST in asymptomatic patients consistent with the
ACCAHA
Language in 2007 Edition with draft revisions in Red (Track changes)
776 Electrocardiograms (EKG) and Stress Tests 7761 A resting EKG shall be performed as part of the baseline medical evaluation and shall be obtained periodically (every 1 to 5 years) thereafter
A7761 A baseline resting EKGs shall be conducted Follow-up resting EKGs should be conducted as clinically indicated but at a minimum of every 1 to 5 years The frequency of these follow-up resting EKGs should increase as a members age increases or with increasing number andor severity of coronary heart disease risk factors Members above the age of 40 should have annual resting EKGs (Schlant et al 1992)
7762 The fire department physician or other qualified medical evaluator shall compare baseline and subsequent EKGs
7763 Stress testing with or without echocardiography or radionuclide scanning shall be performed as clinically indicated by history or symptoms
A7763 No firm guidelines for stress testing in asymptomatic individuals have been developed Stress testing as a screening tool is used as part of an evaluation of aerobic capacity during the annual occupational fitness evaluation Submaximal stress testing testing to 85 percent is commonly used as part of this screening
Submaximal stress testing should not be used for diagnostic purposes Cardiology evaluation with maximal stress testing together with imaging techniques (eg echocardiography technetium Tc99m sestamibi study) is necessary for diagnosticprognostic purposes for the following
(1) Fire fighters with positive or questionably positive changes on screening submaximal stress tests
(2) Fire fighters with new onset chest pain or other symptoms suggestive of coronary artery disease (CAD)
45
(3) Fire fighters with diabetes mellitus who
(a) are gt35 years old or
(b) have type I diabetes for more than 15 years or
(c) have type II diabetes for more than 10 years or
(d) have any other CHD risk factor (see below) or
(e) have the presence of microvascular disease (proliferative retinopathy)
(4) Fire fighters over the age of 45 (for men) and 55 (for women) with one or more risk factors for CAD Risk factors for CAD include hypercholesterolemia (total cholesterol greater than 240 mgdL) hypertension (systolic gt140 mmHg or diastolic gt90 mmHg) smoking or family history of premature CAD (heart attack or sudden cardiac death in a first degree relative less than 60 years of age)
(5) Fire fighters with a Framingham Risk Score gt10 Risk calculator is available at [httphp2010nhlbihinnetatpiiicalculatorasp]
(6) Fire fighters identified in 9431
Negative stress tests should be repeated as clinically indicated or at least every 2 to 5 years
Interpreting stress tests as ldquopositiverdquo or ldquonegativerdquo is beyond the scope of this document However factors that should be taken into consideration should include the individualrsquos exercise capacity symptoms blood pressure response heart rate response EKG changes and the presence of arrhythmias (Gibbon et al 2002)
There are other non-invasive tests to screen for coronary artery disease One of the most promising appears to be coronary artery calcium (CAD) scoring by computed tomography In 2007 an expert committee published an update to their original guidance document The committeersquos consensus was that ldquoit may be reasonable to consider use of CAC measurement in such patients [between 10 and 20 10-year risk of estimated coronary event]helliprdquo The committee did not recommend CAC measurement in low risk patients [lt10 10-year risk of estimated coronary event] or in high risk patients [gt20 10-year risk of estimate coronary event] (Greenland et al 2007]
D22 Cardiology
Resting EKG and Stress Tests
46
Chobanian AV Bakris GL Black HR Cushman WC Green LA Izzo JL Jr Jones DW Materson BJ Oparil S Wright JT Jr Roccella EJ the National High Blood Pressure Education Program Coordinating Committee [2003] The seventh report of the Joint National Committee [JNC-7] on Prevention Detection Evaluation and Treatment of High Blood Pressure JAMA 2892560ndash2571
Gibbons RJ Balady GJ Bricker JT Chaitman BR Fletcher GF Froelicher VF Mark DB McCallister BD Mooss AN OrsquoReilly MG Winters WL Jr [2002] ACCAHA 2002 guideline update for exercise testing summary article a report of the ACCAHA Task Force on Practice Guidelines (Committee to Update the 1997 Exercise Testing guidelines) J Am Coll Cardiol 401531ndash 1540
Greenland et al [2007] ACCFAHA 2007 Clinical Expert Consensus Document on Coronary Artery Calcium Scoring By Computed Tomography in Global Cardiovascular Risk Assessment and in Evaluation of Patients With Chest Pain A Report of the American College of Cardiology Foundation Clinical Expert Consensus Task Force (ACCFAHA Writing Committee to Update the 2000 Expert Consensus Document on Electron Beam Computed Tomography) J Am Coll Cardiol 49378-402
Kales SN Tsismenakis AJ Zhang C Soteriades ES [2009] Blood pressure in fire fighters police officers and other emergency responders Am J Hypertens 2211-20
Schlant RC Adolph RJ DiMarco JP Dreifus LS Dunn MI Fisch C Garson A Jr Haywood LJ Levine HJ Murray JA Noble RJ Ronan JA Jr [1992] Guidelines for electrocardiography A report of the American College of CardiologyAmerican Heart Association Task Force on Assessment of Diagnostic and Therapeutic Cardiovascular Procedures (Committee on Electrocardiography) Circulation 85(3)1221-1228
Soteriades ES Kales SN Liarokapis D Christiani DC [2003] Prospective surveillance of hypertension in firefighters J Clin Hypertens 5315-320
47
ATTACHMENT F
48
1
Current 1582 (2007) language in reference to pregnancy 43 (4) Report to the fire department physician any medical condition that could interfere with the ability of the individual to safely perform essential job tasks such as illness or injury use of prescription or nonprescription drugs and pregnancy 6112 Category B medical conditions shall include the following (1) Pregnancy for its duration A7792 (e) If HIV prophylaxis is to be given the following tests should be done i CBC ii Glucose renal and hepatic chemical function iii Pregnancy test for females B121 Pregnancy and Reproduction Federal regulations as well as many court decisions including the US Supreme Courtrsquos decision in International Union et al v Johnson Controls Inc [499 US 187 111 S Ct 1196 (1991)] have interpreted the requirements of Title VII with respect to pregnancy and reproduction The AHJ should seek the advice of counsel in resolving specific questions concerning these requirements as well as other requirements that can be imposed by state or local laws C211 (4) Review health status with the individual being evaluated Contraindications for evaluations shall be reviewed addressing any changes in the individualrsquos health status since their last medical evaluation that would warrant deferring the evaluation including (g) Pregnancy Recommendations to language enhancement
A female employee who is assigned to regular fire line duty shall report a pregnancy immediately to their respective Supervisor and the fire department physician The employee will then be given the option of a non-hazardous alternative duty position for the duration of her pregnancy (can we say this or is it even appropriate) Any pregnant employee wishing to remain on regular line duty shall be informed of the possible risks and consequences to herself and her fetus that are associated with continued line fire fighting duty Among those risk factors are exposure to teratogens known to have negative effects on the developing fetus such as smoke diesel fumes hazardous chemicals and extreme heat
49
Page 2
appendix It is recommended that the pregnant employee complete a release of liability form signed by herself and her health care provider utilizing NFPArsquos 13 critical tasks as a reference This will inform the health care provider of specific job-related tasks that will need to be performed in order to continue regular line duty These tasks are basic physical standards that any entry level firefighter would have to be able to complete competently The employeersquos health condition will be kept confidential by the department in accordance with HIPAA standards Employees are allowed to remain on active regular duty until they are no longer able to perform their duties in a reasonable manner andor their protective gear no longer fits correctly It is the responsibility of the health care provider to evaluate the pregnant employee If at any time the health care provider feels the pregnant employee can no longer perform the job related tasks this should be reported to the employer by the employee immediately
50
ATTACHMENT G
51
From GLENN BENARICKTo Sawyer SteveSubject RE RE 7743Date Monday August 30 2010 21633 PM
Yes thats my understanding
Glenn P Benarick 211 Winged Elm CircleAiken SC 29803803-644-7093gbenarprodigynet
--- On Mon 83010 Sawyer Steve ltssawyerNFPAorggt wrote
From Sawyer Steve ltssawyerNFPAorggtSubject RE RE 7743To GLENN BENARICK ltgbenarprodigynetgtDate Monday August 30 2010 212 PM
So it should be ldquoorrdquo instead of ldquoandrdquo for now
Steven F Sawyer
Senior Fire Service Specialist
Executive Secretary IFMAFire Service Section
NFPA
1 Batterymarch Park
Quincy MA 02169
6179847423
Fax 6179847056
ssawyernfpaorg
From GLENN BENARICK [mailtogbenarprodigynet] Sent Monday August 30 2010 1202 PMTo Sawyer SteveSubject Fw RE 7743
52
Steve a couple of our docs agree with April Boyer
Glenn P Benarick 211 Winged Elm Circle
Aiken SC 29803
803-644-7093
gbenarprodigynet
--- On Mon 83010 David Prezant ltprezandfdnynycgovgt wrote
From David Prezant ltprezandfdnynycgovgtSubject RE 7743To Thomas R (CDCNIOSHDSHEFS) Hales lttrh1cdcgovgt GLENNBENARICK ltgbenarprodigynetgtCc Sandy Bogucki ltsandyboguckiyaleedugtDate Monday August 30 2010 1004 AM
agree
we should change this to NHANES III rather than Knudson we should alsomodify this to allow not only for predicted cutoffs but all for use of thelower limit of normal cutoff This is important to prevent false-classificationof spirometry as abnormal in older groups and in taller grps The latter ofparticular import to firefighter occupational health surveillance
thanks
David Prezant MDChief Medical Officer Office of Medical AffairsCo-Director WTC Medical Monitoring amp Treatment ProgramsNew York City Fire Department9 Metrotech Center - Rm 4W-1Brooklyn NY 11201Phone 718-999-2696Fax 718-999-0665
Life is full of twists and turns
53
This email may contain confidential information If you are the unintendedrecipient of this email please send it back and delete from your directory
gtgtgt Hales Thomas R (CDCNIOSHDSHEFS) lttrh1cdcgovgt 8302010955 AM gtgtgt
Glen
This seems like a very reasonable comment and illustrates the importance of having clinicians providefeedback on the std Im not familiar with the software program of the various spirometers (NHANES IIIvs KnudsonATS vs both) Given the large role both Dave Prezant and Sandy Bogucki had for thepulmonary section let me forward to them for clarification
Tom
From GLENN BENARICK [mailtogbenarprodigynet] Sent Sunday August 29 2010 456 PMTo Hales Thomas R (CDCNIOSHDSHEFS)Subject FW 7743
Tom is April Boyer correct
Glenn P Benarick 211 Winged Elm Circle
Aiken SC 29803
803-644-7093
gbenarprodigynet
--- On Thu 82610 Sawyer Steve ltssawyerNFPAorggt wrote
From Sawyer Steve ltssawyerNFPAorggtSubject FW 7743To GLENN BENARICK ltgbenarprodigynetgtDate Thursday August 26 2010 925 PM
FYI Do you have any answer She is write
Steven
54
Steven F Sawyer
Senior Fire Service Specialist
Executive Secretary IFMAFire Service Section
NFPA
1 Batterymarch Park
Quincy MA 02169
6179847423
Fax 6179847056
ssawyernfpaorg
From April Boyer [mailtoaboyerbicclinicorg] Sent Thursday August 26 2010 232 PMTo Sawyer SteveCc RobinMWebbmilstateorusSubject 7743
Steven
The spirometry tests cannot be corrected according to both references as the NFPA states because thereferences are contradictory The first part of 7743 states to follow the ATS guidelines and use theKnudsen (we at Basin Immediate Care use the Nhanes III) The second part states to follow the ACOEMguidelines and use the Nhanes III in the occupational setting if available with your unit (which is availableon ours) 7743 does not use the word OR regarding both requirements it uses the word AND whenreferring to the first and second parts thence making 7743 contradictory I realize the NFPA 1582 hasnot been updated since 2007 unless I have just not received an updated version
Our question to you is which part of 7743 do you want us to follow the first or the second part Anyfacility that has an updated computerized spirometry system (as we do) will not be able to follow bothrequired parts for obvious reasons We can either follow the first part of 7743 and use an oldercorrected version of the Knudson by going into our system and changing out of the Nhanes III conversionOR we can follow the second part of 7743 and use the newer corrected version of Nhanes III which ourunit offers too
If you have any questions you may contact me at anytime and I also have many references in regards toboth parts of 7743 if you would like to see them
55
Thank you~
April
Confidentiality NoticeThis message may contain information that isconfidential or privileged
If you are not the intended recipientPlease advise the sender immediately and delete this message
56
ATTACHMENT H
57
NFPA 1582 771(7) Proposed revisions
Why
Preliminary results of two prospective randomized trials on the PSA test were published in 2009 These studies resulted in medical organizations that previously providing guidance to modify their recommendations
Current language
771 Blood Tests Blood tests shall be performed annually and shall include the following
(7) Prostate specific antigen (PSA) after age 40 for positive family history if African American or if otherwise clinically indicated after age 50 for all other male member
Suggested Revision
771 Blood Tests Blood tests shall be performed annually and shall include the following
(7) Prostate specific antigen (PSA) after age 40 for positive family history if African American or if otherwise clinically indicated after age 50 for all other male member
772 Prostate-Specific Antigen (PSA) test At age 50 fire fighters shall have an opportunity to make an informed decision with either the Fire Department physician or their health care provider concerning the PSA test For fire fighters at increased risk of prostate cancer (African-Americans or those with a first degree relative diagnosed with prostate cancer before age 65) shall have the opportunity for this informed decision at age 40
A772 The PSA as a screening test for prostate cancer in asymptomatic men is controversial controversial for two reasons First there is no consensus that PSA screening actually saves lives For example the PSA test may detect small cancers that would never become life threatening Second it is unclear that the benefits of PSA screening outweigh the risks of follow-up diagnostic tests and cancer treatments For example the prostate biopsy used to diagnose prostate cancer may cause bleeding and infection And prostate cancer treatments such as surgery and radiation therapy may cause incontinence (inability to control urine flow) erectile dysfunction (erections inadequate for intercourse) and other complications For these reasons it is important that the benefits and risks of prostate diagnostic procedures and treatment be taken into account when considering the PSA screening test These considerations can be taken account during discussions with the fire department physician or onersquos health care provider
D211 Cancer Screening
Smith R A C J Mettlin K J Davis and H Eyre 2000 ldquoAmerican Cancer Society guidelines for the early detection of cancerrdquo CA J Clin 50(1)34ndash49
Added references
58
Carroll P Albertsen PC Greene K et al [2010] Prostate-specific antigen best practice statement 2009 update Am Urological Assoc Available at httpwwwauanetorgcontentguidelines-and-quality-careclinical-guidelinesmain-reportspsa09pdf Date accessed September 2010
Ferrini R Woolf SH [2009] Screening for prostate cancer in American men American College of Preventive Medicine Practice Policy Statement Available at httpwwwacpmorgprostatehtm Date accessed September 2010
National Cancer Institute [2009] Prostate-specific antigen test National Cancer Institute Fact Sheet Available at httpwwwcancergovcancertopicsfactsheetDetectionPSA Date accessed September 2010
Wolf AMD Wender RC Etzioni RB et al [2010] American Cancer Society guideline for the early detection of prostate cancer Update 2010 Available at httpcaonlineamcancersocorgcgicontentfullcaac20066v1 Date accessed September 2010
59
4334 The LEO has had hemoglobin A1C measured at least 4 times a year (intervals of 2 to 3 months) over
the last 12 months prior to evaluation if diagnosis has been present for more than a year4 If hemoglobin A1C is
gt8 this may signal a problem with the LEOrsquos diabetes management that warrants further assessment5
434 ndash INCAPACITATING EVENTS
4341 The LEO has not had any incapacitating episodes within the past 1 year and no more than 2 episodes
in the past 3 years or since diagnosis of diabetes (whichever is shorter) of
43411 Severe hypoglycemia (loss of consciousness seizures or coma requiring assistance of others or
needing urgent treatment [glucagon injectionIV glucose]) or
43412 Blood sugar lt60 mgdl with unawareness demonstrated in current glucose logs6
435 ndash CHRONIC COMPLICATION SCREENING
4351 Chronic complications of diabetes are associated with increased risk for severe hypoglycemic
episodes and warrant further assessmente
4352 The components of screening for chronic complications are
43521 A complete eye exam by a qualified ophthalmologist or optometrist including a dilated retinal
exam demonstrating no more than mild background diabetic retinopathyf7
43522 Normal vibratory testing with a 128 Hz tuning forkg normal testing with 10 gram Semmes-
Weinstein monofilamentg and normal orthostatic blood pressureh and pulse testing89
ACOEM Guidance for the Medical Evaluation of Law Enforcement Officers 3
43 ndash DIABETES MELLITUS
ePresence of chronic complications of diabetes in and of themselves may not require the implementation of work restrictions
fNo more than one dot blot or flame-shaped hemorrhages or microaneurysm in all four fundus quadrants
gThe Michigan Diabetes Research and Training Center of the University of Michigan Health System recommends the following guidance
(see wwwmedumichedumdrtcprofsdocumentssviMNSI_howtopdf) for conducting vibratory and monofilament testing8
Vibration Sensation Vibration sensation should be performed with the great toe unsupported Vibration sensation will be tested bi-
laterally using a 128 Hz tuning fork placed over the dorsum of the great toe on the boney prominence of the DIP joint Patients whose
eyes are closed will be asked to indicate when they can no longer sense the vibration from the vibrating tuning fork In general the
examiner should be able to feel vibration from the hand-held tuning fork for 5 seconds longer on his distal forefinger than a normal subject
can at the great toe (eg examiners DIP joint of the first finger versus patients toe) If the examiner feels vibration for 10 or more seconds
on his or her finger then vibration is considered decreased A trial should be given when the tuning fork is not vibrating to be certain that
the patient is responding to vibration and not pressure or some other clue Vibration is scored as 1) present if the examiner senses the
vibration on his or her finger for lt10 seconds 2) reduced if sensed for 10 seconds or 3) absent (no vibration detection)
Monofilament Testing For this examination it is important that the patients foot be supported (ie allow the sole of the foot to rest on
a flat warm surface) The filament should initially be pre-stressed (4-6 perpendicular applications to the dorsum of the examiner s first
finger) The filament is then applied to the dorsum of the great toe midway between the nail fold and the DIP joint Do not hold the toe
directly The filament is applied perpendicularly and briefly (lt1 second) with an even pressure When the filament bends the force of
10 grams has been applied The patient whose eyes are closed is asked to respond yes if heshe feels the filament Eight correct responses
out of 10 applications is considered normal 1 to 7 correct responses indicates reduced sensation and no correct answers translates into
absent sensation
hOrthostatic hypotension is a physical finding defined by the American Autonomic Society and the American Academy of Neurology as a
systolic blood pressure decrease of at least 20 mm Hg or a diastolic blood pressure decrease of at least 10 mm Hg within 3 minutes of
standing
22
43523 Normal cardiac physical exam Cardiac stress testing to at least 12 METS is recommended and
should begin based on either the criteria of the American Heart AssociationAmerican College of
Cardiologyi10 or those of the American Diabetes Associationj11
Diabetics who have a normal cardiac stress test will be retested every one to three years based on
individual clinical assessment This assessment should consider
the age of the individual
the number and persistence of coronary artery disease (CAD) risk factors
the severity of CAD risk factors
43524 Microalbumincreatinine ratio 301 measured or calculatedk creatinine clearance
gt60 mlmin12
436 ndash ONGOING EVALUATION AND REQUIREMENTS
4361 Should have medical records and glucose meter logs reviewed periodically Because of the nature of
diabetes it is important that regular medical follow up be provided to the LEO The frequency and content of
the evaluation should be determined on an individual basis by the police physician in consultation with the
treating physicianl
4362 Must advise police physician of any change in type of medication
4363 Must advise police physician of any episodes of significant hypoglycemia or hyperglycemia
Urine microalbumincreatinine ratio _________________
III Treating Physician Statement
The above named individual meets all of the criteria provided on this form
Yes No ndash not recommended for position
No but IS recommended for position (letter of explanation attached)
It is my opinion that the above named individual is well-educated and well-motivated in diabetes self-management and has
achieved a level of diabetes management to be capable of safe and effective job performance as a law enforcement officer
I have reached this opinion after careful review of the above criteria
___________________________________________________________ ___________________________Signature of Physician Date
______________________________________________________________ ___________________________Printed or Typed Name of Physician Telephone Number
10 ACOEM Guidance for the Medical Evaluation of Law Enforcement Officers
43 ndash DIABETES MELLITUS
29
439 ndash REFERENCES
1 American Diabetes Association Diagnosis and classification of diabetes mellitus Diabetes Care 200427 Suppl
1S5-S10 See httpcarediabetesjournalsorgcgicontentfull27suppl_1s5
2 American Diabetes Association Continuous subcutaneous insulin infusion Diabetes Care 200427 Suppl 1S110
See httpcarediabetesjournalsorgcgicontentfull27suppl_1s110
3 Mensing C Boucher J Cypress M et al National standards for diabetes self-management education Diabetes
Care 200528 Suppl 1S72-9 See httpcarediabetesjournalsorgcgicontentfull28suppl_1s72
4 Goldstein DE Little RR Lorenz RA Malone JI Nathan DM Peterson CM American Diabetes Association Tests
of glycemia in diabetes Diabetes Care 200427 Suppl 1S91-3
See httpcarediabetesjournalsorgcgicontentfull27suppl_1s91
5 The Diabetes Control and Complications Trial Research Group Hypoglycemia in the Diabetes Control and
Complications Trial Diabetes 199746(2)271-86 See wwwncbinlmnihgovpubmed9000705 for abstract
6 American Diabetes Association Hypoglycemia and employmentlicensure Diabetes Care 200528 Suppl 1S61
See httpcarediabetesjournalsorgcgicontentfull28suppl_1s61
7 Viswanath K McGavin DD Diabetic Retinopathy Clinical Findings and Management J Comm Eye Health
200316(46)21-4 See wwwcehjournalorg0953-683316jceh_16_46_021html
8 Michigan Diabetes Research and Training Center University of Michigan Health System How to use the Michigan
Neuropathy Screening Instrument See wwwmedumichedumdrtcprofsdocumentssviMNSI_howtopdf
9 Bradley JG Davis KA Orthostatic hypotension Am Fam Physician 200368(12)2393-8
See wwwaafporgafp200312152393html
10 Gibbons RJ Balady GJ Bricker JT et al ACCAHA 2002 guideline update for exercise testing a report of the
American College of CardiologyAmerican Heart Association Task Force on Practice Guidelines (Committee on
Exercise Testing) J Am Coll Cardiol 200240(8)1531-40
See wwwaccorgqualityandscienceclinicalguidelinesexerciseexercise_cleanpdf
11 American Diabetes Association Standards of medical care in diabetes Diabetes Care 200528 Suppl 1S4-S36
Erratum in Diabetes Care 200528(4)990 See httpcarediabetesjournalsorgcgicontentfull28suppl_1s4
12 Molitch ME DeFronzo RA Franz MJ et al American Diabetes Association Nephropathy in diabetes Diabetes
Care 200427 Suppl 1S79-83 See httpcarediabetesjournalsorgcgicontentfull27suppl_1s79
13 Kitabchi AE Umpierrez GE Murphy MB et al American Diabetes Association Hyperglycemic crises in diabetes
Diabetes Care 200427 Suppl 1S94-102 See httpcarediabetesjournalsorgcgicontentfull27suppl_1s94
14 US Centers for Disease Control and Prevention National Diabetes Fact Sheet 2007
See wwwcdcgovdiabetespubspdfndfs_2007pdf
ACOEM Guidance for the Medical Evaluation of Law Enforcement Officers 11
43 ndash DIABETES MELLITUS
30
ATTACHMENT E
31
Typos A6921(2) 7th line down test should be plural 94201 Paragraph 2 target organ damage is used though end organ damage was defined earlier and in the appendix for that paragraph
A94201 Para A (1) d Id suggest deleting the phrases in brackets Im not sure either are predictably true or politically wise
a) tests for left ventricular hypertrophy Unfortunately use of the EKG to detect left ventricular hypertrophy is very insensitive (eg 5 sensitivity) The echocardiogram is the best test for diagnosing left ventricular hypertrophy but [it is relatively expensive and not readily available in small rural communities ] conducting echocardiograms on asymptomatic fire fighters with Stage 1 hypertension should be reserved only for those with long-standing hypertension
In addition
7761 A resting EKG shall be performed as part of the baseline medical evaluation and shall be obtained periodically thereafter
Changing from annually to periodically is noted has the language in the wellness-fitness initiative been changed as well Our previous decision was that we would support the W-F language since there was no compelling evidence to either support or refute it
Thanks
Sandy
32
NFPA 1582‐ HTN Draft 1
Reason for Revision
1) New classification of BP by the Joint National Commission [Chobanian et al 2002]
2) A high prevalence of FF have either HTN (~20) and Pre‐HTN (~20) [Soteriades et al 2003]
3) Among FF studies have shown a strong association between HTN and a number of adverse
cardiovascular events [Kales et al 2009]
4) A large percentage of on‐duty FF fatalities were found to have left ventricular hypertrophy a
complication of HTN at autopsy
Language in 2007 Edition with draft revisions in Red (Track changes)
611 The medical evaluation of a candidate shall include a medical history examination and any laboratory tests required to detect physical or medical condition(s) that could adversely affect hisher ability to safely perform the essential job tasks outlined in 511 A611 The medical history should include the candidates known health problems such as major illnesses surgeries medication use and allergies Symptom review is also important for detecting early signs of illness A medical history should also include a personal health history a family health history a health habit history an immunization history and a reproductive history
An occupational history should also be obtained to collect information about the persons past occupational and environmental exposures
(a) BP should be measured according to the Joint National Commission (JNC) -7 recommendations BP should be measured with a properly calibrated and validated instrument Patients should be seated quietly for at least 5 minutes in a chair with feet on the floor and arm supported at heart level An appropriate-sized cuff (cuff bladder encircling at least 80 of the arm) should be used to ensure accuracy At least 2 measurements should be made Systolic BP is the point at which the first of 2 or more sounds is heard (phase 1) and diastolic BP is the point before the disappearance of sounds (phase 5) [Chobanian et al 2003]
(2) Head eyes ears nose and throat (HEENT)
Formatted Font (Default) Times New RomanFont color Black
33
692 Vascular System 6921 Category A medical conditions shall include the following
(1) Uncontrolled or poorly controlled hypertension
(2) Hypertension with evidence of end organ damage
or not controlled by approved medications
A6921(1) Uncontrolled or poorly controlled hHypertension increases the risk of a sudden cardiac event This sudden cardiac event would cause sudden incapacitation which that is uncontrolled poorly controlled or requires medication likely to interferes with the safe performance of essential job tasks Uncontrolled or poorly controlled hypertension can be defined as the presence of end organ damage (see below) or stage 2 hypertension (BP systolic gt160 mmHg or BP diastolic gt100 mmHg) is an illness that can lead to functional impairment and potential for sudden incapacitation Individuals with pre- stage 1 or stage 2 hypertension should be referred to their primary care physician for evaluation lifestyle modification and treatment [QUESTION FOR GROUP _- WHAT ABOUT HAVING CANDIDATE RETURN IN ONE MONTH UNDER TREATMENT WITH NORMAL BP]
A6921(2)
Chronic hypertension can damage the eye (retinopathy) the kidneys (nephropathy) the vascular system (stroke transient ischemic attack or peripheral artery disease) or the heart (left ventricular hypertrophy and heart failure) These hypertension complications are known as end organ damage The cardiac and vascular complications are associated with an increased risk of sudden incapacitation and sudden cardiac death (Koren et al 1991) Unfortunately the cardiac complications are frequently asymptomatic and valid screening tests are not fast and are not inexpensive Therefore determining who to screen for cardiac complications (such as echocardiogram for LVH or a measurement of left ventricular ejection fraction for heart failure) should be based on the severity and the duration of HTN
76 Physical Examination The annual physical examination shall include each of the following components
(a) BP shall be measured according to the Joint National Commission (JNC)-7 recommendations
A76(1)(a) BP should be measured with a properly calibrated and validated instrument Patients should be seated quietly for at least 5 minutes in a chair with feet on the floor and arm supported at heart level An appropriate-sized cuff (cuff bladder encircling at least 80 of the arm) should be used to ensure accuracy At least 2 measurements should be made Systolic BP is the point at which the first of 2 or more sounds is heard (phase 1) and diastolic BP is the point before the disappearance of sounds (phase 5) [Chobanian et al 2003]
(2) Head eyes ears nose and throat (HEENT)
34
9420 Uncontrolled Hypertension 94201 Physician Evaluation Severe uncontrolled hypertension [defined as systolic pressure greater than 180 mm Hg diastolic pressure greater than 100 mm Hg or mean systolic blood
pressure ( systolic + diastolic) greater than 120 mm Hg] or malignant hypertension (defined as hypertension with the presence of target organ damage) compromises the members ability to safely perform essential job tasks 1 5 7 9 and 13 and the physician shall report the applicable job limitations to the fire department
Members with Pre-hypertention (systolic 120-139 mmHg or diastolic 80-89 mmHg) Stage 1 hypertension (systolic 140-159 mmHg or diastolic 90-99 mmHg) or Stage 2 hypertension (systolic ge160 mmHg or diastolic ge100 mmHg) should be referred to their primary care physician for evaluation lifestyle modification and treatment
(1) Members with Stage I hypertension should be followed-up not only by their primary care physician but also by the FD physician every 3 to 6 months to ensure their blood pressure is under control and to determine whether screening tests for asymptomatic end organ damage are appropriate
(2) Members with Stage 2 hypertension or with end organ damage (retinopathy nephropathy vascular or cardiac complications) compromises the members ability to safely perform essential job tasks 1 5 7 9 and 130 and the physician shall report the applicable job limitations to the fire department
A94201 Severe uncontrolled hypertension is a significant risk factor for the development of coronary artery disease congestive heart failure and stroke Blood pressure increases as a normal response to exercise This response is further exaggerated by the emotional and physical stress of performing these critical tasks while operating in personal protective clothing at extremes of temperature This normal elevation of blood pressure under these response conditions can lead to life-threatening hypertensive emergencies if a members daily blood pressure is already elevated to high levels In addition hypertension is a progressive illness that when uncontrolled ultimately and inevitably leads to target organ damage Target organs that are sensitive to the effects of elevated blood pressure are the central nervous system vision heart major blood vessels and kidneys
Chronic hypertension can damage the eye (retinopathy) the kidneys (nephropathy) the vascular system (stroke transient ischemic attack or peripheral artery disease) or the heart (left ventricular hypertrophy and heart failure) These hypertension complications are known as end organ damage The cardiac and vascular complications are associated with an increased risk of sudden incapacitation and sudden cardiac death (Koren et al 1991) Fortunately with proper evaluation life style modification and treatment these complications can be avoided Life style modification includes weight reduction DASH eating plan reduction in dietary sodium an increase in aerobic physical activity and moderation in alcohol consumption [Chobanian 2003]
Formatted Font (Default) Times New Roman12 pt Font color Black
Formatted Font (Default) Times New Roman12 pt Font color Black
35
A94201 (1) Members with Stage I hypertension whose BP returns to either pre-hypertenion or normal with lifestyle modification andor treatment can return to an annual medical evaluation For members with long-standing Stage I hypertension whose BP has not been reduced additional evaluation for possible end organ damage should be considered This evaluation could include any or all of the following
a) a compete patient history for symptoms of heart failure (eg shortness of breath upon exertion) or transient ischemic attacks (TIAs)
b) dilated eye examination for retinopathy
c) blood creatinine measurement for nephropathy
d) tests for left ventricular hypertrophy Unfortunately use of the resting EKG to detect left ventricular hypertrophy is very insensitive (eg 5 sensitivity) The echocardiogram is the best test for diagnosing left ventricular hypertrophy
A 94201 (2) Due to the high risk of a sudden cardiovascular event members with Stage 2 hypertension should be restricted until their BP can be brought under control Once the BP is brought under control they should be followed in the same manner as a member with Stage I hypertension
Formatted Font (Default) Times New Roman12 pt
36
D22 Cardiology Gibbons R J GJ Balady J W Beasley et al 1997 ACCAHA guidelines for exercise testing a report of American College of CardiologyAmerican Heart Association Task Force on Practice Guidelines (Committee on Exercise Testing) J Am Coll Cardiol 30260ndash311
Gibbons RJ Balady GJ Bricker JT Chaitman BR Fletcher GF Froelicher VF Mark DB McCallister BD Mooss AN OrsquoReilly MG Winters WL Jr [2002] ACCAHA 2002 guideline update for exercise testing summary article a report of the ACCAHA Task Force on Practice Guidelines (Committee to Update the 1997 Exercise Testing guidelines) J Am Coll Cardiol 401531ndash 40
Chobanian AV Bakris GL Black HR Cushman WC Green LA Izzo JL Jr Jones DW Materson BJ Oparil S Wright JT Jr Roccella EJ the National High Blood Pressure Education Program Coordinating Committee [2003] The seventh report of the Joint National Committee [JNC-7] on Prevention Detection Evaluation and Treatment of High Blood Pressure JAMA 2892560ndash2571
Soteriades ES Kales SN Liarokapis D Christiani DC [2003] Prospective surveillance of hypertension in firefighters J Clin Hypertens 5315-320
Kales SN Tsismenakis AJ Zhang C Soteriades ES [2009] Blood pressure in fire fighters police officers and other emergency responders Am J Hypertens 2211-20
37
NFPA 1582‐ HTN Draft 1
Reason for Revision
1) New classification of BP by the Joint National Commission [Chobanian et al 2002]
2) A high prevalence of FF have either HTN (~20) and Pre‐HTN (~20) [Soteriades et al 2003]
3) Among FF studies have shown a strong association between HTN and a number of adverse
cardiovascular events [Kales et al 2009]
4) A large percentage of on‐duty FF fatalities were found to have left ventricular hypertrophy a
complication of HTN at autopsy
Language in 2007 Edition with draft revisions in Red (Track changes)
611 The medical evaluation of a candidate shall include a medical history examination and any laboratory tests required to detect physical or medical condition(s) that could adversely affect hisher ability to safely perform the essential job tasks outlined in 511 A611 The medical history should include the candidates known health problems such as major illnesses surgeries medication use and allergies Symptom review is also important for detecting early signs of illness A medical history should also include a personal health history a family health history a health habit history an immunization history and a reproductive history
An occupational history should also be obtained to collect information about the persons past occupational and environmental exposures
(a) BP should be measured according to the Joint National Commission (JNC) -7 recommendations BP should be measured with a properly calibrated and validated instrument Patients should be seated quietly for at least 5 minutes in a chair with feet on the floor and arm supported at heart level An appropriate-sized cuff (cuff bladder encircling at least 80 of the arm) should be used to ensure accuracy At least 2 measurements should be made Systolic BP is the point at which the first of 2 or more sounds is heard (phase 1) and diastolic BP is the point before the disappearance of sounds (phase 5) [Chobanian et al 2003]
(2) Head eyes ears nose and throat
38
692 Vascular System 6921 Category A medical conditions shall include the following
(1) Uncontrolled or poorly controlled hypertension
(2) Hypertension with evidence of end organ damage
A6921(1) Uncontrolled or poorly controlled hypertension increases the risk of a sudden cardiac event This sudden cardiac event would cause sudden incapacitation which interferes with the safe performance of essential job tasks Uncontrolled or poorly controlled hypertension can be defined as the presence of end organ damage (see below) or stage 2 hypertension (BP systolic gt160 mmHg or BP diastolic gt100 mmHg) Individuals with pre- stage 1 or stage 2 hypertension should be referred to their primary care physician for evaluation lifestyle modification and treatment [QUESTION FOR GROUP _- WHAT ABOUT HAVING CANDIDATE RETURN IN ONE MONTH UNDER TREATMENT WITH NORMAL BP]
A6921(2)Chronic hypertension can damage the eye (retinopathy) the kidneys (nephropathy) the vascular system (stroke transient ischemic attack or peripheral artery disease) or the heart (left ventricular hypertrophy and heart failure) These hypertension complications are known as end organ damage The cardiac and vascular complications are associated with an increased risk of sudden incapacitation and sudden cardiac death (Koren et al 1991) Unfortunately the cardiac complications are frequently asymptomatic and valid screening tests are not fast and are not inexpensive Therefore determining who to screen for cardiac complications (such as echocardiogram for LVH or a measurement of left ventricular ejection fraction for heart failure) should be based on the severity and the duration of HTN
76 Physical Examination The annual physical examination shall include each of the following components
(a) BP shall be measured according to the Joint National Commission (JNC)-7 recommendations
A76(1)(a) BP should be measured with a properly calibrated and validated instrument Patients should be seated quietly for at least 5 minutes in a chair with feet on the floor and arm supported at heart level An appropriate-sized cuff (cuff bladder encircling at least 80 of the arm) should be used to ensure accuracy At least 2 measurements should be made Systolic BP is the point at which the first of 2 or more sounds is heard (phase 1) and diastolic BP is the point before the disappearance of sounds (phase 5) [Chobanian et al 2003]
(2) Head eyes ears nose and throat9420 Hypertension 94201 Physician Evaluation Members with Pre-hypertention (systolic 120-139 mmHg or diastolic 80-89 mmHg) Stage 1 hypertension (systolic 140-159 mmHg or diastolic 90-99 mmHg) or Stage 2 hypertension (systolic ge160 mmHg or diastolic ge100 mmHg) should be referred to their primary care physician for evaluation lifestyle modification and treatment
39
(1) Members with Stage I hypertension should be followed-up not only by their primary care physician but also by the FD physician every 3 to 6 months to ensure their blood pressure is under control and to determine whether screening tests for asymptomatic end organ damage are appropriate
(2) Members with Stage 2 hypertension or with end organ damage (retinopathy nephropathy vascular or cardiac complications) compromises the members ability to safely perform essential job tasks 1 5 7 9 and 130 and the physician shall report the applicable job limitations to the fire department
A94201 Chronic hypertension can damage the eye (retinopathy) the kidneys (nephropathy) the vascular system (stroke transient ischemic attack or peripheral artery disease) or the heart (left ventricular hypertrophy and heart failure) These hypertension complications are known as end organ damage The cardiac and vascular complications are associated with an increased risk of sudden incapacitation and sudden cardiac death (Koren et al 1991) Fortunately with proper evaluation life style modification and treatment these complications can be avoided Life style modification includes weight reduction DASH eating plan reduction in dietary sodium an increase in aerobic physical activity and moderation in alcohol consumption [Chobanian 2003]
A94201 (1) Members with Stage I hypertension whose BP returns to either pre-hypertenion or normal with lifestyle modification andor treatment can return to an annual medical evaluation For members with long-standing Stage I hypertension whose BP has not been reduced additional evaluation for possible end organ damage should be considered This evaluation could include any or all of the following
a) a compete patient history for symptoms of heart failure (eg shortness of breath upon exertion) or transient ischemic attacks (TIAs)
b) dilated eye examination for retinopathy
c) blood creatinine measurement for nephropathy
d) tests for left ventricular hypertrophy Unfortunately use of the resting EKG to detect left ventricular hypertrophy is very insensitive (eg 5 sensitivity) The echocardiogram is the best test for diagnosing left ventricular hypertrophy
A 94201 (2) Due to the high risk of a sudden cardiovascular event members with Stage 2 hypertension should be restricted until their BP can be brought under control Once the BP is brought under control they should be followed in the same manner as a member with Stage I hypertension
D22 Cardiology
40
Hypertension
Gibbons RJ Balady GJ Bricker JT Chaitman BR Fletcher GF Froelicher VF Mark DB McCallister BD Mooss AN OrsquoReilly MG Winters WL Jr [2002] ACCAHA 2002 guideline update for exercise testing summary article a report of the ACCAHA Task Force on Practice Guidelines (Committee to Update the 1997 Exercise Testing guidelines) J Am Coll Cardiol 401531ndash 40
Chobanian AV Bakris GL Black HR Cushman WC Green LA Izzo JL Jr Jones DW Materson BJ Oparil S Wright JT Jr Roccella EJ the National High Blood Pressure Education Program Coordinating Committee [2003] The seventh report of the Joint National Committee [JNC-7] on Prevention Detection Evaluation and Treatment of High Blood Pressure JAMA 2892560ndash2571
Soteriades ES Kales SN Liarokapis D Christiani DC [2003] Prospective surveillance of hypertension in firefighters J Clin Hypertens 5315-320
Kales SN Tsismenakis AJ Zhang C Soteriades ES [2009] Blood pressure in fire fighters police officers and other emergency responders Am J Hypertens 2211-20
41
NFPA 1582‐ Draft Revisions for CVDHTN
EKG and stress tests
Reason for Revision
1) Change requirement for annual resting EKG to periodically to be more consistent with ACCAHA
recommendation (Schlant et al 1992)
2) Add language to clarify what constitutes a positive ST
3) Make criteria for conducting diagnostic ST in asymptomatic patients consistent with the
ACCAHA
Language in 2007 Edition with draft revisions in Red (Track changes)
776 Electrocardiograms (EKG)) and Stress Tests 7761 A resting EKG shall be performed as part of the baseline medical evaluation and shall be obtained periodically (every 1 to 5 years) annually thereafter
A7761 A baseline resting EKGs shall be conducted Follow-up resting EKGs should be conducted as clinically indicated but at a minimum of every 1 to 5 years The frequency of these follow-up resting EKGs should increase as a members age increases or with increasing number andor severity of coronary heart disease risk factors Members above the age of 40 should have annual resting EKGs (Schlant et al 1992)
7762 The fire department physician or other qualified medical evaluator shall compare EKGs obtained during yearly evaluations with baseline and subsequent EKGs
7763 Stress testing EKG with or without echocardiography or radionuclide scanning shall be performed as clinically indicated by history or symptoms
A7761 Baseline electrocardiography should be conducted (Periodic resting electrocardiograms have not been shown to be useful but can be reasonable as a members agefactors increase)
A7763 No firm guidelines for stress testingelectrocardiography in asymptomatic individuals have been developed Stress testingelectrocardiography as a screening tool is used as part of an evaluation of aerobic capacity during the annual occupational fitness evaluation Submaximal stress testingelectrocardiography testing to 85 percent is commonly used as part of this screening
Submaximal stress electrocardiography testing should not be used for diagnostic purposes Cardiology evaluation with maximal stress testingelectrocardiography together with imaging techniques (eg echocardiography technetium Tc99m sestamibi study andor coronary angiography) is necessary for diagnosticprognostic purposes for the following
42
(1) Fire fighters with positive or questionably positive changes on screening submaximal stress tests
(2) Fire fighters with new onset chest pain or other symptoms suggestive of coronary artery disease (CAD)
(3) Fire fighters with diabetes mellitus who
(a) are gt35 years old or
(b) have type I diabetes for more than 15 years or
(c) have type II diabetes for more than 10 years or
(d) have any other CHD risk factor (see below) or
(e) have the presence of microvascular disease (proliferative retinopathy)
(4) Fire fighters over the age of 45 (for men) and 55 (for women) with onetwo or more risk factors for CAD Risk factors for CAD include hypercholesterolemia (total cholesterol greater than 240 mgdL) hypertension (systolic gt140 mmHg or diastolic gt90 mmHg) smoking or family history of premature CAD (heart attack or sudden cardiac death in a first degree relative less than 60 years of age)
as defined below if stress electrocardiography with imaging is negative then repeat as clinically indicated or at least every 5 years
(5) Fire fighters with a Framingham Risk Score gt10 Risk calculator is available at [httphp2010nhlbihinnetatpiiicalculatorasp]
(6) Fire fighters identified in 9431
Negative stress tests should be repeated as clinically indicated or at least every 2 to 5 years
Interpreting stress tests as ldquopositiverdquo or ldquonegativerdquo is beyond the scope of this document However factors that should be taken into consideration should include the individualrsquos exercise capacity symptoms blood pressure response heart rate response EKG changes and the presence of arrhythmias (Gibbon et al 2002)
Risk factors for CAD include hypercholesterolemia (total cholesterol greater than 240 mgdL) hypertension (systolic greater than 140 andor diastolic greater than 90) smoking diabetes mellitus or family history of premature CAD (heart attack or sudden cardiac death in a first degree relative less than 60 years of age)
There are other non-invasive tests to screen for coronary artery disease One of the most promising appears to be coronary artery calcium (CAD) scoring by computed tomography In 2007 an expert committee published an update to their original guidance document The committeersquos consensus was that ldquoit may be reasonable to consider use of CAC measurement in such patients [between 10 and 20 10-year risk of estimated coronary event]helliprdquo The committee did not recommend CAC measurement in low risk patients [lt10 10-year risk of estimated coronary event] or in high risk patients [gt20 10-year risk of estimate coronary event] (Greenland et al 2007]
43
D22 Cardiology
Chobanian AV Bakris GL Black HR Cushman WC Green LA Izzo JL Jr Jones DW Materson BJ Oparil S Wright JT Jr Roccella EJ the National High Blood Pressure Education Program Coordinating Committee [2003] The seventh report of the Joint National Committee [JNC-7] on Prevention Detection Evaluation and Treatment of High Blood Pressure JAMA 2892560ndash2571
Gibbons RJ Balady GJ Bricker JT Chaitman BR Fletcher GF Froelicher VF Mark DB McCallister BD Mooss AN OrsquoReilly MG Winters WL Jr [2002] ACCAHA 2002 guideline update for exercise testing summary article a report of the ACCAHA Task Force on Practice Guidelines (Committee to Update the 1997 Exercise Testing guidelines) J Am Coll Cardiol 401531ndash 1540
Greenland et al [2007] ACCFAHA 2007 Clinical Expert Consensus Document on Coronary Artery Calcium Scoring By Computed Tomography in Global Cardiovascular Risk Assessment and in Evaluation of Patients With Chest Pain A Report of the American College of Cardiology Foundation Clinical Expert Consensus Task Force (ACCFAHA Writing Committee to Update the 2000 Expert Consensus Document on Electron Beam Computed Tomography) J Am Coll Cardiol 49378-402
Kales SN Tsismenakis AJ Zhang C Soteriades ES [2009] Blood pressure in fire fighters police officers and other emergency responders Am J Hypertens 2211-20
Schlant RC Adolph RJ DiMarco JP Dreifus LS Dunn MI Fisch C Garson A Jr Haywood LJ Levine HJ Murray JA Noble RJ Ronan JA Jr [1992] Guidelines for electrocardiography A report of the American College of CardiologyAmerican Heart Association Task Force on Assessment of Diagnostic and Therapeutic Cardiovascular Procedures (Committee on Electrocardiography) Circulation 85(3)1221-1228
Soteriades ES Kales SN Liarokapis D Christiani DC [2003] Prospective surveillance of hypertension in firefighters J Clin Hypertens 5315-320
Formatted Font Italic
Formatted Line spacing single
Formatted Font Italic
Formatted Font Italic
44
NFPA 1582‐ Draft Revisions for CVDHTN
EKG and stress tests
Reason for Revision
1) Change requirement for annual resting EKG to periodically to be more consistent with ACCAHA
recommendation (Schlant et al 1992)
2) Add language to clarify what constitutes a positive ST
3) Make criteria for conducting diagnostic ST in asymptomatic patients consistent with the
ACCAHA
Language in 2007 Edition with draft revisions in Red (Track changes)
776 Electrocardiograms (EKG) and Stress Tests 7761 A resting EKG shall be performed as part of the baseline medical evaluation and shall be obtained periodically (every 1 to 5 years) thereafter
A7761 A baseline resting EKGs shall be conducted Follow-up resting EKGs should be conducted as clinically indicated but at a minimum of every 1 to 5 years The frequency of these follow-up resting EKGs should increase as a members age increases or with increasing number andor severity of coronary heart disease risk factors Members above the age of 40 should have annual resting EKGs (Schlant et al 1992)
7762 The fire department physician or other qualified medical evaluator shall compare baseline and subsequent EKGs
7763 Stress testing with or without echocardiography or radionuclide scanning shall be performed as clinically indicated by history or symptoms
A7763 No firm guidelines for stress testing in asymptomatic individuals have been developed Stress testing as a screening tool is used as part of an evaluation of aerobic capacity during the annual occupational fitness evaluation Submaximal stress testing testing to 85 percent is commonly used as part of this screening
Submaximal stress testing should not be used for diagnostic purposes Cardiology evaluation with maximal stress testing together with imaging techniques (eg echocardiography technetium Tc99m sestamibi study) is necessary for diagnosticprognostic purposes for the following
(1) Fire fighters with positive or questionably positive changes on screening submaximal stress tests
(2) Fire fighters with new onset chest pain or other symptoms suggestive of coronary artery disease (CAD)
45
(3) Fire fighters with diabetes mellitus who
(a) are gt35 years old or
(b) have type I diabetes for more than 15 years or
(c) have type II diabetes for more than 10 years or
(d) have any other CHD risk factor (see below) or
(e) have the presence of microvascular disease (proliferative retinopathy)
(4) Fire fighters over the age of 45 (for men) and 55 (for women) with one or more risk factors for CAD Risk factors for CAD include hypercholesterolemia (total cholesterol greater than 240 mgdL) hypertension (systolic gt140 mmHg or diastolic gt90 mmHg) smoking or family history of premature CAD (heart attack or sudden cardiac death in a first degree relative less than 60 years of age)
(5) Fire fighters with a Framingham Risk Score gt10 Risk calculator is available at [httphp2010nhlbihinnetatpiiicalculatorasp]
(6) Fire fighters identified in 9431
Negative stress tests should be repeated as clinically indicated or at least every 2 to 5 years
Interpreting stress tests as ldquopositiverdquo or ldquonegativerdquo is beyond the scope of this document However factors that should be taken into consideration should include the individualrsquos exercise capacity symptoms blood pressure response heart rate response EKG changes and the presence of arrhythmias (Gibbon et al 2002)
There are other non-invasive tests to screen for coronary artery disease One of the most promising appears to be coronary artery calcium (CAD) scoring by computed tomography In 2007 an expert committee published an update to their original guidance document The committeersquos consensus was that ldquoit may be reasonable to consider use of CAC measurement in such patients [between 10 and 20 10-year risk of estimated coronary event]helliprdquo The committee did not recommend CAC measurement in low risk patients [lt10 10-year risk of estimated coronary event] or in high risk patients [gt20 10-year risk of estimate coronary event] (Greenland et al 2007]
D22 Cardiology
Resting EKG and Stress Tests
46
Chobanian AV Bakris GL Black HR Cushman WC Green LA Izzo JL Jr Jones DW Materson BJ Oparil S Wright JT Jr Roccella EJ the National High Blood Pressure Education Program Coordinating Committee [2003] The seventh report of the Joint National Committee [JNC-7] on Prevention Detection Evaluation and Treatment of High Blood Pressure JAMA 2892560ndash2571
Gibbons RJ Balady GJ Bricker JT Chaitman BR Fletcher GF Froelicher VF Mark DB McCallister BD Mooss AN OrsquoReilly MG Winters WL Jr [2002] ACCAHA 2002 guideline update for exercise testing summary article a report of the ACCAHA Task Force on Practice Guidelines (Committee to Update the 1997 Exercise Testing guidelines) J Am Coll Cardiol 401531ndash 1540
Greenland et al [2007] ACCFAHA 2007 Clinical Expert Consensus Document on Coronary Artery Calcium Scoring By Computed Tomography in Global Cardiovascular Risk Assessment and in Evaluation of Patients With Chest Pain A Report of the American College of Cardiology Foundation Clinical Expert Consensus Task Force (ACCFAHA Writing Committee to Update the 2000 Expert Consensus Document on Electron Beam Computed Tomography) J Am Coll Cardiol 49378-402
Kales SN Tsismenakis AJ Zhang C Soteriades ES [2009] Blood pressure in fire fighters police officers and other emergency responders Am J Hypertens 2211-20
Schlant RC Adolph RJ DiMarco JP Dreifus LS Dunn MI Fisch C Garson A Jr Haywood LJ Levine HJ Murray JA Noble RJ Ronan JA Jr [1992] Guidelines for electrocardiography A report of the American College of CardiologyAmerican Heart Association Task Force on Assessment of Diagnostic and Therapeutic Cardiovascular Procedures (Committee on Electrocardiography) Circulation 85(3)1221-1228
Soteriades ES Kales SN Liarokapis D Christiani DC [2003] Prospective surveillance of hypertension in firefighters J Clin Hypertens 5315-320
47
ATTACHMENT F
48
1
Current 1582 (2007) language in reference to pregnancy 43 (4) Report to the fire department physician any medical condition that could interfere with the ability of the individual to safely perform essential job tasks such as illness or injury use of prescription or nonprescription drugs and pregnancy 6112 Category B medical conditions shall include the following (1) Pregnancy for its duration A7792 (e) If HIV prophylaxis is to be given the following tests should be done i CBC ii Glucose renal and hepatic chemical function iii Pregnancy test for females B121 Pregnancy and Reproduction Federal regulations as well as many court decisions including the US Supreme Courtrsquos decision in International Union et al v Johnson Controls Inc [499 US 187 111 S Ct 1196 (1991)] have interpreted the requirements of Title VII with respect to pregnancy and reproduction The AHJ should seek the advice of counsel in resolving specific questions concerning these requirements as well as other requirements that can be imposed by state or local laws C211 (4) Review health status with the individual being evaluated Contraindications for evaluations shall be reviewed addressing any changes in the individualrsquos health status since their last medical evaluation that would warrant deferring the evaluation including (g) Pregnancy Recommendations to language enhancement
A female employee who is assigned to regular fire line duty shall report a pregnancy immediately to their respective Supervisor and the fire department physician The employee will then be given the option of a non-hazardous alternative duty position for the duration of her pregnancy (can we say this or is it even appropriate) Any pregnant employee wishing to remain on regular line duty shall be informed of the possible risks and consequences to herself and her fetus that are associated with continued line fire fighting duty Among those risk factors are exposure to teratogens known to have negative effects on the developing fetus such as smoke diesel fumes hazardous chemicals and extreme heat
49
Page 2
appendix It is recommended that the pregnant employee complete a release of liability form signed by herself and her health care provider utilizing NFPArsquos 13 critical tasks as a reference This will inform the health care provider of specific job-related tasks that will need to be performed in order to continue regular line duty These tasks are basic physical standards that any entry level firefighter would have to be able to complete competently The employeersquos health condition will be kept confidential by the department in accordance with HIPAA standards Employees are allowed to remain on active regular duty until they are no longer able to perform their duties in a reasonable manner andor their protective gear no longer fits correctly It is the responsibility of the health care provider to evaluate the pregnant employee If at any time the health care provider feels the pregnant employee can no longer perform the job related tasks this should be reported to the employer by the employee immediately
50
ATTACHMENT G
51
From GLENN BENARICKTo Sawyer SteveSubject RE RE 7743Date Monday August 30 2010 21633 PM
Yes thats my understanding
Glenn P Benarick 211 Winged Elm CircleAiken SC 29803803-644-7093gbenarprodigynet
--- On Mon 83010 Sawyer Steve ltssawyerNFPAorggt wrote
From Sawyer Steve ltssawyerNFPAorggtSubject RE RE 7743To GLENN BENARICK ltgbenarprodigynetgtDate Monday August 30 2010 212 PM
So it should be ldquoorrdquo instead of ldquoandrdquo for now
Steven F Sawyer
Senior Fire Service Specialist
Executive Secretary IFMAFire Service Section
NFPA
1 Batterymarch Park
Quincy MA 02169
6179847423
Fax 6179847056
ssawyernfpaorg
From GLENN BENARICK [mailtogbenarprodigynet] Sent Monday August 30 2010 1202 PMTo Sawyer SteveSubject Fw RE 7743
52
Steve a couple of our docs agree with April Boyer
Glenn P Benarick 211 Winged Elm Circle
Aiken SC 29803
803-644-7093
gbenarprodigynet
--- On Mon 83010 David Prezant ltprezandfdnynycgovgt wrote
From David Prezant ltprezandfdnynycgovgtSubject RE 7743To Thomas R (CDCNIOSHDSHEFS) Hales lttrh1cdcgovgt GLENNBENARICK ltgbenarprodigynetgtCc Sandy Bogucki ltsandyboguckiyaleedugtDate Monday August 30 2010 1004 AM
agree
we should change this to NHANES III rather than Knudson we should alsomodify this to allow not only for predicted cutoffs but all for use of thelower limit of normal cutoff This is important to prevent false-classificationof spirometry as abnormal in older groups and in taller grps The latter ofparticular import to firefighter occupational health surveillance
thanks
David Prezant MDChief Medical Officer Office of Medical AffairsCo-Director WTC Medical Monitoring amp Treatment ProgramsNew York City Fire Department9 Metrotech Center - Rm 4W-1Brooklyn NY 11201Phone 718-999-2696Fax 718-999-0665
Life is full of twists and turns
53
This email may contain confidential information If you are the unintendedrecipient of this email please send it back and delete from your directory
gtgtgt Hales Thomas R (CDCNIOSHDSHEFS) lttrh1cdcgovgt 8302010955 AM gtgtgt
Glen
This seems like a very reasonable comment and illustrates the importance of having clinicians providefeedback on the std Im not familiar with the software program of the various spirometers (NHANES IIIvs KnudsonATS vs both) Given the large role both Dave Prezant and Sandy Bogucki had for thepulmonary section let me forward to them for clarification
Tom
From GLENN BENARICK [mailtogbenarprodigynet] Sent Sunday August 29 2010 456 PMTo Hales Thomas R (CDCNIOSHDSHEFS)Subject FW 7743
Tom is April Boyer correct
Glenn P Benarick 211 Winged Elm Circle
Aiken SC 29803
803-644-7093
gbenarprodigynet
--- On Thu 82610 Sawyer Steve ltssawyerNFPAorggt wrote
From Sawyer Steve ltssawyerNFPAorggtSubject FW 7743To GLENN BENARICK ltgbenarprodigynetgtDate Thursday August 26 2010 925 PM
FYI Do you have any answer She is write
Steven
54
Steven F Sawyer
Senior Fire Service Specialist
Executive Secretary IFMAFire Service Section
NFPA
1 Batterymarch Park
Quincy MA 02169
6179847423
Fax 6179847056
ssawyernfpaorg
From April Boyer [mailtoaboyerbicclinicorg] Sent Thursday August 26 2010 232 PMTo Sawyer SteveCc RobinMWebbmilstateorusSubject 7743
Steven
The spirometry tests cannot be corrected according to both references as the NFPA states because thereferences are contradictory The first part of 7743 states to follow the ATS guidelines and use theKnudsen (we at Basin Immediate Care use the Nhanes III) The second part states to follow the ACOEMguidelines and use the Nhanes III in the occupational setting if available with your unit (which is availableon ours) 7743 does not use the word OR regarding both requirements it uses the word AND whenreferring to the first and second parts thence making 7743 contradictory I realize the NFPA 1582 hasnot been updated since 2007 unless I have just not received an updated version
Our question to you is which part of 7743 do you want us to follow the first or the second part Anyfacility that has an updated computerized spirometry system (as we do) will not be able to follow bothrequired parts for obvious reasons We can either follow the first part of 7743 and use an oldercorrected version of the Knudson by going into our system and changing out of the Nhanes III conversionOR we can follow the second part of 7743 and use the newer corrected version of Nhanes III which ourunit offers too
If you have any questions you may contact me at anytime and I also have many references in regards toboth parts of 7743 if you would like to see them
55
Thank you~
April
Confidentiality NoticeThis message may contain information that isconfidential or privileged
If you are not the intended recipientPlease advise the sender immediately and delete this message
56
ATTACHMENT H
57
NFPA 1582 771(7) Proposed revisions
Why
Preliminary results of two prospective randomized trials on the PSA test were published in 2009 These studies resulted in medical organizations that previously providing guidance to modify their recommendations
Current language
771 Blood Tests Blood tests shall be performed annually and shall include the following
(7) Prostate specific antigen (PSA) after age 40 for positive family history if African American or if otherwise clinically indicated after age 50 for all other male member
Suggested Revision
771 Blood Tests Blood tests shall be performed annually and shall include the following
(7) Prostate specific antigen (PSA) after age 40 for positive family history if African American or if otherwise clinically indicated after age 50 for all other male member
772 Prostate-Specific Antigen (PSA) test At age 50 fire fighters shall have an opportunity to make an informed decision with either the Fire Department physician or their health care provider concerning the PSA test For fire fighters at increased risk of prostate cancer (African-Americans or those with a first degree relative diagnosed with prostate cancer before age 65) shall have the opportunity for this informed decision at age 40
A772 The PSA as a screening test for prostate cancer in asymptomatic men is controversial controversial for two reasons First there is no consensus that PSA screening actually saves lives For example the PSA test may detect small cancers that would never become life threatening Second it is unclear that the benefits of PSA screening outweigh the risks of follow-up diagnostic tests and cancer treatments For example the prostate biopsy used to diagnose prostate cancer may cause bleeding and infection And prostate cancer treatments such as surgery and radiation therapy may cause incontinence (inability to control urine flow) erectile dysfunction (erections inadequate for intercourse) and other complications For these reasons it is important that the benefits and risks of prostate diagnostic procedures and treatment be taken into account when considering the PSA screening test These considerations can be taken account during discussions with the fire department physician or onersquos health care provider
D211 Cancer Screening
Smith R A C J Mettlin K J Davis and H Eyre 2000 ldquoAmerican Cancer Society guidelines for the early detection of cancerrdquo CA J Clin 50(1)34ndash49
Added references
58
Carroll P Albertsen PC Greene K et al [2010] Prostate-specific antigen best practice statement 2009 update Am Urological Assoc Available at httpwwwauanetorgcontentguidelines-and-quality-careclinical-guidelinesmain-reportspsa09pdf Date accessed September 2010
Ferrini R Woolf SH [2009] Screening for prostate cancer in American men American College of Preventive Medicine Practice Policy Statement Available at httpwwwacpmorgprostatehtm Date accessed September 2010
National Cancer Institute [2009] Prostate-specific antigen test National Cancer Institute Fact Sheet Available at httpwwwcancergovcancertopicsfactsheetDetectionPSA Date accessed September 2010
Wolf AMD Wender RC Etzioni RB et al [2010] American Cancer Society guideline for the early detection of prostate cancer Update 2010 Available at httpcaonlineamcancersocorgcgicontentfullcaac20066v1 Date accessed September 2010
59
43523 Normal cardiac physical exam Cardiac stress testing to at least 12 METS is recommended and
should begin based on either the criteria of the American Heart AssociationAmerican College of
Cardiologyi10 or those of the American Diabetes Associationj11
Diabetics who have a normal cardiac stress test will be retested every one to three years based on
individual clinical assessment This assessment should consider
the age of the individual
the number and persistence of coronary artery disease (CAD) risk factors
the severity of CAD risk factors
43524 Microalbumincreatinine ratio 301 measured or calculatedk creatinine clearance
gt60 mlmin12
436 ndash ONGOING EVALUATION AND REQUIREMENTS
4361 Should have medical records and glucose meter logs reviewed periodically Because of the nature of
diabetes it is important that regular medical follow up be provided to the LEO The frequency and content of
the evaluation should be determined on an individual basis by the police physician in consultation with the
treating physicianl
4362 Must advise police physician of any change in type of medication
4363 Must advise police physician of any episodes of significant hypoglycemia or hyperglycemia
Urine microalbumincreatinine ratio _________________
III Treating Physician Statement
The above named individual meets all of the criteria provided on this form
Yes No ndash not recommended for position
No but IS recommended for position (letter of explanation attached)
It is my opinion that the above named individual is well-educated and well-motivated in diabetes self-management and has
achieved a level of diabetes management to be capable of safe and effective job performance as a law enforcement officer
I have reached this opinion after careful review of the above criteria
___________________________________________________________ ___________________________Signature of Physician Date
______________________________________________________________ ___________________________Printed or Typed Name of Physician Telephone Number
10 ACOEM Guidance for the Medical Evaluation of Law Enforcement Officers
43 ndash DIABETES MELLITUS
29
439 ndash REFERENCES
1 American Diabetes Association Diagnosis and classification of diabetes mellitus Diabetes Care 200427 Suppl
1S5-S10 See httpcarediabetesjournalsorgcgicontentfull27suppl_1s5
2 American Diabetes Association Continuous subcutaneous insulin infusion Diabetes Care 200427 Suppl 1S110
See httpcarediabetesjournalsorgcgicontentfull27suppl_1s110
3 Mensing C Boucher J Cypress M et al National standards for diabetes self-management education Diabetes
Care 200528 Suppl 1S72-9 See httpcarediabetesjournalsorgcgicontentfull28suppl_1s72
4 Goldstein DE Little RR Lorenz RA Malone JI Nathan DM Peterson CM American Diabetes Association Tests
of glycemia in diabetes Diabetes Care 200427 Suppl 1S91-3
See httpcarediabetesjournalsorgcgicontentfull27suppl_1s91
5 The Diabetes Control and Complications Trial Research Group Hypoglycemia in the Diabetes Control and
Complications Trial Diabetes 199746(2)271-86 See wwwncbinlmnihgovpubmed9000705 for abstract
6 American Diabetes Association Hypoglycemia and employmentlicensure Diabetes Care 200528 Suppl 1S61
See httpcarediabetesjournalsorgcgicontentfull28suppl_1s61
7 Viswanath K McGavin DD Diabetic Retinopathy Clinical Findings and Management J Comm Eye Health
200316(46)21-4 See wwwcehjournalorg0953-683316jceh_16_46_021html
8 Michigan Diabetes Research and Training Center University of Michigan Health System How to use the Michigan
Neuropathy Screening Instrument See wwwmedumichedumdrtcprofsdocumentssviMNSI_howtopdf
9 Bradley JG Davis KA Orthostatic hypotension Am Fam Physician 200368(12)2393-8
See wwwaafporgafp200312152393html
10 Gibbons RJ Balady GJ Bricker JT et al ACCAHA 2002 guideline update for exercise testing a report of the
American College of CardiologyAmerican Heart Association Task Force on Practice Guidelines (Committee on
Exercise Testing) J Am Coll Cardiol 200240(8)1531-40
See wwwaccorgqualityandscienceclinicalguidelinesexerciseexercise_cleanpdf
11 American Diabetes Association Standards of medical care in diabetes Diabetes Care 200528 Suppl 1S4-S36
Erratum in Diabetes Care 200528(4)990 See httpcarediabetesjournalsorgcgicontentfull28suppl_1s4
12 Molitch ME DeFronzo RA Franz MJ et al American Diabetes Association Nephropathy in diabetes Diabetes
Care 200427 Suppl 1S79-83 See httpcarediabetesjournalsorgcgicontentfull27suppl_1s79
13 Kitabchi AE Umpierrez GE Murphy MB et al American Diabetes Association Hyperglycemic crises in diabetes
Diabetes Care 200427 Suppl 1S94-102 See httpcarediabetesjournalsorgcgicontentfull27suppl_1s94
14 US Centers for Disease Control and Prevention National Diabetes Fact Sheet 2007
See wwwcdcgovdiabetespubspdfndfs_2007pdf
ACOEM Guidance for the Medical Evaluation of Law Enforcement Officers 11
43 ndash DIABETES MELLITUS
30
ATTACHMENT E
31
Typos A6921(2) 7th line down test should be plural 94201 Paragraph 2 target organ damage is used though end organ damage was defined earlier and in the appendix for that paragraph
A94201 Para A (1) d Id suggest deleting the phrases in brackets Im not sure either are predictably true or politically wise
a) tests for left ventricular hypertrophy Unfortunately use of the EKG to detect left ventricular hypertrophy is very insensitive (eg 5 sensitivity) The echocardiogram is the best test for diagnosing left ventricular hypertrophy but [it is relatively expensive and not readily available in small rural communities ] conducting echocardiograms on asymptomatic fire fighters with Stage 1 hypertension should be reserved only for those with long-standing hypertension
In addition
7761 A resting EKG shall be performed as part of the baseline medical evaluation and shall be obtained periodically thereafter
Changing from annually to periodically is noted has the language in the wellness-fitness initiative been changed as well Our previous decision was that we would support the W-F language since there was no compelling evidence to either support or refute it
Thanks
Sandy
32
NFPA 1582‐ HTN Draft 1
Reason for Revision
1) New classification of BP by the Joint National Commission [Chobanian et al 2002]
2) A high prevalence of FF have either HTN (~20) and Pre‐HTN (~20) [Soteriades et al 2003]
3) Among FF studies have shown a strong association between HTN and a number of adverse
cardiovascular events [Kales et al 2009]
4) A large percentage of on‐duty FF fatalities were found to have left ventricular hypertrophy a
complication of HTN at autopsy
Language in 2007 Edition with draft revisions in Red (Track changes)
611 The medical evaluation of a candidate shall include a medical history examination and any laboratory tests required to detect physical or medical condition(s) that could adversely affect hisher ability to safely perform the essential job tasks outlined in 511 A611 The medical history should include the candidates known health problems such as major illnesses surgeries medication use and allergies Symptom review is also important for detecting early signs of illness A medical history should also include a personal health history a family health history a health habit history an immunization history and a reproductive history
An occupational history should also be obtained to collect information about the persons past occupational and environmental exposures
(a) BP should be measured according to the Joint National Commission (JNC) -7 recommendations BP should be measured with a properly calibrated and validated instrument Patients should be seated quietly for at least 5 minutes in a chair with feet on the floor and arm supported at heart level An appropriate-sized cuff (cuff bladder encircling at least 80 of the arm) should be used to ensure accuracy At least 2 measurements should be made Systolic BP is the point at which the first of 2 or more sounds is heard (phase 1) and diastolic BP is the point before the disappearance of sounds (phase 5) [Chobanian et al 2003]
(2) Head eyes ears nose and throat (HEENT)
Formatted Font (Default) Times New RomanFont color Black
33
692 Vascular System 6921 Category A medical conditions shall include the following
(1) Uncontrolled or poorly controlled hypertension
(2) Hypertension with evidence of end organ damage
or not controlled by approved medications
A6921(1) Uncontrolled or poorly controlled hHypertension increases the risk of a sudden cardiac event This sudden cardiac event would cause sudden incapacitation which that is uncontrolled poorly controlled or requires medication likely to interferes with the safe performance of essential job tasks Uncontrolled or poorly controlled hypertension can be defined as the presence of end organ damage (see below) or stage 2 hypertension (BP systolic gt160 mmHg or BP diastolic gt100 mmHg) is an illness that can lead to functional impairment and potential for sudden incapacitation Individuals with pre- stage 1 or stage 2 hypertension should be referred to their primary care physician for evaluation lifestyle modification and treatment [QUESTION FOR GROUP _- WHAT ABOUT HAVING CANDIDATE RETURN IN ONE MONTH UNDER TREATMENT WITH NORMAL BP]
A6921(2)
Chronic hypertension can damage the eye (retinopathy) the kidneys (nephropathy) the vascular system (stroke transient ischemic attack or peripheral artery disease) or the heart (left ventricular hypertrophy and heart failure) These hypertension complications are known as end organ damage The cardiac and vascular complications are associated with an increased risk of sudden incapacitation and sudden cardiac death (Koren et al 1991) Unfortunately the cardiac complications are frequently asymptomatic and valid screening tests are not fast and are not inexpensive Therefore determining who to screen for cardiac complications (such as echocardiogram for LVH or a measurement of left ventricular ejection fraction for heart failure) should be based on the severity and the duration of HTN
76 Physical Examination The annual physical examination shall include each of the following components
(a) BP shall be measured according to the Joint National Commission (JNC)-7 recommendations
A76(1)(a) BP should be measured with a properly calibrated and validated instrument Patients should be seated quietly for at least 5 minutes in a chair with feet on the floor and arm supported at heart level An appropriate-sized cuff (cuff bladder encircling at least 80 of the arm) should be used to ensure accuracy At least 2 measurements should be made Systolic BP is the point at which the first of 2 or more sounds is heard (phase 1) and diastolic BP is the point before the disappearance of sounds (phase 5) [Chobanian et al 2003]
(2) Head eyes ears nose and throat (HEENT)
34
9420 Uncontrolled Hypertension 94201 Physician Evaluation Severe uncontrolled hypertension [defined as systolic pressure greater than 180 mm Hg diastolic pressure greater than 100 mm Hg or mean systolic blood
pressure ( systolic + diastolic) greater than 120 mm Hg] or malignant hypertension (defined as hypertension with the presence of target organ damage) compromises the members ability to safely perform essential job tasks 1 5 7 9 and 13 and the physician shall report the applicable job limitations to the fire department
Members with Pre-hypertention (systolic 120-139 mmHg or diastolic 80-89 mmHg) Stage 1 hypertension (systolic 140-159 mmHg or diastolic 90-99 mmHg) or Stage 2 hypertension (systolic ge160 mmHg or diastolic ge100 mmHg) should be referred to their primary care physician for evaluation lifestyle modification and treatment
(1) Members with Stage I hypertension should be followed-up not only by their primary care physician but also by the FD physician every 3 to 6 months to ensure their blood pressure is under control and to determine whether screening tests for asymptomatic end organ damage are appropriate
(2) Members with Stage 2 hypertension or with end organ damage (retinopathy nephropathy vascular or cardiac complications) compromises the members ability to safely perform essential job tasks 1 5 7 9 and 130 and the physician shall report the applicable job limitations to the fire department
A94201 Severe uncontrolled hypertension is a significant risk factor for the development of coronary artery disease congestive heart failure and stroke Blood pressure increases as a normal response to exercise This response is further exaggerated by the emotional and physical stress of performing these critical tasks while operating in personal protective clothing at extremes of temperature This normal elevation of blood pressure under these response conditions can lead to life-threatening hypertensive emergencies if a members daily blood pressure is already elevated to high levels In addition hypertension is a progressive illness that when uncontrolled ultimately and inevitably leads to target organ damage Target organs that are sensitive to the effects of elevated blood pressure are the central nervous system vision heart major blood vessels and kidneys
Chronic hypertension can damage the eye (retinopathy) the kidneys (nephropathy) the vascular system (stroke transient ischemic attack or peripheral artery disease) or the heart (left ventricular hypertrophy and heart failure) These hypertension complications are known as end organ damage The cardiac and vascular complications are associated with an increased risk of sudden incapacitation and sudden cardiac death (Koren et al 1991) Fortunately with proper evaluation life style modification and treatment these complications can be avoided Life style modification includes weight reduction DASH eating plan reduction in dietary sodium an increase in aerobic physical activity and moderation in alcohol consumption [Chobanian 2003]
Formatted Font (Default) Times New Roman12 pt Font color Black
Formatted Font (Default) Times New Roman12 pt Font color Black
35
A94201 (1) Members with Stage I hypertension whose BP returns to either pre-hypertenion or normal with lifestyle modification andor treatment can return to an annual medical evaluation For members with long-standing Stage I hypertension whose BP has not been reduced additional evaluation for possible end organ damage should be considered This evaluation could include any or all of the following
a) a compete patient history for symptoms of heart failure (eg shortness of breath upon exertion) or transient ischemic attacks (TIAs)
b) dilated eye examination for retinopathy
c) blood creatinine measurement for nephropathy
d) tests for left ventricular hypertrophy Unfortunately use of the resting EKG to detect left ventricular hypertrophy is very insensitive (eg 5 sensitivity) The echocardiogram is the best test for diagnosing left ventricular hypertrophy
A 94201 (2) Due to the high risk of a sudden cardiovascular event members with Stage 2 hypertension should be restricted until their BP can be brought under control Once the BP is brought under control they should be followed in the same manner as a member with Stage I hypertension
Formatted Font (Default) Times New Roman12 pt
36
D22 Cardiology Gibbons R J GJ Balady J W Beasley et al 1997 ACCAHA guidelines for exercise testing a report of American College of CardiologyAmerican Heart Association Task Force on Practice Guidelines (Committee on Exercise Testing) J Am Coll Cardiol 30260ndash311
Gibbons RJ Balady GJ Bricker JT Chaitman BR Fletcher GF Froelicher VF Mark DB McCallister BD Mooss AN OrsquoReilly MG Winters WL Jr [2002] ACCAHA 2002 guideline update for exercise testing summary article a report of the ACCAHA Task Force on Practice Guidelines (Committee to Update the 1997 Exercise Testing guidelines) J Am Coll Cardiol 401531ndash 40
Chobanian AV Bakris GL Black HR Cushman WC Green LA Izzo JL Jr Jones DW Materson BJ Oparil S Wright JT Jr Roccella EJ the National High Blood Pressure Education Program Coordinating Committee [2003] The seventh report of the Joint National Committee [JNC-7] on Prevention Detection Evaluation and Treatment of High Blood Pressure JAMA 2892560ndash2571
Soteriades ES Kales SN Liarokapis D Christiani DC [2003] Prospective surveillance of hypertension in firefighters J Clin Hypertens 5315-320
Kales SN Tsismenakis AJ Zhang C Soteriades ES [2009] Blood pressure in fire fighters police officers and other emergency responders Am J Hypertens 2211-20
37
NFPA 1582‐ HTN Draft 1
Reason for Revision
1) New classification of BP by the Joint National Commission [Chobanian et al 2002]
2) A high prevalence of FF have either HTN (~20) and Pre‐HTN (~20) [Soteriades et al 2003]
3) Among FF studies have shown a strong association between HTN and a number of adverse
cardiovascular events [Kales et al 2009]
4) A large percentage of on‐duty FF fatalities were found to have left ventricular hypertrophy a
complication of HTN at autopsy
Language in 2007 Edition with draft revisions in Red (Track changes)
611 The medical evaluation of a candidate shall include a medical history examination and any laboratory tests required to detect physical or medical condition(s) that could adversely affect hisher ability to safely perform the essential job tasks outlined in 511 A611 The medical history should include the candidates known health problems such as major illnesses surgeries medication use and allergies Symptom review is also important for detecting early signs of illness A medical history should also include a personal health history a family health history a health habit history an immunization history and a reproductive history
An occupational history should also be obtained to collect information about the persons past occupational and environmental exposures
(a) BP should be measured according to the Joint National Commission (JNC) -7 recommendations BP should be measured with a properly calibrated and validated instrument Patients should be seated quietly for at least 5 minutes in a chair with feet on the floor and arm supported at heart level An appropriate-sized cuff (cuff bladder encircling at least 80 of the arm) should be used to ensure accuracy At least 2 measurements should be made Systolic BP is the point at which the first of 2 or more sounds is heard (phase 1) and diastolic BP is the point before the disappearance of sounds (phase 5) [Chobanian et al 2003]
(2) Head eyes ears nose and throat
38
692 Vascular System 6921 Category A medical conditions shall include the following
(1) Uncontrolled or poorly controlled hypertension
(2) Hypertension with evidence of end organ damage
A6921(1) Uncontrolled or poorly controlled hypertension increases the risk of a sudden cardiac event This sudden cardiac event would cause sudden incapacitation which interferes with the safe performance of essential job tasks Uncontrolled or poorly controlled hypertension can be defined as the presence of end organ damage (see below) or stage 2 hypertension (BP systolic gt160 mmHg or BP diastolic gt100 mmHg) Individuals with pre- stage 1 or stage 2 hypertension should be referred to their primary care physician for evaluation lifestyle modification and treatment [QUESTION FOR GROUP _- WHAT ABOUT HAVING CANDIDATE RETURN IN ONE MONTH UNDER TREATMENT WITH NORMAL BP]
A6921(2)Chronic hypertension can damage the eye (retinopathy) the kidneys (nephropathy) the vascular system (stroke transient ischemic attack or peripheral artery disease) or the heart (left ventricular hypertrophy and heart failure) These hypertension complications are known as end organ damage The cardiac and vascular complications are associated with an increased risk of sudden incapacitation and sudden cardiac death (Koren et al 1991) Unfortunately the cardiac complications are frequently asymptomatic and valid screening tests are not fast and are not inexpensive Therefore determining who to screen for cardiac complications (such as echocardiogram for LVH or a measurement of left ventricular ejection fraction for heart failure) should be based on the severity and the duration of HTN
76 Physical Examination The annual physical examination shall include each of the following components
(a) BP shall be measured according to the Joint National Commission (JNC)-7 recommendations
A76(1)(a) BP should be measured with a properly calibrated and validated instrument Patients should be seated quietly for at least 5 minutes in a chair with feet on the floor and arm supported at heart level An appropriate-sized cuff (cuff bladder encircling at least 80 of the arm) should be used to ensure accuracy At least 2 measurements should be made Systolic BP is the point at which the first of 2 or more sounds is heard (phase 1) and diastolic BP is the point before the disappearance of sounds (phase 5) [Chobanian et al 2003]
(2) Head eyes ears nose and throat9420 Hypertension 94201 Physician Evaluation Members with Pre-hypertention (systolic 120-139 mmHg or diastolic 80-89 mmHg) Stage 1 hypertension (systolic 140-159 mmHg or diastolic 90-99 mmHg) or Stage 2 hypertension (systolic ge160 mmHg or diastolic ge100 mmHg) should be referred to their primary care physician for evaluation lifestyle modification and treatment
39
(1) Members with Stage I hypertension should be followed-up not only by their primary care physician but also by the FD physician every 3 to 6 months to ensure their blood pressure is under control and to determine whether screening tests for asymptomatic end organ damage are appropriate
(2) Members with Stage 2 hypertension or with end organ damage (retinopathy nephropathy vascular or cardiac complications) compromises the members ability to safely perform essential job tasks 1 5 7 9 and 130 and the physician shall report the applicable job limitations to the fire department
A94201 Chronic hypertension can damage the eye (retinopathy) the kidneys (nephropathy) the vascular system (stroke transient ischemic attack or peripheral artery disease) or the heart (left ventricular hypertrophy and heart failure) These hypertension complications are known as end organ damage The cardiac and vascular complications are associated with an increased risk of sudden incapacitation and sudden cardiac death (Koren et al 1991) Fortunately with proper evaluation life style modification and treatment these complications can be avoided Life style modification includes weight reduction DASH eating plan reduction in dietary sodium an increase in aerobic physical activity and moderation in alcohol consumption [Chobanian 2003]
A94201 (1) Members with Stage I hypertension whose BP returns to either pre-hypertenion or normal with lifestyle modification andor treatment can return to an annual medical evaluation For members with long-standing Stage I hypertension whose BP has not been reduced additional evaluation for possible end organ damage should be considered This evaluation could include any or all of the following
a) a compete patient history for symptoms of heart failure (eg shortness of breath upon exertion) or transient ischemic attacks (TIAs)
b) dilated eye examination for retinopathy
c) blood creatinine measurement for nephropathy
d) tests for left ventricular hypertrophy Unfortunately use of the resting EKG to detect left ventricular hypertrophy is very insensitive (eg 5 sensitivity) The echocardiogram is the best test for diagnosing left ventricular hypertrophy
A 94201 (2) Due to the high risk of a sudden cardiovascular event members with Stage 2 hypertension should be restricted until their BP can be brought under control Once the BP is brought under control they should be followed in the same manner as a member with Stage I hypertension
D22 Cardiology
40
Hypertension
Gibbons RJ Balady GJ Bricker JT Chaitman BR Fletcher GF Froelicher VF Mark DB McCallister BD Mooss AN OrsquoReilly MG Winters WL Jr [2002] ACCAHA 2002 guideline update for exercise testing summary article a report of the ACCAHA Task Force on Practice Guidelines (Committee to Update the 1997 Exercise Testing guidelines) J Am Coll Cardiol 401531ndash 40
Chobanian AV Bakris GL Black HR Cushman WC Green LA Izzo JL Jr Jones DW Materson BJ Oparil S Wright JT Jr Roccella EJ the National High Blood Pressure Education Program Coordinating Committee [2003] The seventh report of the Joint National Committee [JNC-7] on Prevention Detection Evaluation and Treatment of High Blood Pressure JAMA 2892560ndash2571
Soteriades ES Kales SN Liarokapis D Christiani DC [2003] Prospective surveillance of hypertension in firefighters J Clin Hypertens 5315-320
Kales SN Tsismenakis AJ Zhang C Soteriades ES [2009] Blood pressure in fire fighters police officers and other emergency responders Am J Hypertens 2211-20
41
NFPA 1582‐ Draft Revisions for CVDHTN
EKG and stress tests
Reason for Revision
1) Change requirement for annual resting EKG to periodically to be more consistent with ACCAHA
recommendation (Schlant et al 1992)
2) Add language to clarify what constitutes a positive ST
3) Make criteria for conducting diagnostic ST in asymptomatic patients consistent with the
ACCAHA
Language in 2007 Edition with draft revisions in Red (Track changes)
776 Electrocardiograms (EKG)) and Stress Tests 7761 A resting EKG shall be performed as part of the baseline medical evaluation and shall be obtained periodically (every 1 to 5 years) annually thereafter
A7761 A baseline resting EKGs shall be conducted Follow-up resting EKGs should be conducted as clinically indicated but at a minimum of every 1 to 5 years The frequency of these follow-up resting EKGs should increase as a members age increases or with increasing number andor severity of coronary heart disease risk factors Members above the age of 40 should have annual resting EKGs (Schlant et al 1992)
7762 The fire department physician or other qualified medical evaluator shall compare EKGs obtained during yearly evaluations with baseline and subsequent EKGs
7763 Stress testing EKG with or without echocardiography or radionuclide scanning shall be performed as clinically indicated by history or symptoms
A7761 Baseline electrocardiography should be conducted (Periodic resting electrocardiograms have not been shown to be useful but can be reasonable as a members agefactors increase)
A7763 No firm guidelines for stress testingelectrocardiography in asymptomatic individuals have been developed Stress testingelectrocardiography as a screening tool is used as part of an evaluation of aerobic capacity during the annual occupational fitness evaluation Submaximal stress testingelectrocardiography testing to 85 percent is commonly used as part of this screening
Submaximal stress electrocardiography testing should not be used for diagnostic purposes Cardiology evaluation with maximal stress testingelectrocardiography together with imaging techniques (eg echocardiography technetium Tc99m sestamibi study andor coronary angiography) is necessary for diagnosticprognostic purposes for the following
42
(1) Fire fighters with positive or questionably positive changes on screening submaximal stress tests
(2) Fire fighters with new onset chest pain or other symptoms suggestive of coronary artery disease (CAD)
(3) Fire fighters with diabetes mellitus who
(a) are gt35 years old or
(b) have type I diabetes for more than 15 years or
(c) have type II diabetes for more than 10 years or
(d) have any other CHD risk factor (see below) or
(e) have the presence of microvascular disease (proliferative retinopathy)
(4) Fire fighters over the age of 45 (for men) and 55 (for women) with onetwo or more risk factors for CAD Risk factors for CAD include hypercholesterolemia (total cholesterol greater than 240 mgdL) hypertension (systolic gt140 mmHg or diastolic gt90 mmHg) smoking or family history of premature CAD (heart attack or sudden cardiac death in a first degree relative less than 60 years of age)
as defined below if stress electrocardiography with imaging is negative then repeat as clinically indicated or at least every 5 years
(5) Fire fighters with a Framingham Risk Score gt10 Risk calculator is available at [httphp2010nhlbihinnetatpiiicalculatorasp]
(6) Fire fighters identified in 9431
Negative stress tests should be repeated as clinically indicated or at least every 2 to 5 years
Interpreting stress tests as ldquopositiverdquo or ldquonegativerdquo is beyond the scope of this document However factors that should be taken into consideration should include the individualrsquos exercise capacity symptoms blood pressure response heart rate response EKG changes and the presence of arrhythmias (Gibbon et al 2002)
Risk factors for CAD include hypercholesterolemia (total cholesterol greater than 240 mgdL) hypertension (systolic greater than 140 andor diastolic greater than 90) smoking diabetes mellitus or family history of premature CAD (heart attack or sudden cardiac death in a first degree relative less than 60 years of age)
There are other non-invasive tests to screen for coronary artery disease One of the most promising appears to be coronary artery calcium (CAD) scoring by computed tomography In 2007 an expert committee published an update to their original guidance document The committeersquos consensus was that ldquoit may be reasonable to consider use of CAC measurement in such patients [between 10 and 20 10-year risk of estimated coronary event]helliprdquo The committee did not recommend CAC measurement in low risk patients [lt10 10-year risk of estimated coronary event] or in high risk patients [gt20 10-year risk of estimate coronary event] (Greenland et al 2007]
43
D22 Cardiology
Chobanian AV Bakris GL Black HR Cushman WC Green LA Izzo JL Jr Jones DW Materson BJ Oparil S Wright JT Jr Roccella EJ the National High Blood Pressure Education Program Coordinating Committee [2003] The seventh report of the Joint National Committee [JNC-7] on Prevention Detection Evaluation and Treatment of High Blood Pressure JAMA 2892560ndash2571
Gibbons RJ Balady GJ Bricker JT Chaitman BR Fletcher GF Froelicher VF Mark DB McCallister BD Mooss AN OrsquoReilly MG Winters WL Jr [2002] ACCAHA 2002 guideline update for exercise testing summary article a report of the ACCAHA Task Force on Practice Guidelines (Committee to Update the 1997 Exercise Testing guidelines) J Am Coll Cardiol 401531ndash 1540
Greenland et al [2007] ACCFAHA 2007 Clinical Expert Consensus Document on Coronary Artery Calcium Scoring By Computed Tomography in Global Cardiovascular Risk Assessment and in Evaluation of Patients With Chest Pain A Report of the American College of Cardiology Foundation Clinical Expert Consensus Task Force (ACCFAHA Writing Committee to Update the 2000 Expert Consensus Document on Electron Beam Computed Tomography) J Am Coll Cardiol 49378-402
Kales SN Tsismenakis AJ Zhang C Soteriades ES [2009] Blood pressure in fire fighters police officers and other emergency responders Am J Hypertens 2211-20
Schlant RC Adolph RJ DiMarco JP Dreifus LS Dunn MI Fisch C Garson A Jr Haywood LJ Levine HJ Murray JA Noble RJ Ronan JA Jr [1992] Guidelines for electrocardiography A report of the American College of CardiologyAmerican Heart Association Task Force on Assessment of Diagnostic and Therapeutic Cardiovascular Procedures (Committee on Electrocardiography) Circulation 85(3)1221-1228
Soteriades ES Kales SN Liarokapis D Christiani DC [2003] Prospective surveillance of hypertension in firefighters J Clin Hypertens 5315-320
Formatted Font Italic
Formatted Line spacing single
Formatted Font Italic
Formatted Font Italic
44
NFPA 1582‐ Draft Revisions for CVDHTN
EKG and stress tests
Reason for Revision
1) Change requirement for annual resting EKG to periodically to be more consistent with ACCAHA
recommendation (Schlant et al 1992)
2) Add language to clarify what constitutes a positive ST
3) Make criteria for conducting diagnostic ST in asymptomatic patients consistent with the
ACCAHA
Language in 2007 Edition with draft revisions in Red (Track changes)
776 Electrocardiograms (EKG) and Stress Tests 7761 A resting EKG shall be performed as part of the baseline medical evaluation and shall be obtained periodically (every 1 to 5 years) thereafter
A7761 A baseline resting EKGs shall be conducted Follow-up resting EKGs should be conducted as clinically indicated but at a minimum of every 1 to 5 years The frequency of these follow-up resting EKGs should increase as a members age increases or with increasing number andor severity of coronary heart disease risk factors Members above the age of 40 should have annual resting EKGs (Schlant et al 1992)
7762 The fire department physician or other qualified medical evaluator shall compare baseline and subsequent EKGs
7763 Stress testing with or without echocardiography or radionuclide scanning shall be performed as clinically indicated by history or symptoms
A7763 No firm guidelines for stress testing in asymptomatic individuals have been developed Stress testing as a screening tool is used as part of an evaluation of aerobic capacity during the annual occupational fitness evaluation Submaximal stress testing testing to 85 percent is commonly used as part of this screening
Submaximal stress testing should not be used for diagnostic purposes Cardiology evaluation with maximal stress testing together with imaging techniques (eg echocardiography technetium Tc99m sestamibi study) is necessary for diagnosticprognostic purposes for the following
(1) Fire fighters with positive or questionably positive changes on screening submaximal stress tests
(2) Fire fighters with new onset chest pain or other symptoms suggestive of coronary artery disease (CAD)
45
(3) Fire fighters with diabetes mellitus who
(a) are gt35 years old or
(b) have type I diabetes for more than 15 years or
(c) have type II diabetes for more than 10 years or
(d) have any other CHD risk factor (see below) or
(e) have the presence of microvascular disease (proliferative retinopathy)
(4) Fire fighters over the age of 45 (for men) and 55 (for women) with one or more risk factors for CAD Risk factors for CAD include hypercholesterolemia (total cholesterol greater than 240 mgdL) hypertension (systolic gt140 mmHg or diastolic gt90 mmHg) smoking or family history of premature CAD (heart attack or sudden cardiac death in a first degree relative less than 60 years of age)
(5) Fire fighters with a Framingham Risk Score gt10 Risk calculator is available at [httphp2010nhlbihinnetatpiiicalculatorasp]
(6) Fire fighters identified in 9431
Negative stress tests should be repeated as clinically indicated or at least every 2 to 5 years
Interpreting stress tests as ldquopositiverdquo or ldquonegativerdquo is beyond the scope of this document However factors that should be taken into consideration should include the individualrsquos exercise capacity symptoms blood pressure response heart rate response EKG changes and the presence of arrhythmias (Gibbon et al 2002)
There are other non-invasive tests to screen for coronary artery disease One of the most promising appears to be coronary artery calcium (CAD) scoring by computed tomography In 2007 an expert committee published an update to their original guidance document The committeersquos consensus was that ldquoit may be reasonable to consider use of CAC measurement in such patients [between 10 and 20 10-year risk of estimated coronary event]helliprdquo The committee did not recommend CAC measurement in low risk patients [lt10 10-year risk of estimated coronary event] or in high risk patients [gt20 10-year risk of estimate coronary event] (Greenland et al 2007]
D22 Cardiology
Resting EKG and Stress Tests
46
Chobanian AV Bakris GL Black HR Cushman WC Green LA Izzo JL Jr Jones DW Materson BJ Oparil S Wright JT Jr Roccella EJ the National High Blood Pressure Education Program Coordinating Committee [2003] The seventh report of the Joint National Committee [JNC-7] on Prevention Detection Evaluation and Treatment of High Blood Pressure JAMA 2892560ndash2571
Gibbons RJ Balady GJ Bricker JT Chaitman BR Fletcher GF Froelicher VF Mark DB McCallister BD Mooss AN OrsquoReilly MG Winters WL Jr [2002] ACCAHA 2002 guideline update for exercise testing summary article a report of the ACCAHA Task Force on Practice Guidelines (Committee to Update the 1997 Exercise Testing guidelines) J Am Coll Cardiol 401531ndash 1540
Greenland et al [2007] ACCFAHA 2007 Clinical Expert Consensus Document on Coronary Artery Calcium Scoring By Computed Tomography in Global Cardiovascular Risk Assessment and in Evaluation of Patients With Chest Pain A Report of the American College of Cardiology Foundation Clinical Expert Consensus Task Force (ACCFAHA Writing Committee to Update the 2000 Expert Consensus Document on Electron Beam Computed Tomography) J Am Coll Cardiol 49378-402
Kales SN Tsismenakis AJ Zhang C Soteriades ES [2009] Blood pressure in fire fighters police officers and other emergency responders Am J Hypertens 2211-20
Schlant RC Adolph RJ DiMarco JP Dreifus LS Dunn MI Fisch C Garson A Jr Haywood LJ Levine HJ Murray JA Noble RJ Ronan JA Jr [1992] Guidelines for electrocardiography A report of the American College of CardiologyAmerican Heart Association Task Force on Assessment of Diagnostic and Therapeutic Cardiovascular Procedures (Committee on Electrocardiography) Circulation 85(3)1221-1228
Soteriades ES Kales SN Liarokapis D Christiani DC [2003] Prospective surveillance of hypertension in firefighters J Clin Hypertens 5315-320
47
ATTACHMENT F
48
1
Current 1582 (2007) language in reference to pregnancy 43 (4) Report to the fire department physician any medical condition that could interfere with the ability of the individual to safely perform essential job tasks such as illness or injury use of prescription or nonprescription drugs and pregnancy 6112 Category B medical conditions shall include the following (1) Pregnancy for its duration A7792 (e) If HIV prophylaxis is to be given the following tests should be done i CBC ii Glucose renal and hepatic chemical function iii Pregnancy test for females B121 Pregnancy and Reproduction Federal regulations as well as many court decisions including the US Supreme Courtrsquos decision in International Union et al v Johnson Controls Inc [499 US 187 111 S Ct 1196 (1991)] have interpreted the requirements of Title VII with respect to pregnancy and reproduction The AHJ should seek the advice of counsel in resolving specific questions concerning these requirements as well as other requirements that can be imposed by state or local laws C211 (4) Review health status with the individual being evaluated Contraindications for evaluations shall be reviewed addressing any changes in the individualrsquos health status since their last medical evaluation that would warrant deferring the evaluation including (g) Pregnancy Recommendations to language enhancement
A female employee who is assigned to regular fire line duty shall report a pregnancy immediately to their respective Supervisor and the fire department physician The employee will then be given the option of a non-hazardous alternative duty position for the duration of her pregnancy (can we say this or is it even appropriate) Any pregnant employee wishing to remain on regular line duty shall be informed of the possible risks and consequences to herself and her fetus that are associated with continued line fire fighting duty Among those risk factors are exposure to teratogens known to have negative effects on the developing fetus such as smoke diesel fumes hazardous chemicals and extreme heat
49
Page 2
appendix It is recommended that the pregnant employee complete a release of liability form signed by herself and her health care provider utilizing NFPArsquos 13 critical tasks as a reference This will inform the health care provider of specific job-related tasks that will need to be performed in order to continue regular line duty These tasks are basic physical standards that any entry level firefighter would have to be able to complete competently The employeersquos health condition will be kept confidential by the department in accordance with HIPAA standards Employees are allowed to remain on active regular duty until they are no longer able to perform their duties in a reasonable manner andor their protective gear no longer fits correctly It is the responsibility of the health care provider to evaluate the pregnant employee If at any time the health care provider feels the pregnant employee can no longer perform the job related tasks this should be reported to the employer by the employee immediately
50
ATTACHMENT G
51
From GLENN BENARICKTo Sawyer SteveSubject RE RE 7743Date Monday August 30 2010 21633 PM
Yes thats my understanding
Glenn P Benarick 211 Winged Elm CircleAiken SC 29803803-644-7093gbenarprodigynet
--- On Mon 83010 Sawyer Steve ltssawyerNFPAorggt wrote
From Sawyer Steve ltssawyerNFPAorggtSubject RE RE 7743To GLENN BENARICK ltgbenarprodigynetgtDate Monday August 30 2010 212 PM
So it should be ldquoorrdquo instead of ldquoandrdquo for now
Steven F Sawyer
Senior Fire Service Specialist
Executive Secretary IFMAFire Service Section
NFPA
1 Batterymarch Park
Quincy MA 02169
6179847423
Fax 6179847056
ssawyernfpaorg
From GLENN BENARICK [mailtogbenarprodigynet] Sent Monday August 30 2010 1202 PMTo Sawyer SteveSubject Fw RE 7743
52
Steve a couple of our docs agree with April Boyer
Glenn P Benarick 211 Winged Elm Circle
Aiken SC 29803
803-644-7093
gbenarprodigynet
--- On Mon 83010 David Prezant ltprezandfdnynycgovgt wrote
From David Prezant ltprezandfdnynycgovgtSubject RE 7743To Thomas R (CDCNIOSHDSHEFS) Hales lttrh1cdcgovgt GLENNBENARICK ltgbenarprodigynetgtCc Sandy Bogucki ltsandyboguckiyaleedugtDate Monday August 30 2010 1004 AM
agree
we should change this to NHANES III rather than Knudson we should alsomodify this to allow not only for predicted cutoffs but all for use of thelower limit of normal cutoff This is important to prevent false-classificationof spirometry as abnormal in older groups and in taller grps The latter ofparticular import to firefighter occupational health surveillance
thanks
David Prezant MDChief Medical Officer Office of Medical AffairsCo-Director WTC Medical Monitoring amp Treatment ProgramsNew York City Fire Department9 Metrotech Center - Rm 4W-1Brooklyn NY 11201Phone 718-999-2696Fax 718-999-0665
Life is full of twists and turns
53
This email may contain confidential information If you are the unintendedrecipient of this email please send it back and delete from your directory
gtgtgt Hales Thomas R (CDCNIOSHDSHEFS) lttrh1cdcgovgt 8302010955 AM gtgtgt
Glen
This seems like a very reasonable comment and illustrates the importance of having clinicians providefeedback on the std Im not familiar with the software program of the various spirometers (NHANES IIIvs KnudsonATS vs both) Given the large role both Dave Prezant and Sandy Bogucki had for thepulmonary section let me forward to them for clarification
Tom
From GLENN BENARICK [mailtogbenarprodigynet] Sent Sunday August 29 2010 456 PMTo Hales Thomas R (CDCNIOSHDSHEFS)Subject FW 7743
Tom is April Boyer correct
Glenn P Benarick 211 Winged Elm Circle
Aiken SC 29803
803-644-7093
gbenarprodigynet
--- On Thu 82610 Sawyer Steve ltssawyerNFPAorggt wrote
From Sawyer Steve ltssawyerNFPAorggtSubject FW 7743To GLENN BENARICK ltgbenarprodigynetgtDate Thursday August 26 2010 925 PM
FYI Do you have any answer She is write
Steven
54
Steven F Sawyer
Senior Fire Service Specialist
Executive Secretary IFMAFire Service Section
NFPA
1 Batterymarch Park
Quincy MA 02169
6179847423
Fax 6179847056
ssawyernfpaorg
From April Boyer [mailtoaboyerbicclinicorg] Sent Thursday August 26 2010 232 PMTo Sawyer SteveCc RobinMWebbmilstateorusSubject 7743
Steven
The spirometry tests cannot be corrected according to both references as the NFPA states because thereferences are contradictory The first part of 7743 states to follow the ATS guidelines and use theKnudsen (we at Basin Immediate Care use the Nhanes III) The second part states to follow the ACOEMguidelines and use the Nhanes III in the occupational setting if available with your unit (which is availableon ours) 7743 does not use the word OR regarding both requirements it uses the word AND whenreferring to the first and second parts thence making 7743 contradictory I realize the NFPA 1582 hasnot been updated since 2007 unless I have just not received an updated version
Our question to you is which part of 7743 do you want us to follow the first or the second part Anyfacility that has an updated computerized spirometry system (as we do) will not be able to follow bothrequired parts for obvious reasons We can either follow the first part of 7743 and use an oldercorrected version of the Knudson by going into our system and changing out of the Nhanes III conversionOR we can follow the second part of 7743 and use the newer corrected version of Nhanes III which ourunit offers too
If you have any questions you may contact me at anytime and I also have many references in regards toboth parts of 7743 if you would like to see them
55
Thank you~
April
Confidentiality NoticeThis message may contain information that isconfidential or privileged
If you are not the intended recipientPlease advise the sender immediately and delete this message
56
ATTACHMENT H
57
NFPA 1582 771(7) Proposed revisions
Why
Preliminary results of two prospective randomized trials on the PSA test were published in 2009 These studies resulted in medical organizations that previously providing guidance to modify their recommendations
Current language
771 Blood Tests Blood tests shall be performed annually and shall include the following
(7) Prostate specific antigen (PSA) after age 40 for positive family history if African American or if otherwise clinically indicated after age 50 for all other male member
Suggested Revision
771 Blood Tests Blood tests shall be performed annually and shall include the following
(7) Prostate specific antigen (PSA) after age 40 for positive family history if African American or if otherwise clinically indicated after age 50 for all other male member
772 Prostate-Specific Antigen (PSA) test At age 50 fire fighters shall have an opportunity to make an informed decision with either the Fire Department physician or their health care provider concerning the PSA test For fire fighters at increased risk of prostate cancer (African-Americans or those with a first degree relative diagnosed with prostate cancer before age 65) shall have the opportunity for this informed decision at age 40
A772 The PSA as a screening test for prostate cancer in asymptomatic men is controversial controversial for two reasons First there is no consensus that PSA screening actually saves lives For example the PSA test may detect small cancers that would never become life threatening Second it is unclear that the benefits of PSA screening outweigh the risks of follow-up diagnostic tests and cancer treatments For example the prostate biopsy used to diagnose prostate cancer may cause bleeding and infection And prostate cancer treatments such as surgery and radiation therapy may cause incontinence (inability to control urine flow) erectile dysfunction (erections inadequate for intercourse) and other complications For these reasons it is important that the benefits and risks of prostate diagnostic procedures and treatment be taken into account when considering the PSA screening test These considerations can be taken account during discussions with the fire department physician or onersquos health care provider
D211 Cancer Screening
Smith R A C J Mettlin K J Davis and H Eyre 2000 ldquoAmerican Cancer Society guidelines for the early detection of cancerrdquo CA J Clin 50(1)34ndash49
Added references
58
Carroll P Albertsen PC Greene K et al [2010] Prostate-specific antigen best practice statement 2009 update Am Urological Assoc Available at httpwwwauanetorgcontentguidelines-and-quality-careclinical-guidelinesmain-reportspsa09pdf Date accessed September 2010
Ferrini R Woolf SH [2009] Screening for prostate cancer in American men American College of Preventive Medicine Practice Policy Statement Available at httpwwwacpmorgprostatehtm Date accessed September 2010
National Cancer Institute [2009] Prostate-specific antigen test National Cancer Institute Fact Sheet Available at httpwwwcancergovcancertopicsfactsheetDetectionPSA Date accessed September 2010
Wolf AMD Wender RC Etzioni RB et al [2010] American Cancer Society guideline for the early detection of prostate cancer Update 2010 Available at httpcaonlineamcancersocorgcgicontentfullcaac20066v1 Date accessed September 2010
59
437 ndash APPENDIX A COMMENTARY
Diabetes Definitions and Treatments
Type 1 diabetes was previously called insulin-dependent diabetes mellitus (IDDM) or juvenile-onset diabetes Type 1
diabetes develops when the bodys immune system destroys pancreatic beta cells the only cells in the body that
make the hormone insulin that regulates blood glucose This form of diabetes usually strikes children and young
adults although disease onset can occur at any age Type 1 diabetes may account for 5 to 10 of all diagnosed
cases of diabetes In order to survive people with type 1 diabetes must have insulin delivered by injections or a
pump
Type 2 diabetes was previously called non-insulin-dependent diabetes mellitus (NIDDM) or adult-onset diabetes
Type 2 diabetes may account for 90to 95 of all diagnosed cases of diabetes It usually begins as insulin resis-
tance a disorder in which the cells do not use insulin properly As the need for insulin rises the pancreas gradually
loses its ability to produce sufficient insulin Type 2 diabetes is associated with older age obesity family history of
diabetes prior history of gestational diabetes impaired glucose tolerance physical inactivity and raceethnicity
Type 2 diabetes is increasingly being diagnosed in children and adolescents Many people with type 2 diabetes can
control their blood glucose by following a careful diet and exercise program losing excess weight and taking oral
medication According to 2007 statistics from the US Centers for Disease Control and Prevention (CDC) among
adults with diagnosed diabetes about 13 take both insulin and oral medications 14 take insulin only 57 take
oral medications only and 16 do not take either insulin or oral medications14
Risk of hypoglycemia remains the major concern in regard to those with diabetes being or becoming law enforce-
ment officers (LEOs) This risk occurs primarily in those taking insulin particularly those with type 1 diabetes
although it may also occur in those with type 2 diabetes who take insulin andor certain oral anti-diabetic medica-
tions Patients treated with metformin alpha-glucosidase inhibitors or thiazolidinediones alone or in combination
with each other are at little or no risk of significant hypoglycemia
Law enforcement entails a unique set of conditions that need to be considered in regard to those with diabetes and
the risks of impairment from either hypo or hyperglycemia These may include (depending upon the duties of the
particular LEO position)
unpredictable meal schedules
brief periods of maximal physical exertion
prolonged driving with responsibility for others in the vehicle
high-speed pursuit driving
surveillance requiring sustained attention for prolonged periods of time
rapid decision making regarding the use of force including deadly force
rapid analysis of complex visual stimuli to differentiate weapons from other objects and
control of onersquos emotions under stress
ACOEM Guidance for the Medical Evaluation of Law Enforcement Officers 5
43 ndash DIABETES MELLITUS
Drug Class Brand Names Generic Names Hypoglycemia Risk
Compared to
Insulin
Sulfonylurea Amaryl Glucotrol
Micronase
Glimepiride Glipizide
Glyburide
05
Short acting secretagogues Prandin Starlix Repaglinide Nateglinide 02
Urine microalbumincreatinine ratio _________________
III Treating Physician Statement
The above named individual meets all of the criteria provided on this form
Yes No ndash not recommended for position
No but IS recommended for position (letter of explanation attached)
It is my opinion that the above named individual is well-educated and well-motivated in diabetes self-management and has
achieved a level of diabetes management to be capable of safe and effective job performance as a law enforcement officer
I have reached this opinion after careful review of the above criteria
___________________________________________________________ ___________________________Signature of Physician Date
______________________________________________________________ ___________________________Printed or Typed Name of Physician Telephone Number
10 ACOEM Guidance for the Medical Evaluation of Law Enforcement Officers
43 ndash DIABETES MELLITUS
29
439 ndash REFERENCES
1 American Diabetes Association Diagnosis and classification of diabetes mellitus Diabetes Care 200427 Suppl
1S5-S10 See httpcarediabetesjournalsorgcgicontentfull27suppl_1s5
2 American Diabetes Association Continuous subcutaneous insulin infusion Diabetes Care 200427 Suppl 1S110
See httpcarediabetesjournalsorgcgicontentfull27suppl_1s110
3 Mensing C Boucher J Cypress M et al National standards for diabetes self-management education Diabetes
Care 200528 Suppl 1S72-9 See httpcarediabetesjournalsorgcgicontentfull28suppl_1s72
4 Goldstein DE Little RR Lorenz RA Malone JI Nathan DM Peterson CM American Diabetes Association Tests
of glycemia in diabetes Diabetes Care 200427 Suppl 1S91-3
See httpcarediabetesjournalsorgcgicontentfull27suppl_1s91
5 The Diabetes Control and Complications Trial Research Group Hypoglycemia in the Diabetes Control and
Complications Trial Diabetes 199746(2)271-86 See wwwncbinlmnihgovpubmed9000705 for abstract
6 American Diabetes Association Hypoglycemia and employmentlicensure Diabetes Care 200528 Suppl 1S61
See httpcarediabetesjournalsorgcgicontentfull28suppl_1s61
7 Viswanath K McGavin DD Diabetic Retinopathy Clinical Findings and Management J Comm Eye Health
200316(46)21-4 See wwwcehjournalorg0953-683316jceh_16_46_021html
8 Michigan Diabetes Research and Training Center University of Michigan Health System How to use the Michigan
Neuropathy Screening Instrument See wwwmedumichedumdrtcprofsdocumentssviMNSI_howtopdf
9 Bradley JG Davis KA Orthostatic hypotension Am Fam Physician 200368(12)2393-8
See wwwaafporgafp200312152393html
10 Gibbons RJ Balady GJ Bricker JT et al ACCAHA 2002 guideline update for exercise testing a report of the
American College of CardiologyAmerican Heart Association Task Force on Practice Guidelines (Committee on
Exercise Testing) J Am Coll Cardiol 200240(8)1531-40
See wwwaccorgqualityandscienceclinicalguidelinesexerciseexercise_cleanpdf
11 American Diabetes Association Standards of medical care in diabetes Diabetes Care 200528 Suppl 1S4-S36
Erratum in Diabetes Care 200528(4)990 See httpcarediabetesjournalsorgcgicontentfull28suppl_1s4
12 Molitch ME DeFronzo RA Franz MJ et al American Diabetes Association Nephropathy in diabetes Diabetes
Care 200427 Suppl 1S79-83 See httpcarediabetesjournalsorgcgicontentfull27suppl_1s79
13 Kitabchi AE Umpierrez GE Murphy MB et al American Diabetes Association Hyperglycemic crises in diabetes
Diabetes Care 200427 Suppl 1S94-102 See httpcarediabetesjournalsorgcgicontentfull27suppl_1s94
14 US Centers for Disease Control and Prevention National Diabetes Fact Sheet 2007
See wwwcdcgovdiabetespubspdfndfs_2007pdf
ACOEM Guidance for the Medical Evaluation of Law Enforcement Officers 11
43 ndash DIABETES MELLITUS
30
ATTACHMENT E
31
Typos A6921(2) 7th line down test should be plural 94201 Paragraph 2 target organ damage is used though end organ damage was defined earlier and in the appendix for that paragraph
A94201 Para A (1) d Id suggest deleting the phrases in brackets Im not sure either are predictably true or politically wise
a) tests for left ventricular hypertrophy Unfortunately use of the EKG to detect left ventricular hypertrophy is very insensitive (eg 5 sensitivity) The echocardiogram is the best test for diagnosing left ventricular hypertrophy but [it is relatively expensive and not readily available in small rural communities ] conducting echocardiograms on asymptomatic fire fighters with Stage 1 hypertension should be reserved only for those with long-standing hypertension
In addition
7761 A resting EKG shall be performed as part of the baseline medical evaluation and shall be obtained periodically thereafter
Changing from annually to periodically is noted has the language in the wellness-fitness initiative been changed as well Our previous decision was that we would support the W-F language since there was no compelling evidence to either support or refute it
Thanks
Sandy
32
NFPA 1582‐ HTN Draft 1
Reason for Revision
1) New classification of BP by the Joint National Commission [Chobanian et al 2002]
2) A high prevalence of FF have either HTN (~20) and Pre‐HTN (~20) [Soteriades et al 2003]
3) Among FF studies have shown a strong association between HTN and a number of adverse
cardiovascular events [Kales et al 2009]
4) A large percentage of on‐duty FF fatalities were found to have left ventricular hypertrophy a
complication of HTN at autopsy
Language in 2007 Edition with draft revisions in Red (Track changes)
611 The medical evaluation of a candidate shall include a medical history examination and any laboratory tests required to detect physical or medical condition(s) that could adversely affect hisher ability to safely perform the essential job tasks outlined in 511 A611 The medical history should include the candidates known health problems such as major illnesses surgeries medication use and allergies Symptom review is also important for detecting early signs of illness A medical history should also include a personal health history a family health history a health habit history an immunization history and a reproductive history
An occupational history should also be obtained to collect information about the persons past occupational and environmental exposures
(a) BP should be measured according to the Joint National Commission (JNC) -7 recommendations BP should be measured with a properly calibrated and validated instrument Patients should be seated quietly for at least 5 minutes in a chair with feet on the floor and arm supported at heart level An appropriate-sized cuff (cuff bladder encircling at least 80 of the arm) should be used to ensure accuracy At least 2 measurements should be made Systolic BP is the point at which the first of 2 or more sounds is heard (phase 1) and diastolic BP is the point before the disappearance of sounds (phase 5) [Chobanian et al 2003]
(2) Head eyes ears nose and throat (HEENT)
Formatted Font (Default) Times New RomanFont color Black
33
692 Vascular System 6921 Category A medical conditions shall include the following
(1) Uncontrolled or poorly controlled hypertension
(2) Hypertension with evidence of end organ damage
or not controlled by approved medications
A6921(1) Uncontrolled or poorly controlled hHypertension increases the risk of a sudden cardiac event This sudden cardiac event would cause sudden incapacitation which that is uncontrolled poorly controlled or requires medication likely to interferes with the safe performance of essential job tasks Uncontrolled or poorly controlled hypertension can be defined as the presence of end organ damage (see below) or stage 2 hypertension (BP systolic gt160 mmHg or BP diastolic gt100 mmHg) is an illness that can lead to functional impairment and potential for sudden incapacitation Individuals with pre- stage 1 or stage 2 hypertension should be referred to their primary care physician for evaluation lifestyle modification and treatment [QUESTION FOR GROUP _- WHAT ABOUT HAVING CANDIDATE RETURN IN ONE MONTH UNDER TREATMENT WITH NORMAL BP]
A6921(2)
Chronic hypertension can damage the eye (retinopathy) the kidneys (nephropathy) the vascular system (stroke transient ischemic attack or peripheral artery disease) or the heart (left ventricular hypertrophy and heart failure) These hypertension complications are known as end organ damage The cardiac and vascular complications are associated with an increased risk of sudden incapacitation and sudden cardiac death (Koren et al 1991) Unfortunately the cardiac complications are frequently asymptomatic and valid screening tests are not fast and are not inexpensive Therefore determining who to screen for cardiac complications (such as echocardiogram for LVH or a measurement of left ventricular ejection fraction for heart failure) should be based on the severity and the duration of HTN
76 Physical Examination The annual physical examination shall include each of the following components
(a) BP shall be measured according to the Joint National Commission (JNC)-7 recommendations
A76(1)(a) BP should be measured with a properly calibrated and validated instrument Patients should be seated quietly for at least 5 minutes in a chair with feet on the floor and arm supported at heart level An appropriate-sized cuff (cuff bladder encircling at least 80 of the arm) should be used to ensure accuracy At least 2 measurements should be made Systolic BP is the point at which the first of 2 or more sounds is heard (phase 1) and diastolic BP is the point before the disappearance of sounds (phase 5) [Chobanian et al 2003]
(2) Head eyes ears nose and throat (HEENT)
34
9420 Uncontrolled Hypertension 94201 Physician Evaluation Severe uncontrolled hypertension [defined as systolic pressure greater than 180 mm Hg diastolic pressure greater than 100 mm Hg or mean systolic blood
pressure ( systolic + diastolic) greater than 120 mm Hg] or malignant hypertension (defined as hypertension with the presence of target organ damage) compromises the members ability to safely perform essential job tasks 1 5 7 9 and 13 and the physician shall report the applicable job limitations to the fire department
Members with Pre-hypertention (systolic 120-139 mmHg or diastolic 80-89 mmHg) Stage 1 hypertension (systolic 140-159 mmHg or diastolic 90-99 mmHg) or Stage 2 hypertension (systolic ge160 mmHg or diastolic ge100 mmHg) should be referred to their primary care physician for evaluation lifestyle modification and treatment
(1) Members with Stage I hypertension should be followed-up not only by their primary care physician but also by the FD physician every 3 to 6 months to ensure their blood pressure is under control and to determine whether screening tests for asymptomatic end organ damage are appropriate
(2) Members with Stage 2 hypertension or with end organ damage (retinopathy nephropathy vascular or cardiac complications) compromises the members ability to safely perform essential job tasks 1 5 7 9 and 130 and the physician shall report the applicable job limitations to the fire department
A94201 Severe uncontrolled hypertension is a significant risk factor for the development of coronary artery disease congestive heart failure and stroke Blood pressure increases as a normal response to exercise This response is further exaggerated by the emotional and physical stress of performing these critical tasks while operating in personal protective clothing at extremes of temperature This normal elevation of blood pressure under these response conditions can lead to life-threatening hypertensive emergencies if a members daily blood pressure is already elevated to high levels In addition hypertension is a progressive illness that when uncontrolled ultimately and inevitably leads to target organ damage Target organs that are sensitive to the effects of elevated blood pressure are the central nervous system vision heart major blood vessels and kidneys
Chronic hypertension can damage the eye (retinopathy) the kidneys (nephropathy) the vascular system (stroke transient ischemic attack or peripheral artery disease) or the heart (left ventricular hypertrophy and heart failure) These hypertension complications are known as end organ damage The cardiac and vascular complications are associated with an increased risk of sudden incapacitation and sudden cardiac death (Koren et al 1991) Fortunately with proper evaluation life style modification and treatment these complications can be avoided Life style modification includes weight reduction DASH eating plan reduction in dietary sodium an increase in aerobic physical activity and moderation in alcohol consumption [Chobanian 2003]
Formatted Font (Default) Times New Roman12 pt Font color Black
Formatted Font (Default) Times New Roman12 pt Font color Black
35
A94201 (1) Members with Stage I hypertension whose BP returns to either pre-hypertenion or normal with lifestyle modification andor treatment can return to an annual medical evaluation For members with long-standing Stage I hypertension whose BP has not been reduced additional evaluation for possible end organ damage should be considered This evaluation could include any or all of the following
a) a compete patient history for symptoms of heart failure (eg shortness of breath upon exertion) or transient ischemic attacks (TIAs)
b) dilated eye examination for retinopathy
c) blood creatinine measurement for nephropathy
d) tests for left ventricular hypertrophy Unfortunately use of the resting EKG to detect left ventricular hypertrophy is very insensitive (eg 5 sensitivity) The echocardiogram is the best test for diagnosing left ventricular hypertrophy
A 94201 (2) Due to the high risk of a sudden cardiovascular event members with Stage 2 hypertension should be restricted until their BP can be brought under control Once the BP is brought under control they should be followed in the same manner as a member with Stage I hypertension
Formatted Font (Default) Times New Roman12 pt
36
D22 Cardiology Gibbons R J GJ Balady J W Beasley et al 1997 ACCAHA guidelines for exercise testing a report of American College of CardiologyAmerican Heart Association Task Force on Practice Guidelines (Committee on Exercise Testing) J Am Coll Cardiol 30260ndash311
Gibbons RJ Balady GJ Bricker JT Chaitman BR Fletcher GF Froelicher VF Mark DB McCallister BD Mooss AN OrsquoReilly MG Winters WL Jr [2002] ACCAHA 2002 guideline update for exercise testing summary article a report of the ACCAHA Task Force on Practice Guidelines (Committee to Update the 1997 Exercise Testing guidelines) J Am Coll Cardiol 401531ndash 40
Chobanian AV Bakris GL Black HR Cushman WC Green LA Izzo JL Jr Jones DW Materson BJ Oparil S Wright JT Jr Roccella EJ the National High Blood Pressure Education Program Coordinating Committee [2003] The seventh report of the Joint National Committee [JNC-7] on Prevention Detection Evaluation and Treatment of High Blood Pressure JAMA 2892560ndash2571
Soteriades ES Kales SN Liarokapis D Christiani DC [2003] Prospective surveillance of hypertension in firefighters J Clin Hypertens 5315-320
Kales SN Tsismenakis AJ Zhang C Soteriades ES [2009] Blood pressure in fire fighters police officers and other emergency responders Am J Hypertens 2211-20
37
NFPA 1582‐ HTN Draft 1
Reason for Revision
1) New classification of BP by the Joint National Commission [Chobanian et al 2002]
2) A high prevalence of FF have either HTN (~20) and Pre‐HTN (~20) [Soteriades et al 2003]
3) Among FF studies have shown a strong association between HTN and a number of adverse
cardiovascular events [Kales et al 2009]
4) A large percentage of on‐duty FF fatalities were found to have left ventricular hypertrophy a
complication of HTN at autopsy
Language in 2007 Edition with draft revisions in Red (Track changes)
611 The medical evaluation of a candidate shall include a medical history examination and any laboratory tests required to detect physical or medical condition(s) that could adversely affect hisher ability to safely perform the essential job tasks outlined in 511 A611 The medical history should include the candidates known health problems such as major illnesses surgeries medication use and allergies Symptom review is also important for detecting early signs of illness A medical history should also include a personal health history a family health history a health habit history an immunization history and a reproductive history
An occupational history should also be obtained to collect information about the persons past occupational and environmental exposures
(a) BP should be measured according to the Joint National Commission (JNC) -7 recommendations BP should be measured with a properly calibrated and validated instrument Patients should be seated quietly for at least 5 minutes in a chair with feet on the floor and arm supported at heart level An appropriate-sized cuff (cuff bladder encircling at least 80 of the arm) should be used to ensure accuracy At least 2 measurements should be made Systolic BP is the point at which the first of 2 or more sounds is heard (phase 1) and diastolic BP is the point before the disappearance of sounds (phase 5) [Chobanian et al 2003]
(2) Head eyes ears nose and throat
38
692 Vascular System 6921 Category A medical conditions shall include the following
(1) Uncontrolled or poorly controlled hypertension
(2) Hypertension with evidence of end organ damage
A6921(1) Uncontrolled or poorly controlled hypertension increases the risk of a sudden cardiac event This sudden cardiac event would cause sudden incapacitation which interferes with the safe performance of essential job tasks Uncontrolled or poorly controlled hypertension can be defined as the presence of end organ damage (see below) or stage 2 hypertension (BP systolic gt160 mmHg or BP diastolic gt100 mmHg) Individuals with pre- stage 1 or stage 2 hypertension should be referred to their primary care physician for evaluation lifestyle modification and treatment [QUESTION FOR GROUP _- WHAT ABOUT HAVING CANDIDATE RETURN IN ONE MONTH UNDER TREATMENT WITH NORMAL BP]
A6921(2)Chronic hypertension can damage the eye (retinopathy) the kidneys (nephropathy) the vascular system (stroke transient ischemic attack or peripheral artery disease) or the heart (left ventricular hypertrophy and heart failure) These hypertension complications are known as end organ damage The cardiac and vascular complications are associated with an increased risk of sudden incapacitation and sudden cardiac death (Koren et al 1991) Unfortunately the cardiac complications are frequently asymptomatic and valid screening tests are not fast and are not inexpensive Therefore determining who to screen for cardiac complications (such as echocardiogram for LVH or a measurement of left ventricular ejection fraction for heart failure) should be based on the severity and the duration of HTN
76 Physical Examination The annual physical examination shall include each of the following components
(a) BP shall be measured according to the Joint National Commission (JNC)-7 recommendations
A76(1)(a) BP should be measured with a properly calibrated and validated instrument Patients should be seated quietly for at least 5 minutes in a chair with feet on the floor and arm supported at heart level An appropriate-sized cuff (cuff bladder encircling at least 80 of the arm) should be used to ensure accuracy At least 2 measurements should be made Systolic BP is the point at which the first of 2 or more sounds is heard (phase 1) and diastolic BP is the point before the disappearance of sounds (phase 5) [Chobanian et al 2003]
(2) Head eyes ears nose and throat9420 Hypertension 94201 Physician Evaluation Members with Pre-hypertention (systolic 120-139 mmHg or diastolic 80-89 mmHg) Stage 1 hypertension (systolic 140-159 mmHg or diastolic 90-99 mmHg) or Stage 2 hypertension (systolic ge160 mmHg or diastolic ge100 mmHg) should be referred to their primary care physician for evaluation lifestyle modification and treatment
39
(1) Members with Stage I hypertension should be followed-up not only by their primary care physician but also by the FD physician every 3 to 6 months to ensure their blood pressure is under control and to determine whether screening tests for asymptomatic end organ damage are appropriate
(2) Members with Stage 2 hypertension or with end organ damage (retinopathy nephropathy vascular or cardiac complications) compromises the members ability to safely perform essential job tasks 1 5 7 9 and 130 and the physician shall report the applicable job limitations to the fire department
A94201 Chronic hypertension can damage the eye (retinopathy) the kidneys (nephropathy) the vascular system (stroke transient ischemic attack or peripheral artery disease) or the heart (left ventricular hypertrophy and heart failure) These hypertension complications are known as end organ damage The cardiac and vascular complications are associated with an increased risk of sudden incapacitation and sudden cardiac death (Koren et al 1991) Fortunately with proper evaluation life style modification and treatment these complications can be avoided Life style modification includes weight reduction DASH eating plan reduction in dietary sodium an increase in aerobic physical activity and moderation in alcohol consumption [Chobanian 2003]
A94201 (1) Members with Stage I hypertension whose BP returns to either pre-hypertenion or normal with lifestyle modification andor treatment can return to an annual medical evaluation For members with long-standing Stage I hypertension whose BP has not been reduced additional evaluation for possible end organ damage should be considered This evaluation could include any or all of the following
a) a compete patient history for symptoms of heart failure (eg shortness of breath upon exertion) or transient ischemic attacks (TIAs)
b) dilated eye examination for retinopathy
c) blood creatinine measurement for nephropathy
d) tests for left ventricular hypertrophy Unfortunately use of the resting EKG to detect left ventricular hypertrophy is very insensitive (eg 5 sensitivity) The echocardiogram is the best test for diagnosing left ventricular hypertrophy
A 94201 (2) Due to the high risk of a sudden cardiovascular event members with Stage 2 hypertension should be restricted until their BP can be brought under control Once the BP is brought under control they should be followed in the same manner as a member with Stage I hypertension
D22 Cardiology
40
Hypertension
Gibbons RJ Balady GJ Bricker JT Chaitman BR Fletcher GF Froelicher VF Mark DB McCallister BD Mooss AN OrsquoReilly MG Winters WL Jr [2002] ACCAHA 2002 guideline update for exercise testing summary article a report of the ACCAHA Task Force on Practice Guidelines (Committee to Update the 1997 Exercise Testing guidelines) J Am Coll Cardiol 401531ndash 40
Chobanian AV Bakris GL Black HR Cushman WC Green LA Izzo JL Jr Jones DW Materson BJ Oparil S Wright JT Jr Roccella EJ the National High Blood Pressure Education Program Coordinating Committee [2003] The seventh report of the Joint National Committee [JNC-7] on Prevention Detection Evaluation and Treatment of High Blood Pressure JAMA 2892560ndash2571
Soteriades ES Kales SN Liarokapis D Christiani DC [2003] Prospective surveillance of hypertension in firefighters J Clin Hypertens 5315-320
Kales SN Tsismenakis AJ Zhang C Soteriades ES [2009] Blood pressure in fire fighters police officers and other emergency responders Am J Hypertens 2211-20
41
NFPA 1582‐ Draft Revisions for CVDHTN
EKG and stress tests
Reason for Revision
1) Change requirement for annual resting EKG to periodically to be more consistent with ACCAHA
recommendation (Schlant et al 1992)
2) Add language to clarify what constitutes a positive ST
3) Make criteria for conducting diagnostic ST in asymptomatic patients consistent with the
ACCAHA
Language in 2007 Edition with draft revisions in Red (Track changes)
776 Electrocardiograms (EKG)) and Stress Tests 7761 A resting EKG shall be performed as part of the baseline medical evaluation and shall be obtained periodically (every 1 to 5 years) annually thereafter
A7761 A baseline resting EKGs shall be conducted Follow-up resting EKGs should be conducted as clinically indicated but at a minimum of every 1 to 5 years The frequency of these follow-up resting EKGs should increase as a members age increases or with increasing number andor severity of coronary heart disease risk factors Members above the age of 40 should have annual resting EKGs (Schlant et al 1992)
7762 The fire department physician or other qualified medical evaluator shall compare EKGs obtained during yearly evaluations with baseline and subsequent EKGs
7763 Stress testing EKG with or without echocardiography or radionuclide scanning shall be performed as clinically indicated by history or symptoms
A7761 Baseline electrocardiography should be conducted (Periodic resting electrocardiograms have not been shown to be useful but can be reasonable as a members agefactors increase)
A7763 No firm guidelines for stress testingelectrocardiography in asymptomatic individuals have been developed Stress testingelectrocardiography as a screening tool is used as part of an evaluation of aerobic capacity during the annual occupational fitness evaluation Submaximal stress testingelectrocardiography testing to 85 percent is commonly used as part of this screening
Submaximal stress electrocardiography testing should not be used for diagnostic purposes Cardiology evaluation with maximal stress testingelectrocardiography together with imaging techniques (eg echocardiography technetium Tc99m sestamibi study andor coronary angiography) is necessary for diagnosticprognostic purposes for the following
42
(1) Fire fighters with positive or questionably positive changes on screening submaximal stress tests
(2) Fire fighters with new onset chest pain or other symptoms suggestive of coronary artery disease (CAD)
(3) Fire fighters with diabetes mellitus who
(a) are gt35 years old or
(b) have type I diabetes for more than 15 years or
(c) have type II diabetes for more than 10 years or
(d) have any other CHD risk factor (see below) or
(e) have the presence of microvascular disease (proliferative retinopathy)
(4) Fire fighters over the age of 45 (for men) and 55 (for women) with onetwo or more risk factors for CAD Risk factors for CAD include hypercholesterolemia (total cholesterol greater than 240 mgdL) hypertension (systolic gt140 mmHg or diastolic gt90 mmHg) smoking or family history of premature CAD (heart attack or sudden cardiac death in a first degree relative less than 60 years of age)
as defined below if stress electrocardiography with imaging is negative then repeat as clinically indicated or at least every 5 years
(5) Fire fighters with a Framingham Risk Score gt10 Risk calculator is available at [httphp2010nhlbihinnetatpiiicalculatorasp]
(6) Fire fighters identified in 9431
Negative stress tests should be repeated as clinically indicated or at least every 2 to 5 years
Interpreting stress tests as ldquopositiverdquo or ldquonegativerdquo is beyond the scope of this document However factors that should be taken into consideration should include the individualrsquos exercise capacity symptoms blood pressure response heart rate response EKG changes and the presence of arrhythmias (Gibbon et al 2002)
Risk factors for CAD include hypercholesterolemia (total cholesterol greater than 240 mgdL) hypertension (systolic greater than 140 andor diastolic greater than 90) smoking diabetes mellitus or family history of premature CAD (heart attack or sudden cardiac death in a first degree relative less than 60 years of age)
There are other non-invasive tests to screen for coronary artery disease One of the most promising appears to be coronary artery calcium (CAD) scoring by computed tomography In 2007 an expert committee published an update to their original guidance document The committeersquos consensus was that ldquoit may be reasonable to consider use of CAC measurement in such patients [between 10 and 20 10-year risk of estimated coronary event]helliprdquo The committee did not recommend CAC measurement in low risk patients [lt10 10-year risk of estimated coronary event] or in high risk patients [gt20 10-year risk of estimate coronary event] (Greenland et al 2007]
43
D22 Cardiology
Chobanian AV Bakris GL Black HR Cushman WC Green LA Izzo JL Jr Jones DW Materson BJ Oparil S Wright JT Jr Roccella EJ the National High Blood Pressure Education Program Coordinating Committee [2003] The seventh report of the Joint National Committee [JNC-7] on Prevention Detection Evaluation and Treatment of High Blood Pressure JAMA 2892560ndash2571
Gibbons RJ Balady GJ Bricker JT Chaitman BR Fletcher GF Froelicher VF Mark DB McCallister BD Mooss AN OrsquoReilly MG Winters WL Jr [2002] ACCAHA 2002 guideline update for exercise testing summary article a report of the ACCAHA Task Force on Practice Guidelines (Committee to Update the 1997 Exercise Testing guidelines) J Am Coll Cardiol 401531ndash 1540
Greenland et al [2007] ACCFAHA 2007 Clinical Expert Consensus Document on Coronary Artery Calcium Scoring By Computed Tomography in Global Cardiovascular Risk Assessment and in Evaluation of Patients With Chest Pain A Report of the American College of Cardiology Foundation Clinical Expert Consensus Task Force (ACCFAHA Writing Committee to Update the 2000 Expert Consensus Document on Electron Beam Computed Tomography) J Am Coll Cardiol 49378-402
Kales SN Tsismenakis AJ Zhang C Soteriades ES [2009] Blood pressure in fire fighters police officers and other emergency responders Am J Hypertens 2211-20
Schlant RC Adolph RJ DiMarco JP Dreifus LS Dunn MI Fisch C Garson A Jr Haywood LJ Levine HJ Murray JA Noble RJ Ronan JA Jr [1992] Guidelines for electrocardiography A report of the American College of CardiologyAmerican Heart Association Task Force on Assessment of Diagnostic and Therapeutic Cardiovascular Procedures (Committee on Electrocardiography) Circulation 85(3)1221-1228
Soteriades ES Kales SN Liarokapis D Christiani DC [2003] Prospective surveillance of hypertension in firefighters J Clin Hypertens 5315-320
Formatted Font Italic
Formatted Line spacing single
Formatted Font Italic
Formatted Font Italic
44
NFPA 1582‐ Draft Revisions for CVDHTN
EKG and stress tests
Reason for Revision
1) Change requirement for annual resting EKG to periodically to be more consistent with ACCAHA
recommendation (Schlant et al 1992)
2) Add language to clarify what constitutes a positive ST
3) Make criteria for conducting diagnostic ST in asymptomatic patients consistent with the
ACCAHA
Language in 2007 Edition with draft revisions in Red (Track changes)
776 Electrocardiograms (EKG) and Stress Tests 7761 A resting EKG shall be performed as part of the baseline medical evaluation and shall be obtained periodically (every 1 to 5 years) thereafter
A7761 A baseline resting EKGs shall be conducted Follow-up resting EKGs should be conducted as clinically indicated but at a minimum of every 1 to 5 years The frequency of these follow-up resting EKGs should increase as a members age increases or with increasing number andor severity of coronary heart disease risk factors Members above the age of 40 should have annual resting EKGs (Schlant et al 1992)
7762 The fire department physician or other qualified medical evaluator shall compare baseline and subsequent EKGs
7763 Stress testing with or without echocardiography or radionuclide scanning shall be performed as clinically indicated by history or symptoms
A7763 No firm guidelines for stress testing in asymptomatic individuals have been developed Stress testing as a screening tool is used as part of an evaluation of aerobic capacity during the annual occupational fitness evaluation Submaximal stress testing testing to 85 percent is commonly used as part of this screening
Submaximal stress testing should not be used for diagnostic purposes Cardiology evaluation with maximal stress testing together with imaging techniques (eg echocardiography technetium Tc99m sestamibi study) is necessary for diagnosticprognostic purposes for the following
(1) Fire fighters with positive or questionably positive changes on screening submaximal stress tests
(2) Fire fighters with new onset chest pain or other symptoms suggestive of coronary artery disease (CAD)
45
(3) Fire fighters with diabetes mellitus who
(a) are gt35 years old or
(b) have type I diabetes for more than 15 years or
(c) have type II diabetes for more than 10 years or
(d) have any other CHD risk factor (see below) or
(e) have the presence of microvascular disease (proliferative retinopathy)
(4) Fire fighters over the age of 45 (for men) and 55 (for women) with one or more risk factors for CAD Risk factors for CAD include hypercholesterolemia (total cholesterol greater than 240 mgdL) hypertension (systolic gt140 mmHg or diastolic gt90 mmHg) smoking or family history of premature CAD (heart attack or sudden cardiac death in a first degree relative less than 60 years of age)
(5) Fire fighters with a Framingham Risk Score gt10 Risk calculator is available at [httphp2010nhlbihinnetatpiiicalculatorasp]
(6) Fire fighters identified in 9431
Negative stress tests should be repeated as clinically indicated or at least every 2 to 5 years
Interpreting stress tests as ldquopositiverdquo or ldquonegativerdquo is beyond the scope of this document However factors that should be taken into consideration should include the individualrsquos exercise capacity symptoms blood pressure response heart rate response EKG changes and the presence of arrhythmias (Gibbon et al 2002)
There are other non-invasive tests to screen for coronary artery disease One of the most promising appears to be coronary artery calcium (CAD) scoring by computed tomography In 2007 an expert committee published an update to their original guidance document The committeersquos consensus was that ldquoit may be reasonable to consider use of CAC measurement in such patients [between 10 and 20 10-year risk of estimated coronary event]helliprdquo The committee did not recommend CAC measurement in low risk patients [lt10 10-year risk of estimated coronary event] or in high risk patients [gt20 10-year risk of estimate coronary event] (Greenland et al 2007]
D22 Cardiology
Resting EKG and Stress Tests
46
Chobanian AV Bakris GL Black HR Cushman WC Green LA Izzo JL Jr Jones DW Materson BJ Oparil S Wright JT Jr Roccella EJ the National High Blood Pressure Education Program Coordinating Committee [2003] The seventh report of the Joint National Committee [JNC-7] on Prevention Detection Evaluation and Treatment of High Blood Pressure JAMA 2892560ndash2571
Gibbons RJ Balady GJ Bricker JT Chaitman BR Fletcher GF Froelicher VF Mark DB McCallister BD Mooss AN OrsquoReilly MG Winters WL Jr [2002] ACCAHA 2002 guideline update for exercise testing summary article a report of the ACCAHA Task Force on Practice Guidelines (Committee to Update the 1997 Exercise Testing guidelines) J Am Coll Cardiol 401531ndash 1540
Greenland et al [2007] ACCFAHA 2007 Clinical Expert Consensus Document on Coronary Artery Calcium Scoring By Computed Tomography in Global Cardiovascular Risk Assessment and in Evaluation of Patients With Chest Pain A Report of the American College of Cardiology Foundation Clinical Expert Consensus Task Force (ACCFAHA Writing Committee to Update the 2000 Expert Consensus Document on Electron Beam Computed Tomography) J Am Coll Cardiol 49378-402
Kales SN Tsismenakis AJ Zhang C Soteriades ES [2009] Blood pressure in fire fighters police officers and other emergency responders Am J Hypertens 2211-20
Schlant RC Adolph RJ DiMarco JP Dreifus LS Dunn MI Fisch C Garson A Jr Haywood LJ Levine HJ Murray JA Noble RJ Ronan JA Jr [1992] Guidelines for electrocardiography A report of the American College of CardiologyAmerican Heart Association Task Force on Assessment of Diagnostic and Therapeutic Cardiovascular Procedures (Committee on Electrocardiography) Circulation 85(3)1221-1228
Soteriades ES Kales SN Liarokapis D Christiani DC [2003] Prospective surveillance of hypertension in firefighters J Clin Hypertens 5315-320
47
ATTACHMENT F
48
1
Current 1582 (2007) language in reference to pregnancy 43 (4) Report to the fire department physician any medical condition that could interfere with the ability of the individual to safely perform essential job tasks such as illness or injury use of prescription or nonprescription drugs and pregnancy 6112 Category B medical conditions shall include the following (1) Pregnancy for its duration A7792 (e) If HIV prophylaxis is to be given the following tests should be done i CBC ii Glucose renal and hepatic chemical function iii Pregnancy test for females B121 Pregnancy and Reproduction Federal regulations as well as many court decisions including the US Supreme Courtrsquos decision in International Union et al v Johnson Controls Inc [499 US 187 111 S Ct 1196 (1991)] have interpreted the requirements of Title VII with respect to pregnancy and reproduction The AHJ should seek the advice of counsel in resolving specific questions concerning these requirements as well as other requirements that can be imposed by state or local laws C211 (4) Review health status with the individual being evaluated Contraindications for evaluations shall be reviewed addressing any changes in the individualrsquos health status since their last medical evaluation that would warrant deferring the evaluation including (g) Pregnancy Recommendations to language enhancement
A female employee who is assigned to regular fire line duty shall report a pregnancy immediately to their respective Supervisor and the fire department physician The employee will then be given the option of a non-hazardous alternative duty position for the duration of her pregnancy (can we say this or is it even appropriate) Any pregnant employee wishing to remain on regular line duty shall be informed of the possible risks and consequences to herself and her fetus that are associated with continued line fire fighting duty Among those risk factors are exposure to teratogens known to have negative effects on the developing fetus such as smoke diesel fumes hazardous chemicals and extreme heat
49
Page 2
appendix It is recommended that the pregnant employee complete a release of liability form signed by herself and her health care provider utilizing NFPArsquos 13 critical tasks as a reference This will inform the health care provider of specific job-related tasks that will need to be performed in order to continue regular line duty These tasks are basic physical standards that any entry level firefighter would have to be able to complete competently The employeersquos health condition will be kept confidential by the department in accordance with HIPAA standards Employees are allowed to remain on active regular duty until they are no longer able to perform their duties in a reasonable manner andor their protective gear no longer fits correctly It is the responsibility of the health care provider to evaluate the pregnant employee If at any time the health care provider feels the pregnant employee can no longer perform the job related tasks this should be reported to the employer by the employee immediately
50
ATTACHMENT G
51
From GLENN BENARICKTo Sawyer SteveSubject RE RE 7743Date Monday August 30 2010 21633 PM
Yes thats my understanding
Glenn P Benarick 211 Winged Elm CircleAiken SC 29803803-644-7093gbenarprodigynet
--- On Mon 83010 Sawyer Steve ltssawyerNFPAorggt wrote
From Sawyer Steve ltssawyerNFPAorggtSubject RE RE 7743To GLENN BENARICK ltgbenarprodigynetgtDate Monday August 30 2010 212 PM
So it should be ldquoorrdquo instead of ldquoandrdquo for now
Steven F Sawyer
Senior Fire Service Specialist
Executive Secretary IFMAFire Service Section
NFPA
1 Batterymarch Park
Quincy MA 02169
6179847423
Fax 6179847056
ssawyernfpaorg
From GLENN BENARICK [mailtogbenarprodigynet] Sent Monday August 30 2010 1202 PMTo Sawyer SteveSubject Fw RE 7743
52
Steve a couple of our docs agree with April Boyer
Glenn P Benarick 211 Winged Elm Circle
Aiken SC 29803
803-644-7093
gbenarprodigynet
--- On Mon 83010 David Prezant ltprezandfdnynycgovgt wrote
From David Prezant ltprezandfdnynycgovgtSubject RE 7743To Thomas R (CDCNIOSHDSHEFS) Hales lttrh1cdcgovgt GLENNBENARICK ltgbenarprodigynetgtCc Sandy Bogucki ltsandyboguckiyaleedugtDate Monday August 30 2010 1004 AM
agree
we should change this to NHANES III rather than Knudson we should alsomodify this to allow not only for predicted cutoffs but all for use of thelower limit of normal cutoff This is important to prevent false-classificationof spirometry as abnormal in older groups and in taller grps The latter ofparticular import to firefighter occupational health surveillance
thanks
David Prezant MDChief Medical Officer Office of Medical AffairsCo-Director WTC Medical Monitoring amp Treatment ProgramsNew York City Fire Department9 Metrotech Center - Rm 4W-1Brooklyn NY 11201Phone 718-999-2696Fax 718-999-0665
Life is full of twists and turns
53
This email may contain confidential information If you are the unintendedrecipient of this email please send it back and delete from your directory
gtgtgt Hales Thomas R (CDCNIOSHDSHEFS) lttrh1cdcgovgt 8302010955 AM gtgtgt
Glen
This seems like a very reasonable comment and illustrates the importance of having clinicians providefeedback on the std Im not familiar with the software program of the various spirometers (NHANES IIIvs KnudsonATS vs both) Given the large role both Dave Prezant and Sandy Bogucki had for thepulmonary section let me forward to them for clarification
Tom
From GLENN BENARICK [mailtogbenarprodigynet] Sent Sunday August 29 2010 456 PMTo Hales Thomas R (CDCNIOSHDSHEFS)Subject FW 7743
Tom is April Boyer correct
Glenn P Benarick 211 Winged Elm Circle
Aiken SC 29803
803-644-7093
gbenarprodigynet
--- On Thu 82610 Sawyer Steve ltssawyerNFPAorggt wrote
From Sawyer Steve ltssawyerNFPAorggtSubject FW 7743To GLENN BENARICK ltgbenarprodigynetgtDate Thursday August 26 2010 925 PM
FYI Do you have any answer She is write
Steven
54
Steven F Sawyer
Senior Fire Service Specialist
Executive Secretary IFMAFire Service Section
NFPA
1 Batterymarch Park
Quincy MA 02169
6179847423
Fax 6179847056
ssawyernfpaorg
From April Boyer [mailtoaboyerbicclinicorg] Sent Thursday August 26 2010 232 PMTo Sawyer SteveCc RobinMWebbmilstateorusSubject 7743
Steven
The spirometry tests cannot be corrected according to both references as the NFPA states because thereferences are contradictory The first part of 7743 states to follow the ATS guidelines and use theKnudsen (we at Basin Immediate Care use the Nhanes III) The second part states to follow the ACOEMguidelines and use the Nhanes III in the occupational setting if available with your unit (which is availableon ours) 7743 does not use the word OR regarding both requirements it uses the word AND whenreferring to the first and second parts thence making 7743 contradictory I realize the NFPA 1582 hasnot been updated since 2007 unless I have just not received an updated version
Our question to you is which part of 7743 do you want us to follow the first or the second part Anyfacility that has an updated computerized spirometry system (as we do) will not be able to follow bothrequired parts for obvious reasons We can either follow the first part of 7743 and use an oldercorrected version of the Knudson by going into our system and changing out of the Nhanes III conversionOR we can follow the second part of 7743 and use the newer corrected version of Nhanes III which ourunit offers too
If you have any questions you may contact me at anytime and I also have many references in regards toboth parts of 7743 if you would like to see them
55
Thank you~
April
Confidentiality NoticeThis message may contain information that isconfidential or privileged
If you are not the intended recipientPlease advise the sender immediately and delete this message
56
ATTACHMENT H
57
NFPA 1582 771(7) Proposed revisions
Why
Preliminary results of two prospective randomized trials on the PSA test were published in 2009 These studies resulted in medical organizations that previously providing guidance to modify their recommendations
Current language
771 Blood Tests Blood tests shall be performed annually and shall include the following
(7) Prostate specific antigen (PSA) after age 40 for positive family history if African American or if otherwise clinically indicated after age 50 for all other male member
Suggested Revision
771 Blood Tests Blood tests shall be performed annually and shall include the following
(7) Prostate specific antigen (PSA) after age 40 for positive family history if African American or if otherwise clinically indicated after age 50 for all other male member
772 Prostate-Specific Antigen (PSA) test At age 50 fire fighters shall have an opportunity to make an informed decision with either the Fire Department physician or their health care provider concerning the PSA test For fire fighters at increased risk of prostate cancer (African-Americans or those with a first degree relative diagnosed with prostate cancer before age 65) shall have the opportunity for this informed decision at age 40
A772 The PSA as a screening test for prostate cancer in asymptomatic men is controversial controversial for two reasons First there is no consensus that PSA screening actually saves lives For example the PSA test may detect small cancers that would never become life threatening Second it is unclear that the benefits of PSA screening outweigh the risks of follow-up diagnostic tests and cancer treatments For example the prostate biopsy used to diagnose prostate cancer may cause bleeding and infection And prostate cancer treatments such as surgery and radiation therapy may cause incontinence (inability to control urine flow) erectile dysfunction (erections inadequate for intercourse) and other complications For these reasons it is important that the benefits and risks of prostate diagnostic procedures and treatment be taken into account when considering the PSA screening test These considerations can be taken account during discussions with the fire department physician or onersquos health care provider
D211 Cancer Screening
Smith R A C J Mettlin K J Davis and H Eyre 2000 ldquoAmerican Cancer Society guidelines for the early detection of cancerrdquo CA J Clin 50(1)34ndash49
Added references
58
Carroll P Albertsen PC Greene K et al [2010] Prostate-specific antigen best practice statement 2009 update Am Urological Assoc Available at httpwwwauanetorgcontentguidelines-and-quality-careclinical-guidelinesmain-reportspsa09pdf Date accessed September 2010
Ferrini R Woolf SH [2009] Screening for prostate cancer in American men American College of Preventive Medicine Practice Policy Statement Available at httpwwwacpmorgprostatehtm Date accessed September 2010
National Cancer Institute [2009] Prostate-specific antigen test National Cancer Institute Fact Sheet Available at httpwwwcancergovcancertopicsfactsheetDetectionPSA Date accessed September 2010
Wolf AMD Wender RC Etzioni RB et al [2010] American Cancer Society guideline for the early detection of prostate cancer Update 2010 Available at httpcaonlineamcancersocorgcgicontentfullcaac20066v1 Date accessed September 2010
59
The criteria and individualized assessment process included in this Guidance are intended to serve as a means to
minimize the risk to individual LEOs and the public while allowing well motivated well educated persons with
well-controlled diabetes to serve as LEOs Nonetheless certain persons with diabetes despite their motivation and
adherence to optimum care are unable to attain adequate control of their diabetes and therefore have a greater
tendency for significant hypoglycemia Such individuals would not be acceptable candidates to be LEOs
This individualized assessment is possible in large part because a great deal of change has occurred in the treatment
of diabetes over the last number of years Previously patients used insulins that were somewhat unpredictable in the
time course of their action and generally took 2 or fewer injections per day Today there are insulins that are far
more predictable and are either very long acting and essentially treat only basal hepatic glucose production (and
therefore do not depend on a patient eating on a regular schedule) or are very rapid and therefore can be admin-
istered directly before or even shortly after eating significantly decreasing the chance of insulin being taken and
then the meal being interrupted due to professional duties
Regimens now referred to as ldquobasal bolusrdquo are composed of a very long acting basal (or background) insulin and
rapid-acting (bolus) insulins The basal insulin controls glucose levels overnight in the absence of carbohydrate
intake The rapid-acting (bolus) insulins that are dosed just prior to during or after meals based on blood glucose
levels at that time the amount of carbohydrate that the person expects to consume and any anticipated change in
physical activity patterns over the next several hours These regimens have resulted in improved overall blood
glucose control with significantly less risk of hypoglycemia for many patients
Additional major advances in the size speed and sophistication of blood glucose meters provide for easy accurate
and rapid assessment of blood glucose levels All current blood glucose meters can be downloaded to computer
programs facilitating confirmation and review of blood glucose results Such monitoring techniques as well as the
generally increased self-awareness that accompanies consistent self-monitoring enables the motivated person with
diabetes to assess blood glucose levels and ingest a safety net of carbohydrates before entering a hazardous envi-
ronment Similarly major advances in insulin delivery systems have greatly increased the ability of the motivated
individual with diabetes to achieve a level of diabetes self-management consistent with the duties of a LEO
In order to obtain maximum effect from these medical advances and to minimize the risk of hypoglycemia patients
with diabetes must check their blood glucose level frequently (as recommended based on factors such as type of
therapy and glycemic history) review these results on a regular basis and see their diabetes care provider regularly
for discussion in regard to any necessary changes in treatment Patient evaluation needs to look for any of the known
risk factors for serious hypoglycemia or evidence of any of the known microvascular (eye disease kidney disease
or nerve disease) or macrovascular (cardiovascular disease peripheral arterial disease) complications of diabetes
The above described individualized assessment demands a very close and good working relationship between the
patient and the diabetes care provider
Conclusion
Current published data suggest that persons with diabetes who can safely and effectively function as LEOs can be
reliably identified through careful individualized assessment Thus blanket bans of all people with diabetes in
addition to being illegal are not consistent with current medical knowledge Because diabetes affects individuals
very differently whether or not an individual can safely perform a particular job must be determined using the
combined expertise of the treating physician and the police physician This guidance provides the information
necessary for the police physician to work with a diabetes expert on this important task
6 ACOEM Guidance for the Medical Evaluation of Law Enforcement Officers
43 ndash DIABETES MELLITUS
25
438 ndash APPENDIX B PHYSICIAN EVALUATION FORM FOR THE LEO WITH DIABETES
The following evaluation form is based on the guidance established by the American College of Occupational and Environ-
mental Medicine (ACOEM)
I INTRODUCTION
The educated and motivated law enforcement officer (LEO) or applicant with well-managed diabetes mellitus can be
capable of safe and effective job performance An individualized assessment of the LEOrsquos or applicantrsquos diabetes should
be performed including an assessment of the following
history of blood glucose control
current stability of blood glucose
risk for significant hypoglycemia or hyperglycemia
presence of diabetic complications and
knowledge of diabetes and its management
Risk of hypoglycemia remains the major concern in regard to those with diabetes being or becoming LEOs This risk
occurs primarily in those taking insulin particularly those with type 1 diabetes although it may also occur in those with
type 2 diabetes who take insulin andor sulfonylureas and other secretagogues
Law enforcement entails a unique set of conditions that need to be considered in regard to those with diabetes and the risks of
either hypo or hyperglycemia These may include (depending upon the duties of the particular LEO position)
unpredictable meal schedules
brief periods of maximal physical exertion
prolonged driving with responsibility for others in the vehicle
high-speed pursuit driving
surveillance requiring sustained attention for prolonged periods of time
rapid decision making regarding the use of force including deadly force
rapid analysis of complex visual stimuli to differentiate weapons from other objects and
control of onersquos emotions under stress
II ASSESSMENT
1 LEO has been under the care of an endocrinologist or other physician knowledgeable about diabetes management
Outpatient and in-patient medical record(s) of the last three years or since date of diagnosis (whichever is shorter)
should be reviewed by the treating physician and provided to the police physician
My credentials as a physician knowledgeable about diabetes management are as follows (or attach CV)
Urine microalbumincreatinine ratio _________________
III Treating Physician Statement
The above named individual meets all of the criteria provided on this form
Yes No ndash not recommended for position
No but IS recommended for position (letter of explanation attached)
It is my opinion that the above named individual is well-educated and well-motivated in diabetes self-management and has
achieved a level of diabetes management to be capable of safe and effective job performance as a law enforcement officer
I have reached this opinion after careful review of the above criteria
___________________________________________________________ ___________________________Signature of Physician Date
______________________________________________________________ ___________________________Printed or Typed Name of Physician Telephone Number
10 ACOEM Guidance for the Medical Evaluation of Law Enforcement Officers
43 ndash DIABETES MELLITUS
29
439 ndash REFERENCES
1 American Diabetes Association Diagnosis and classification of diabetes mellitus Diabetes Care 200427 Suppl
1S5-S10 See httpcarediabetesjournalsorgcgicontentfull27suppl_1s5
2 American Diabetes Association Continuous subcutaneous insulin infusion Diabetes Care 200427 Suppl 1S110
See httpcarediabetesjournalsorgcgicontentfull27suppl_1s110
3 Mensing C Boucher J Cypress M et al National standards for diabetes self-management education Diabetes
Care 200528 Suppl 1S72-9 See httpcarediabetesjournalsorgcgicontentfull28suppl_1s72
4 Goldstein DE Little RR Lorenz RA Malone JI Nathan DM Peterson CM American Diabetes Association Tests
of glycemia in diabetes Diabetes Care 200427 Suppl 1S91-3
See httpcarediabetesjournalsorgcgicontentfull27suppl_1s91
5 The Diabetes Control and Complications Trial Research Group Hypoglycemia in the Diabetes Control and
Complications Trial Diabetes 199746(2)271-86 See wwwncbinlmnihgovpubmed9000705 for abstract
6 American Diabetes Association Hypoglycemia and employmentlicensure Diabetes Care 200528 Suppl 1S61
See httpcarediabetesjournalsorgcgicontentfull28suppl_1s61
7 Viswanath K McGavin DD Diabetic Retinopathy Clinical Findings and Management J Comm Eye Health
200316(46)21-4 See wwwcehjournalorg0953-683316jceh_16_46_021html
8 Michigan Diabetes Research and Training Center University of Michigan Health System How to use the Michigan
Neuropathy Screening Instrument See wwwmedumichedumdrtcprofsdocumentssviMNSI_howtopdf
9 Bradley JG Davis KA Orthostatic hypotension Am Fam Physician 200368(12)2393-8
See wwwaafporgafp200312152393html
10 Gibbons RJ Balady GJ Bricker JT et al ACCAHA 2002 guideline update for exercise testing a report of the
American College of CardiologyAmerican Heart Association Task Force on Practice Guidelines (Committee on
Exercise Testing) J Am Coll Cardiol 200240(8)1531-40
See wwwaccorgqualityandscienceclinicalguidelinesexerciseexercise_cleanpdf
11 American Diabetes Association Standards of medical care in diabetes Diabetes Care 200528 Suppl 1S4-S36
Erratum in Diabetes Care 200528(4)990 See httpcarediabetesjournalsorgcgicontentfull28suppl_1s4
12 Molitch ME DeFronzo RA Franz MJ et al American Diabetes Association Nephropathy in diabetes Diabetes
Care 200427 Suppl 1S79-83 See httpcarediabetesjournalsorgcgicontentfull27suppl_1s79
13 Kitabchi AE Umpierrez GE Murphy MB et al American Diabetes Association Hyperglycemic crises in diabetes
Diabetes Care 200427 Suppl 1S94-102 See httpcarediabetesjournalsorgcgicontentfull27suppl_1s94
14 US Centers for Disease Control and Prevention National Diabetes Fact Sheet 2007
See wwwcdcgovdiabetespubspdfndfs_2007pdf
ACOEM Guidance for the Medical Evaluation of Law Enforcement Officers 11
43 ndash DIABETES MELLITUS
30
ATTACHMENT E
31
Typos A6921(2) 7th line down test should be plural 94201 Paragraph 2 target organ damage is used though end organ damage was defined earlier and in the appendix for that paragraph
A94201 Para A (1) d Id suggest deleting the phrases in brackets Im not sure either are predictably true or politically wise
a) tests for left ventricular hypertrophy Unfortunately use of the EKG to detect left ventricular hypertrophy is very insensitive (eg 5 sensitivity) The echocardiogram is the best test for diagnosing left ventricular hypertrophy but [it is relatively expensive and not readily available in small rural communities ] conducting echocardiograms on asymptomatic fire fighters with Stage 1 hypertension should be reserved only for those with long-standing hypertension
In addition
7761 A resting EKG shall be performed as part of the baseline medical evaluation and shall be obtained periodically thereafter
Changing from annually to periodically is noted has the language in the wellness-fitness initiative been changed as well Our previous decision was that we would support the W-F language since there was no compelling evidence to either support or refute it
Thanks
Sandy
32
NFPA 1582‐ HTN Draft 1
Reason for Revision
1) New classification of BP by the Joint National Commission [Chobanian et al 2002]
2) A high prevalence of FF have either HTN (~20) and Pre‐HTN (~20) [Soteriades et al 2003]
3) Among FF studies have shown a strong association between HTN and a number of adverse
cardiovascular events [Kales et al 2009]
4) A large percentage of on‐duty FF fatalities were found to have left ventricular hypertrophy a
complication of HTN at autopsy
Language in 2007 Edition with draft revisions in Red (Track changes)
611 The medical evaluation of a candidate shall include a medical history examination and any laboratory tests required to detect physical or medical condition(s) that could adversely affect hisher ability to safely perform the essential job tasks outlined in 511 A611 The medical history should include the candidates known health problems such as major illnesses surgeries medication use and allergies Symptom review is also important for detecting early signs of illness A medical history should also include a personal health history a family health history a health habit history an immunization history and a reproductive history
An occupational history should also be obtained to collect information about the persons past occupational and environmental exposures
(a) BP should be measured according to the Joint National Commission (JNC) -7 recommendations BP should be measured with a properly calibrated and validated instrument Patients should be seated quietly for at least 5 minutes in a chair with feet on the floor and arm supported at heart level An appropriate-sized cuff (cuff bladder encircling at least 80 of the arm) should be used to ensure accuracy At least 2 measurements should be made Systolic BP is the point at which the first of 2 or more sounds is heard (phase 1) and diastolic BP is the point before the disappearance of sounds (phase 5) [Chobanian et al 2003]
(2) Head eyes ears nose and throat (HEENT)
Formatted Font (Default) Times New RomanFont color Black
33
692 Vascular System 6921 Category A medical conditions shall include the following
(1) Uncontrolled or poorly controlled hypertension
(2) Hypertension with evidence of end organ damage
or not controlled by approved medications
A6921(1) Uncontrolled or poorly controlled hHypertension increases the risk of a sudden cardiac event This sudden cardiac event would cause sudden incapacitation which that is uncontrolled poorly controlled or requires medication likely to interferes with the safe performance of essential job tasks Uncontrolled or poorly controlled hypertension can be defined as the presence of end organ damage (see below) or stage 2 hypertension (BP systolic gt160 mmHg or BP diastolic gt100 mmHg) is an illness that can lead to functional impairment and potential for sudden incapacitation Individuals with pre- stage 1 or stage 2 hypertension should be referred to their primary care physician for evaluation lifestyle modification and treatment [QUESTION FOR GROUP _- WHAT ABOUT HAVING CANDIDATE RETURN IN ONE MONTH UNDER TREATMENT WITH NORMAL BP]
A6921(2)
Chronic hypertension can damage the eye (retinopathy) the kidneys (nephropathy) the vascular system (stroke transient ischemic attack or peripheral artery disease) or the heart (left ventricular hypertrophy and heart failure) These hypertension complications are known as end organ damage The cardiac and vascular complications are associated with an increased risk of sudden incapacitation and sudden cardiac death (Koren et al 1991) Unfortunately the cardiac complications are frequently asymptomatic and valid screening tests are not fast and are not inexpensive Therefore determining who to screen for cardiac complications (such as echocardiogram for LVH or a measurement of left ventricular ejection fraction for heart failure) should be based on the severity and the duration of HTN
76 Physical Examination The annual physical examination shall include each of the following components
(a) BP shall be measured according to the Joint National Commission (JNC)-7 recommendations
A76(1)(a) BP should be measured with a properly calibrated and validated instrument Patients should be seated quietly for at least 5 minutes in a chair with feet on the floor and arm supported at heart level An appropriate-sized cuff (cuff bladder encircling at least 80 of the arm) should be used to ensure accuracy At least 2 measurements should be made Systolic BP is the point at which the first of 2 or more sounds is heard (phase 1) and diastolic BP is the point before the disappearance of sounds (phase 5) [Chobanian et al 2003]
(2) Head eyes ears nose and throat (HEENT)
34
9420 Uncontrolled Hypertension 94201 Physician Evaluation Severe uncontrolled hypertension [defined as systolic pressure greater than 180 mm Hg diastolic pressure greater than 100 mm Hg or mean systolic blood
pressure ( systolic + diastolic) greater than 120 mm Hg] or malignant hypertension (defined as hypertension with the presence of target organ damage) compromises the members ability to safely perform essential job tasks 1 5 7 9 and 13 and the physician shall report the applicable job limitations to the fire department
Members with Pre-hypertention (systolic 120-139 mmHg or diastolic 80-89 mmHg) Stage 1 hypertension (systolic 140-159 mmHg or diastolic 90-99 mmHg) or Stage 2 hypertension (systolic ge160 mmHg or diastolic ge100 mmHg) should be referred to their primary care physician for evaluation lifestyle modification and treatment
(1) Members with Stage I hypertension should be followed-up not only by their primary care physician but also by the FD physician every 3 to 6 months to ensure their blood pressure is under control and to determine whether screening tests for asymptomatic end organ damage are appropriate
(2) Members with Stage 2 hypertension or with end organ damage (retinopathy nephropathy vascular or cardiac complications) compromises the members ability to safely perform essential job tasks 1 5 7 9 and 130 and the physician shall report the applicable job limitations to the fire department
A94201 Severe uncontrolled hypertension is a significant risk factor for the development of coronary artery disease congestive heart failure and stroke Blood pressure increases as a normal response to exercise This response is further exaggerated by the emotional and physical stress of performing these critical tasks while operating in personal protective clothing at extremes of temperature This normal elevation of blood pressure under these response conditions can lead to life-threatening hypertensive emergencies if a members daily blood pressure is already elevated to high levels In addition hypertension is a progressive illness that when uncontrolled ultimately and inevitably leads to target organ damage Target organs that are sensitive to the effects of elevated blood pressure are the central nervous system vision heart major blood vessels and kidneys
Chronic hypertension can damage the eye (retinopathy) the kidneys (nephropathy) the vascular system (stroke transient ischemic attack or peripheral artery disease) or the heart (left ventricular hypertrophy and heart failure) These hypertension complications are known as end organ damage The cardiac and vascular complications are associated with an increased risk of sudden incapacitation and sudden cardiac death (Koren et al 1991) Fortunately with proper evaluation life style modification and treatment these complications can be avoided Life style modification includes weight reduction DASH eating plan reduction in dietary sodium an increase in aerobic physical activity and moderation in alcohol consumption [Chobanian 2003]
Formatted Font (Default) Times New Roman12 pt Font color Black
Formatted Font (Default) Times New Roman12 pt Font color Black
35
A94201 (1) Members with Stage I hypertension whose BP returns to either pre-hypertenion or normal with lifestyle modification andor treatment can return to an annual medical evaluation For members with long-standing Stage I hypertension whose BP has not been reduced additional evaluation for possible end organ damage should be considered This evaluation could include any or all of the following
a) a compete patient history for symptoms of heart failure (eg shortness of breath upon exertion) or transient ischemic attacks (TIAs)
b) dilated eye examination for retinopathy
c) blood creatinine measurement for nephropathy
d) tests for left ventricular hypertrophy Unfortunately use of the resting EKG to detect left ventricular hypertrophy is very insensitive (eg 5 sensitivity) The echocardiogram is the best test for diagnosing left ventricular hypertrophy
A 94201 (2) Due to the high risk of a sudden cardiovascular event members with Stage 2 hypertension should be restricted until their BP can be brought under control Once the BP is brought under control they should be followed in the same manner as a member with Stage I hypertension
Formatted Font (Default) Times New Roman12 pt
36
D22 Cardiology Gibbons R J GJ Balady J W Beasley et al 1997 ACCAHA guidelines for exercise testing a report of American College of CardiologyAmerican Heart Association Task Force on Practice Guidelines (Committee on Exercise Testing) J Am Coll Cardiol 30260ndash311
Gibbons RJ Balady GJ Bricker JT Chaitman BR Fletcher GF Froelicher VF Mark DB McCallister BD Mooss AN OrsquoReilly MG Winters WL Jr [2002] ACCAHA 2002 guideline update for exercise testing summary article a report of the ACCAHA Task Force on Practice Guidelines (Committee to Update the 1997 Exercise Testing guidelines) J Am Coll Cardiol 401531ndash 40
Chobanian AV Bakris GL Black HR Cushman WC Green LA Izzo JL Jr Jones DW Materson BJ Oparil S Wright JT Jr Roccella EJ the National High Blood Pressure Education Program Coordinating Committee [2003] The seventh report of the Joint National Committee [JNC-7] on Prevention Detection Evaluation and Treatment of High Blood Pressure JAMA 2892560ndash2571
Soteriades ES Kales SN Liarokapis D Christiani DC [2003] Prospective surveillance of hypertension in firefighters J Clin Hypertens 5315-320
Kales SN Tsismenakis AJ Zhang C Soteriades ES [2009] Blood pressure in fire fighters police officers and other emergency responders Am J Hypertens 2211-20
37
NFPA 1582‐ HTN Draft 1
Reason for Revision
1) New classification of BP by the Joint National Commission [Chobanian et al 2002]
2) A high prevalence of FF have either HTN (~20) and Pre‐HTN (~20) [Soteriades et al 2003]
3) Among FF studies have shown a strong association between HTN and a number of adverse
cardiovascular events [Kales et al 2009]
4) A large percentage of on‐duty FF fatalities were found to have left ventricular hypertrophy a
complication of HTN at autopsy
Language in 2007 Edition with draft revisions in Red (Track changes)
611 The medical evaluation of a candidate shall include a medical history examination and any laboratory tests required to detect physical or medical condition(s) that could adversely affect hisher ability to safely perform the essential job tasks outlined in 511 A611 The medical history should include the candidates known health problems such as major illnesses surgeries medication use and allergies Symptom review is also important for detecting early signs of illness A medical history should also include a personal health history a family health history a health habit history an immunization history and a reproductive history
An occupational history should also be obtained to collect information about the persons past occupational and environmental exposures
(a) BP should be measured according to the Joint National Commission (JNC) -7 recommendations BP should be measured with a properly calibrated and validated instrument Patients should be seated quietly for at least 5 minutes in a chair with feet on the floor and arm supported at heart level An appropriate-sized cuff (cuff bladder encircling at least 80 of the arm) should be used to ensure accuracy At least 2 measurements should be made Systolic BP is the point at which the first of 2 or more sounds is heard (phase 1) and diastolic BP is the point before the disappearance of sounds (phase 5) [Chobanian et al 2003]
(2) Head eyes ears nose and throat
38
692 Vascular System 6921 Category A medical conditions shall include the following
(1) Uncontrolled or poorly controlled hypertension
(2) Hypertension with evidence of end organ damage
A6921(1) Uncontrolled or poorly controlled hypertension increases the risk of a sudden cardiac event This sudden cardiac event would cause sudden incapacitation which interferes with the safe performance of essential job tasks Uncontrolled or poorly controlled hypertension can be defined as the presence of end organ damage (see below) or stage 2 hypertension (BP systolic gt160 mmHg or BP diastolic gt100 mmHg) Individuals with pre- stage 1 or stage 2 hypertension should be referred to their primary care physician for evaluation lifestyle modification and treatment [QUESTION FOR GROUP _- WHAT ABOUT HAVING CANDIDATE RETURN IN ONE MONTH UNDER TREATMENT WITH NORMAL BP]
A6921(2)Chronic hypertension can damage the eye (retinopathy) the kidneys (nephropathy) the vascular system (stroke transient ischemic attack or peripheral artery disease) or the heart (left ventricular hypertrophy and heart failure) These hypertension complications are known as end organ damage The cardiac and vascular complications are associated with an increased risk of sudden incapacitation and sudden cardiac death (Koren et al 1991) Unfortunately the cardiac complications are frequently asymptomatic and valid screening tests are not fast and are not inexpensive Therefore determining who to screen for cardiac complications (such as echocardiogram for LVH or a measurement of left ventricular ejection fraction for heart failure) should be based on the severity and the duration of HTN
76 Physical Examination The annual physical examination shall include each of the following components
(a) BP shall be measured according to the Joint National Commission (JNC)-7 recommendations
A76(1)(a) BP should be measured with a properly calibrated and validated instrument Patients should be seated quietly for at least 5 minutes in a chair with feet on the floor and arm supported at heart level An appropriate-sized cuff (cuff bladder encircling at least 80 of the arm) should be used to ensure accuracy At least 2 measurements should be made Systolic BP is the point at which the first of 2 or more sounds is heard (phase 1) and diastolic BP is the point before the disappearance of sounds (phase 5) [Chobanian et al 2003]
(2) Head eyes ears nose and throat9420 Hypertension 94201 Physician Evaluation Members with Pre-hypertention (systolic 120-139 mmHg or diastolic 80-89 mmHg) Stage 1 hypertension (systolic 140-159 mmHg or diastolic 90-99 mmHg) or Stage 2 hypertension (systolic ge160 mmHg or diastolic ge100 mmHg) should be referred to their primary care physician for evaluation lifestyle modification and treatment
39
(1) Members with Stage I hypertension should be followed-up not only by their primary care physician but also by the FD physician every 3 to 6 months to ensure their blood pressure is under control and to determine whether screening tests for asymptomatic end organ damage are appropriate
(2) Members with Stage 2 hypertension or with end organ damage (retinopathy nephropathy vascular or cardiac complications) compromises the members ability to safely perform essential job tasks 1 5 7 9 and 130 and the physician shall report the applicable job limitations to the fire department
A94201 Chronic hypertension can damage the eye (retinopathy) the kidneys (nephropathy) the vascular system (stroke transient ischemic attack or peripheral artery disease) or the heart (left ventricular hypertrophy and heart failure) These hypertension complications are known as end organ damage The cardiac and vascular complications are associated with an increased risk of sudden incapacitation and sudden cardiac death (Koren et al 1991) Fortunately with proper evaluation life style modification and treatment these complications can be avoided Life style modification includes weight reduction DASH eating plan reduction in dietary sodium an increase in aerobic physical activity and moderation in alcohol consumption [Chobanian 2003]
A94201 (1) Members with Stage I hypertension whose BP returns to either pre-hypertenion or normal with lifestyle modification andor treatment can return to an annual medical evaluation For members with long-standing Stage I hypertension whose BP has not been reduced additional evaluation for possible end organ damage should be considered This evaluation could include any or all of the following
a) a compete patient history for symptoms of heart failure (eg shortness of breath upon exertion) or transient ischemic attacks (TIAs)
b) dilated eye examination for retinopathy
c) blood creatinine measurement for nephropathy
d) tests for left ventricular hypertrophy Unfortunately use of the resting EKG to detect left ventricular hypertrophy is very insensitive (eg 5 sensitivity) The echocardiogram is the best test for diagnosing left ventricular hypertrophy
A 94201 (2) Due to the high risk of a sudden cardiovascular event members with Stage 2 hypertension should be restricted until their BP can be brought under control Once the BP is brought under control they should be followed in the same manner as a member with Stage I hypertension
D22 Cardiology
40
Hypertension
Gibbons RJ Balady GJ Bricker JT Chaitman BR Fletcher GF Froelicher VF Mark DB McCallister BD Mooss AN OrsquoReilly MG Winters WL Jr [2002] ACCAHA 2002 guideline update for exercise testing summary article a report of the ACCAHA Task Force on Practice Guidelines (Committee to Update the 1997 Exercise Testing guidelines) J Am Coll Cardiol 401531ndash 40
Chobanian AV Bakris GL Black HR Cushman WC Green LA Izzo JL Jr Jones DW Materson BJ Oparil S Wright JT Jr Roccella EJ the National High Blood Pressure Education Program Coordinating Committee [2003] The seventh report of the Joint National Committee [JNC-7] on Prevention Detection Evaluation and Treatment of High Blood Pressure JAMA 2892560ndash2571
Soteriades ES Kales SN Liarokapis D Christiani DC [2003] Prospective surveillance of hypertension in firefighters J Clin Hypertens 5315-320
Kales SN Tsismenakis AJ Zhang C Soteriades ES [2009] Blood pressure in fire fighters police officers and other emergency responders Am J Hypertens 2211-20
41
NFPA 1582‐ Draft Revisions for CVDHTN
EKG and stress tests
Reason for Revision
1) Change requirement for annual resting EKG to periodically to be more consistent with ACCAHA
recommendation (Schlant et al 1992)
2) Add language to clarify what constitutes a positive ST
3) Make criteria for conducting diagnostic ST in asymptomatic patients consistent with the
ACCAHA
Language in 2007 Edition with draft revisions in Red (Track changes)
776 Electrocardiograms (EKG)) and Stress Tests 7761 A resting EKG shall be performed as part of the baseline medical evaluation and shall be obtained periodically (every 1 to 5 years) annually thereafter
A7761 A baseline resting EKGs shall be conducted Follow-up resting EKGs should be conducted as clinically indicated but at a minimum of every 1 to 5 years The frequency of these follow-up resting EKGs should increase as a members age increases or with increasing number andor severity of coronary heart disease risk factors Members above the age of 40 should have annual resting EKGs (Schlant et al 1992)
7762 The fire department physician or other qualified medical evaluator shall compare EKGs obtained during yearly evaluations with baseline and subsequent EKGs
7763 Stress testing EKG with or without echocardiography or radionuclide scanning shall be performed as clinically indicated by history or symptoms
A7761 Baseline electrocardiography should be conducted (Periodic resting electrocardiograms have not been shown to be useful but can be reasonable as a members agefactors increase)
A7763 No firm guidelines for stress testingelectrocardiography in asymptomatic individuals have been developed Stress testingelectrocardiography as a screening tool is used as part of an evaluation of aerobic capacity during the annual occupational fitness evaluation Submaximal stress testingelectrocardiography testing to 85 percent is commonly used as part of this screening
Submaximal stress electrocardiography testing should not be used for diagnostic purposes Cardiology evaluation with maximal stress testingelectrocardiography together with imaging techniques (eg echocardiography technetium Tc99m sestamibi study andor coronary angiography) is necessary for diagnosticprognostic purposes for the following
42
(1) Fire fighters with positive or questionably positive changes on screening submaximal stress tests
(2) Fire fighters with new onset chest pain or other symptoms suggestive of coronary artery disease (CAD)
(3) Fire fighters with diabetes mellitus who
(a) are gt35 years old or
(b) have type I diabetes for more than 15 years or
(c) have type II diabetes for more than 10 years or
(d) have any other CHD risk factor (see below) or
(e) have the presence of microvascular disease (proliferative retinopathy)
(4) Fire fighters over the age of 45 (for men) and 55 (for women) with onetwo or more risk factors for CAD Risk factors for CAD include hypercholesterolemia (total cholesterol greater than 240 mgdL) hypertension (systolic gt140 mmHg or diastolic gt90 mmHg) smoking or family history of premature CAD (heart attack or sudden cardiac death in a first degree relative less than 60 years of age)
as defined below if stress electrocardiography with imaging is negative then repeat as clinically indicated or at least every 5 years
(5) Fire fighters with a Framingham Risk Score gt10 Risk calculator is available at [httphp2010nhlbihinnetatpiiicalculatorasp]
(6) Fire fighters identified in 9431
Negative stress tests should be repeated as clinically indicated or at least every 2 to 5 years
Interpreting stress tests as ldquopositiverdquo or ldquonegativerdquo is beyond the scope of this document However factors that should be taken into consideration should include the individualrsquos exercise capacity symptoms blood pressure response heart rate response EKG changes and the presence of arrhythmias (Gibbon et al 2002)
Risk factors for CAD include hypercholesterolemia (total cholesterol greater than 240 mgdL) hypertension (systolic greater than 140 andor diastolic greater than 90) smoking diabetes mellitus or family history of premature CAD (heart attack or sudden cardiac death in a first degree relative less than 60 years of age)
There are other non-invasive tests to screen for coronary artery disease One of the most promising appears to be coronary artery calcium (CAD) scoring by computed tomography In 2007 an expert committee published an update to their original guidance document The committeersquos consensus was that ldquoit may be reasonable to consider use of CAC measurement in such patients [between 10 and 20 10-year risk of estimated coronary event]helliprdquo The committee did not recommend CAC measurement in low risk patients [lt10 10-year risk of estimated coronary event] or in high risk patients [gt20 10-year risk of estimate coronary event] (Greenland et al 2007]
43
D22 Cardiology
Chobanian AV Bakris GL Black HR Cushman WC Green LA Izzo JL Jr Jones DW Materson BJ Oparil S Wright JT Jr Roccella EJ the National High Blood Pressure Education Program Coordinating Committee [2003] The seventh report of the Joint National Committee [JNC-7] on Prevention Detection Evaluation and Treatment of High Blood Pressure JAMA 2892560ndash2571
Gibbons RJ Balady GJ Bricker JT Chaitman BR Fletcher GF Froelicher VF Mark DB McCallister BD Mooss AN OrsquoReilly MG Winters WL Jr [2002] ACCAHA 2002 guideline update for exercise testing summary article a report of the ACCAHA Task Force on Practice Guidelines (Committee to Update the 1997 Exercise Testing guidelines) J Am Coll Cardiol 401531ndash 1540
Greenland et al [2007] ACCFAHA 2007 Clinical Expert Consensus Document on Coronary Artery Calcium Scoring By Computed Tomography in Global Cardiovascular Risk Assessment and in Evaluation of Patients With Chest Pain A Report of the American College of Cardiology Foundation Clinical Expert Consensus Task Force (ACCFAHA Writing Committee to Update the 2000 Expert Consensus Document on Electron Beam Computed Tomography) J Am Coll Cardiol 49378-402
Kales SN Tsismenakis AJ Zhang C Soteriades ES [2009] Blood pressure in fire fighters police officers and other emergency responders Am J Hypertens 2211-20
Schlant RC Adolph RJ DiMarco JP Dreifus LS Dunn MI Fisch C Garson A Jr Haywood LJ Levine HJ Murray JA Noble RJ Ronan JA Jr [1992] Guidelines for electrocardiography A report of the American College of CardiologyAmerican Heart Association Task Force on Assessment of Diagnostic and Therapeutic Cardiovascular Procedures (Committee on Electrocardiography) Circulation 85(3)1221-1228
Soteriades ES Kales SN Liarokapis D Christiani DC [2003] Prospective surveillance of hypertension in firefighters J Clin Hypertens 5315-320
Formatted Font Italic
Formatted Line spacing single
Formatted Font Italic
Formatted Font Italic
44
NFPA 1582‐ Draft Revisions for CVDHTN
EKG and stress tests
Reason for Revision
1) Change requirement for annual resting EKG to periodically to be more consistent with ACCAHA
recommendation (Schlant et al 1992)
2) Add language to clarify what constitutes a positive ST
3) Make criteria for conducting diagnostic ST in asymptomatic patients consistent with the
ACCAHA
Language in 2007 Edition with draft revisions in Red (Track changes)
776 Electrocardiograms (EKG) and Stress Tests 7761 A resting EKG shall be performed as part of the baseline medical evaluation and shall be obtained periodically (every 1 to 5 years) thereafter
A7761 A baseline resting EKGs shall be conducted Follow-up resting EKGs should be conducted as clinically indicated but at a minimum of every 1 to 5 years The frequency of these follow-up resting EKGs should increase as a members age increases or with increasing number andor severity of coronary heart disease risk factors Members above the age of 40 should have annual resting EKGs (Schlant et al 1992)
7762 The fire department physician or other qualified medical evaluator shall compare baseline and subsequent EKGs
7763 Stress testing with or without echocardiography or radionuclide scanning shall be performed as clinically indicated by history or symptoms
A7763 No firm guidelines for stress testing in asymptomatic individuals have been developed Stress testing as a screening tool is used as part of an evaluation of aerobic capacity during the annual occupational fitness evaluation Submaximal stress testing testing to 85 percent is commonly used as part of this screening
Submaximal stress testing should not be used for diagnostic purposes Cardiology evaluation with maximal stress testing together with imaging techniques (eg echocardiography technetium Tc99m sestamibi study) is necessary for diagnosticprognostic purposes for the following
(1) Fire fighters with positive or questionably positive changes on screening submaximal stress tests
(2) Fire fighters with new onset chest pain or other symptoms suggestive of coronary artery disease (CAD)
45
(3) Fire fighters with diabetes mellitus who
(a) are gt35 years old or
(b) have type I diabetes for more than 15 years or
(c) have type II diabetes for more than 10 years or
(d) have any other CHD risk factor (see below) or
(e) have the presence of microvascular disease (proliferative retinopathy)
(4) Fire fighters over the age of 45 (for men) and 55 (for women) with one or more risk factors for CAD Risk factors for CAD include hypercholesterolemia (total cholesterol greater than 240 mgdL) hypertension (systolic gt140 mmHg or diastolic gt90 mmHg) smoking or family history of premature CAD (heart attack or sudden cardiac death in a first degree relative less than 60 years of age)
(5) Fire fighters with a Framingham Risk Score gt10 Risk calculator is available at [httphp2010nhlbihinnetatpiiicalculatorasp]
(6) Fire fighters identified in 9431
Negative stress tests should be repeated as clinically indicated or at least every 2 to 5 years
Interpreting stress tests as ldquopositiverdquo or ldquonegativerdquo is beyond the scope of this document However factors that should be taken into consideration should include the individualrsquos exercise capacity symptoms blood pressure response heart rate response EKG changes and the presence of arrhythmias (Gibbon et al 2002)
There are other non-invasive tests to screen for coronary artery disease One of the most promising appears to be coronary artery calcium (CAD) scoring by computed tomography In 2007 an expert committee published an update to their original guidance document The committeersquos consensus was that ldquoit may be reasonable to consider use of CAC measurement in such patients [between 10 and 20 10-year risk of estimated coronary event]helliprdquo The committee did not recommend CAC measurement in low risk patients [lt10 10-year risk of estimated coronary event] or in high risk patients [gt20 10-year risk of estimate coronary event] (Greenland et al 2007]
D22 Cardiology
Resting EKG and Stress Tests
46
Chobanian AV Bakris GL Black HR Cushman WC Green LA Izzo JL Jr Jones DW Materson BJ Oparil S Wright JT Jr Roccella EJ the National High Blood Pressure Education Program Coordinating Committee [2003] The seventh report of the Joint National Committee [JNC-7] on Prevention Detection Evaluation and Treatment of High Blood Pressure JAMA 2892560ndash2571
Gibbons RJ Balady GJ Bricker JT Chaitman BR Fletcher GF Froelicher VF Mark DB McCallister BD Mooss AN OrsquoReilly MG Winters WL Jr [2002] ACCAHA 2002 guideline update for exercise testing summary article a report of the ACCAHA Task Force on Practice Guidelines (Committee to Update the 1997 Exercise Testing guidelines) J Am Coll Cardiol 401531ndash 1540
Greenland et al [2007] ACCFAHA 2007 Clinical Expert Consensus Document on Coronary Artery Calcium Scoring By Computed Tomography in Global Cardiovascular Risk Assessment and in Evaluation of Patients With Chest Pain A Report of the American College of Cardiology Foundation Clinical Expert Consensus Task Force (ACCFAHA Writing Committee to Update the 2000 Expert Consensus Document on Electron Beam Computed Tomography) J Am Coll Cardiol 49378-402
Kales SN Tsismenakis AJ Zhang C Soteriades ES [2009] Blood pressure in fire fighters police officers and other emergency responders Am J Hypertens 2211-20
Schlant RC Adolph RJ DiMarco JP Dreifus LS Dunn MI Fisch C Garson A Jr Haywood LJ Levine HJ Murray JA Noble RJ Ronan JA Jr [1992] Guidelines for electrocardiography A report of the American College of CardiologyAmerican Heart Association Task Force on Assessment of Diagnostic and Therapeutic Cardiovascular Procedures (Committee on Electrocardiography) Circulation 85(3)1221-1228
Soteriades ES Kales SN Liarokapis D Christiani DC [2003] Prospective surveillance of hypertension in firefighters J Clin Hypertens 5315-320
47
ATTACHMENT F
48
1
Current 1582 (2007) language in reference to pregnancy 43 (4) Report to the fire department physician any medical condition that could interfere with the ability of the individual to safely perform essential job tasks such as illness or injury use of prescription or nonprescription drugs and pregnancy 6112 Category B medical conditions shall include the following (1) Pregnancy for its duration A7792 (e) If HIV prophylaxis is to be given the following tests should be done i CBC ii Glucose renal and hepatic chemical function iii Pregnancy test for females B121 Pregnancy and Reproduction Federal regulations as well as many court decisions including the US Supreme Courtrsquos decision in International Union et al v Johnson Controls Inc [499 US 187 111 S Ct 1196 (1991)] have interpreted the requirements of Title VII with respect to pregnancy and reproduction The AHJ should seek the advice of counsel in resolving specific questions concerning these requirements as well as other requirements that can be imposed by state or local laws C211 (4) Review health status with the individual being evaluated Contraindications for evaluations shall be reviewed addressing any changes in the individualrsquos health status since their last medical evaluation that would warrant deferring the evaluation including (g) Pregnancy Recommendations to language enhancement
A female employee who is assigned to regular fire line duty shall report a pregnancy immediately to their respective Supervisor and the fire department physician The employee will then be given the option of a non-hazardous alternative duty position for the duration of her pregnancy (can we say this or is it even appropriate) Any pregnant employee wishing to remain on regular line duty shall be informed of the possible risks and consequences to herself and her fetus that are associated with continued line fire fighting duty Among those risk factors are exposure to teratogens known to have negative effects on the developing fetus such as smoke diesel fumes hazardous chemicals and extreme heat
49
Page 2
appendix It is recommended that the pregnant employee complete a release of liability form signed by herself and her health care provider utilizing NFPArsquos 13 critical tasks as a reference This will inform the health care provider of specific job-related tasks that will need to be performed in order to continue regular line duty These tasks are basic physical standards that any entry level firefighter would have to be able to complete competently The employeersquos health condition will be kept confidential by the department in accordance with HIPAA standards Employees are allowed to remain on active regular duty until they are no longer able to perform their duties in a reasonable manner andor their protective gear no longer fits correctly It is the responsibility of the health care provider to evaluate the pregnant employee If at any time the health care provider feels the pregnant employee can no longer perform the job related tasks this should be reported to the employer by the employee immediately
50
ATTACHMENT G
51
From GLENN BENARICKTo Sawyer SteveSubject RE RE 7743Date Monday August 30 2010 21633 PM
Yes thats my understanding
Glenn P Benarick 211 Winged Elm CircleAiken SC 29803803-644-7093gbenarprodigynet
--- On Mon 83010 Sawyer Steve ltssawyerNFPAorggt wrote
From Sawyer Steve ltssawyerNFPAorggtSubject RE RE 7743To GLENN BENARICK ltgbenarprodigynetgtDate Monday August 30 2010 212 PM
So it should be ldquoorrdquo instead of ldquoandrdquo for now
Steven F Sawyer
Senior Fire Service Specialist
Executive Secretary IFMAFire Service Section
NFPA
1 Batterymarch Park
Quincy MA 02169
6179847423
Fax 6179847056
ssawyernfpaorg
From GLENN BENARICK [mailtogbenarprodigynet] Sent Monday August 30 2010 1202 PMTo Sawyer SteveSubject Fw RE 7743
52
Steve a couple of our docs agree with April Boyer
Glenn P Benarick 211 Winged Elm Circle
Aiken SC 29803
803-644-7093
gbenarprodigynet
--- On Mon 83010 David Prezant ltprezandfdnynycgovgt wrote
From David Prezant ltprezandfdnynycgovgtSubject RE 7743To Thomas R (CDCNIOSHDSHEFS) Hales lttrh1cdcgovgt GLENNBENARICK ltgbenarprodigynetgtCc Sandy Bogucki ltsandyboguckiyaleedugtDate Monday August 30 2010 1004 AM
agree
we should change this to NHANES III rather than Knudson we should alsomodify this to allow not only for predicted cutoffs but all for use of thelower limit of normal cutoff This is important to prevent false-classificationof spirometry as abnormal in older groups and in taller grps The latter ofparticular import to firefighter occupational health surveillance
thanks
David Prezant MDChief Medical Officer Office of Medical AffairsCo-Director WTC Medical Monitoring amp Treatment ProgramsNew York City Fire Department9 Metrotech Center - Rm 4W-1Brooklyn NY 11201Phone 718-999-2696Fax 718-999-0665
Life is full of twists and turns
53
This email may contain confidential information If you are the unintendedrecipient of this email please send it back and delete from your directory
gtgtgt Hales Thomas R (CDCNIOSHDSHEFS) lttrh1cdcgovgt 8302010955 AM gtgtgt
Glen
This seems like a very reasonable comment and illustrates the importance of having clinicians providefeedback on the std Im not familiar with the software program of the various spirometers (NHANES IIIvs KnudsonATS vs both) Given the large role both Dave Prezant and Sandy Bogucki had for thepulmonary section let me forward to them for clarification
Tom
From GLENN BENARICK [mailtogbenarprodigynet] Sent Sunday August 29 2010 456 PMTo Hales Thomas R (CDCNIOSHDSHEFS)Subject FW 7743
Tom is April Boyer correct
Glenn P Benarick 211 Winged Elm Circle
Aiken SC 29803
803-644-7093
gbenarprodigynet
--- On Thu 82610 Sawyer Steve ltssawyerNFPAorggt wrote
From Sawyer Steve ltssawyerNFPAorggtSubject FW 7743To GLENN BENARICK ltgbenarprodigynetgtDate Thursday August 26 2010 925 PM
FYI Do you have any answer She is write
Steven
54
Steven F Sawyer
Senior Fire Service Specialist
Executive Secretary IFMAFire Service Section
NFPA
1 Batterymarch Park
Quincy MA 02169
6179847423
Fax 6179847056
ssawyernfpaorg
From April Boyer [mailtoaboyerbicclinicorg] Sent Thursday August 26 2010 232 PMTo Sawyer SteveCc RobinMWebbmilstateorusSubject 7743
Steven
The spirometry tests cannot be corrected according to both references as the NFPA states because thereferences are contradictory The first part of 7743 states to follow the ATS guidelines and use theKnudsen (we at Basin Immediate Care use the Nhanes III) The second part states to follow the ACOEMguidelines and use the Nhanes III in the occupational setting if available with your unit (which is availableon ours) 7743 does not use the word OR regarding both requirements it uses the word AND whenreferring to the first and second parts thence making 7743 contradictory I realize the NFPA 1582 hasnot been updated since 2007 unless I have just not received an updated version
Our question to you is which part of 7743 do you want us to follow the first or the second part Anyfacility that has an updated computerized spirometry system (as we do) will not be able to follow bothrequired parts for obvious reasons We can either follow the first part of 7743 and use an oldercorrected version of the Knudson by going into our system and changing out of the Nhanes III conversionOR we can follow the second part of 7743 and use the newer corrected version of Nhanes III which ourunit offers too
If you have any questions you may contact me at anytime and I also have many references in regards toboth parts of 7743 if you would like to see them
55
Thank you~
April
Confidentiality NoticeThis message may contain information that isconfidential or privileged
If you are not the intended recipientPlease advise the sender immediately and delete this message
56
ATTACHMENT H
57
NFPA 1582 771(7) Proposed revisions
Why
Preliminary results of two prospective randomized trials on the PSA test were published in 2009 These studies resulted in medical organizations that previously providing guidance to modify their recommendations
Current language
771 Blood Tests Blood tests shall be performed annually and shall include the following
(7) Prostate specific antigen (PSA) after age 40 for positive family history if African American or if otherwise clinically indicated after age 50 for all other male member
Suggested Revision
771 Blood Tests Blood tests shall be performed annually and shall include the following
(7) Prostate specific antigen (PSA) after age 40 for positive family history if African American or if otherwise clinically indicated after age 50 for all other male member
772 Prostate-Specific Antigen (PSA) test At age 50 fire fighters shall have an opportunity to make an informed decision with either the Fire Department physician or their health care provider concerning the PSA test For fire fighters at increased risk of prostate cancer (African-Americans or those with a first degree relative diagnosed with prostate cancer before age 65) shall have the opportunity for this informed decision at age 40
A772 The PSA as a screening test for prostate cancer in asymptomatic men is controversial controversial for two reasons First there is no consensus that PSA screening actually saves lives For example the PSA test may detect small cancers that would never become life threatening Second it is unclear that the benefits of PSA screening outweigh the risks of follow-up diagnostic tests and cancer treatments For example the prostate biopsy used to diagnose prostate cancer may cause bleeding and infection And prostate cancer treatments such as surgery and radiation therapy may cause incontinence (inability to control urine flow) erectile dysfunction (erections inadequate for intercourse) and other complications For these reasons it is important that the benefits and risks of prostate diagnostic procedures and treatment be taken into account when considering the PSA screening test These considerations can be taken account during discussions with the fire department physician or onersquos health care provider
D211 Cancer Screening
Smith R A C J Mettlin K J Davis and H Eyre 2000 ldquoAmerican Cancer Society guidelines for the early detection of cancerrdquo CA J Clin 50(1)34ndash49
Added references
58
Carroll P Albertsen PC Greene K et al [2010] Prostate-specific antigen best practice statement 2009 update Am Urological Assoc Available at httpwwwauanetorgcontentguidelines-and-quality-careclinical-guidelinesmain-reportspsa09pdf Date accessed September 2010
Ferrini R Woolf SH [2009] Screening for prostate cancer in American men American College of Preventive Medicine Practice Policy Statement Available at httpwwwacpmorgprostatehtm Date accessed September 2010
National Cancer Institute [2009] Prostate-specific antigen test National Cancer Institute Fact Sheet Available at httpwwwcancergovcancertopicsfactsheetDetectionPSA Date accessed September 2010
Wolf AMD Wender RC Etzioni RB et al [2010] American Cancer Society guideline for the early detection of prostate cancer Update 2010 Available at httpcaonlineamcancersocorgcgicontentfullcaac20066v1 Date accessed September 2010
59
438 ndash APPENDIX B PHYSICIAN EVALUATION FORM FOR THE LEO WITH DIABETES
The following evaluation form is based on the guidance established by the American College of Occupational and Environ-
mental Medicine (ACOEM)
I INTRODUCTION
The educated and motivated law enforcement officer (LEO) or applicant with well-managed diabetes mellitus can be
capable of safe and effective job performance An individualized assessment of the LEOrsquos or applicantrsquos diabetes should
be performed including an assessment of the following
history of blood glucose control
current stability of blood glucose
risk for significant hypoglycemia or hyperglycemia
presence of diabetic complications and
knowledge of diabetes and its management
Risk of hypoglycemia remains the major concern in regard to those with diabetes being or becoming LEOs This risk
occurs primarily in those taking insulin particularly those with type 1 diabetes although it may also occur in those with
type 2 diabetes who take insulin andor sulfonylureas and other secretagogues
Law enforcement entails a unique set of conditions that need to be considered in regard to those with diabetes and the risks of
either hypo or hyperglycemia These may include (depending upon the duties of the particular LEO position)
unpredictable meal schedules
brief periods of maximal physical exertion
prolonged driving with responsibility for others in the vehicle
high-speed pursuit driving
surveillance requiring sustained attention for prolonged periods of time
rapid decision making regarding the use of force including deadly force
rapid analysis of complex visual stimuli to differentiate weapons from other objects and
control of onersquos emotions under stress
II ASSESSMENT
1 LEO has been under the care of an endocrinologist or other physician knowledgeable about diabetes management
Outpatient and in-patient medical record(s) of the last three years or since date of diagnosis (whichever is shorter)
should be reviewed by the treating physician and provided to the police physician
My credentials as a physician knowledgeable about diabetes management are as follows (or attach CV)
Urine microalbumincreatinine ratio _________________
III Treating Physician Statement
The above named individual meets all of the criteria provided on this form
Yes No ndash not recommended for position
No but IS recommended for position (letter of explanation attached)
It is my opinion that the above named individual is well-educated and well-motivated in diabetes self-management and has
achieved a level of diabetes management to be capable of safe and effective job performance as a law enforcement officer
I have reached this opinion after careful review of the above criteria
___________________________________________________________ ___________________________Signature of Physician Date
______________________________________________________________ ___________________________Printed or Typed Name of Physician Telephone Number
10 ACOEM Guidance for the Medical Evaluation of Law Enforcement Officers
43 ndash DIABETES MELLITUS
29
439 ndash REFERENCES
1 American Diabetes Association Diagnosis and classification of diabetes mellitus Diabetes Care 200427 Suppl
1S5-S10 See httpcarediabetesjournalsorgcgicontentfull27suppl_1s5
2 American Diabetes Association Continuous subcutaneous insulin infusion Diabetes Care 200427 Suppl 1S110
See httpcarediabetesjournalsorgcgicontentfull27suppl_1s110
3 Mensing C Boucher J Cypress M et al National standards for diabetes self-management education Diabetes
Care 200528 Suppl 1S72-9 See httpcarediabetesjournalsorgcgicontentfull28suppl_1s72
4 Goldstein DE Little RR Lorenz RA Malone JI Nathan DM Peterson CM American Diabetes Association Tests
of glycemia in diabetes Diabetes Care 200427 Suppl 1S91-3
See httpcarediabetesjournalsorgcgicontentfull27suppl_1s91
5 The Diabetes Control and Complications Trial Research Group Hypoglycemia in the Diabetes Control and
Complications Trial Diabetes 199746(2)271-86 See wwwncbinlmnihgovpubmed9000705 for abstract
6 American Diabetes Association Hypoglycemia and employmentlicensure Diabetes Care 200528 Suppl 1S61
See httpcarediabetesjournalsorgcgicontentfull28suppl_1s61
7 Viswanath K McGavin DD Diabetic Retinopathy Clinical Findings and Management J Comm Eye Health
200316(46)21-4 See wwwcehjournalorg0953-683316jceh_16_46_021html
8 Michigan Diabetes Research and Training Center University of Michigan Health System How to use the Michigan
Neuropathy Screening Instrument See wwwmedumichedumdrtcprofsdocumentssviMNSI_howtopdf
9 Bradley JG Davis KA Orthostatic hypotension Am Fam Physician 200368(12)2393-8
See wwwaafporgafp200312152393html
10 Gibbons RJ Balady GJ Bricker JT et al ACCAHA 2002 guideline update for exercise testing a report of the
American College of CardiologyAmerican Heart Association Task Force on Practice Guidelines (Committee on
Exercise Testing) J Am Coll Cardiol 200240(8)1531-40
See wwwaccorgqualityandscienceclinicalguidelinesexerciseexercise_cleanpdf
11 American Diabetes Association Standards of medical care in diabetes Diabetes Care 200528 Suppl 1S4-S36
Erratum in Diabetes Care 200528(4)990 See httpcarediabetesjournalsorgcgicontentfull28suppl_1s4
12 Molitch ME DeFronzo RA Franz MJ et al American Diabetes Association Nephropathy in diabetes Diabetes
Care 200427 Suppl 1S79-83 See httpcarediabetesjournalsorgcgicontentfull27suppl_1s79
13 Kitabchi AE Umpierrez GE Murphy MB et al American Diabetes Association Hyperglycemic crises in diabetes
Diabetes Care 200427 Suppl 1S94-102 See httpcarediabetesjournalsorgcgicontentfull27suppl_1s94
14 US Centers for Disease Control and Prevention National Diabetes Fact Sheet 2007
See wwwcdcgovdiabetespubspdfndfs_2007pdf
ACOEM Guidance for the Medical Evaluation of Law Enforcement Officers 11
43 ndash DIABETES MELLITUS
30
ATTACHMENT E
31
Typos A6921(2) 7th line down test should be plural 94201 Paragraph 2 target organ damage is used though end organ damage was defined earlier and in the appendix for that paragraph
A94201 Para A (1) d Id suggest deleting the phrases in brackets Im not sure either are predictably true or politically wise
a) tests for left ventricular hypertrophy Unfortunately use of the EKG to detect left ventricular hypertrophy is very insensitive (eg 5 sensitivity) The echocardiogram is the best test for diagnosing left ventricular hypertrophy but [it is relatively expensive and not readily available in small rural communities ] conducting echocardiograms on asymptomatic fire fighters with Stage 1 hypertension should be reserved only for those with long-standing hypertension
In addition
7761 A resting EKG shall be performed as part of the baseline medical evaluation and shall be obtained periodically thereafter
Changing from annually to periodically is noted has the language in the wellness-fitness initiative been changed as well Our previous decision was that we would support the W-F language since there was no compelling evidence to either support or refute it
Thanks
Sandy
32
NFPA 1582‐ HTN Draft 1
Reason for Revision
1) New classification of BP by the Joint National Commission [Chobanian et al 2002]
2) A high prevalence of FF have either HTN (~20) and Pre‐HTN (~20) [Soteriades et al 2003]
3) Among FF studies have shown a strong association between HTN and a number of adverse
cardiovascular events [Kales et al 2009]
4) A large percentage of on‐duty FF fatalities were found to have left ventricular hypertrophy a
complication of HTN at autopsy
Language in 2007 Edition with draft revisions in Red (Track changes)
611 The medical evaluation of a candidate shall include a medical history examination and any laboratory tests required to detect physical or medical condition(s) that could adversely affect hisher ability to safely perform the essential job tasks outlined in 511 A611 The medical history should include the candidates known health problems such as major illnesses surgeries medication use and allergies Symptom review is also important for detecting early signs of illness A medical history should also include a personal health history a family health history a health habit history an immunization history and a reproductive history
An occupational history should also be obtained to collect information about the persons past occupational and environmental exposures
(a) BP should be measured according to the Joint National Commission (JNC) -7 recommendations BP should be measured with a properly calibrated and validated instrument Patients should be seated quietly for at least 5 minutes in a chair with feet on the floor and arm supported at heart level An appropriate-sized cuff (cuff bladder encircling at least 80 of the arm) should be used to ensure accuracy At least 2 measurements should be made Systolic BP is the point at which the first of 2 or more sounds is heard (phase 1) and diastolic BP is the point before the disappearance of sounds (phase 5) [Chobanian et al 2003]
(2) Head eyes ears nose and throat (HEENT)
Formatted Font (Default) Times New RomanFont color Black
33
692 Vascular System 6921 Category A medical conditions shall include the following
(1) Uncontrolled or poorly controlled hypertension
(2) Hypertension with evidence of end organ damage
or not controlled by approved medications
A6921(1) Uncontrolled or poorly controlled hHypertension increases the risk of a sudden cardiac event This sudden cardiac event would cause sudden incapacitation which that is uncontrolled poorly controlled or requires medication likely to interferes with the safe performance of essential job tasks Uncontrolled or poorly controlled hypertension can be defined as the presence of end organ damage (see below) or stage 2 hypertension (BP systolic gt160 mmHg or BP diastolic gt100 mmHg) is an illness that can lead to functional impairment and potential for sudden incapacitation Individuals with pre- stage 1 or stage 2 hypertension should be referred to their primary care physician for evaluation lifestyle modification and treatment [QUESTION FOR GROUP _- WHAT ABOUT HAVING CANDIDATE RETURN IN ONE MONTH UNDER TREATMENT WITH NORMAL BP]
A6921(2)
Chronic hypertension can damage the eye (retinopathy) the kidneys (nephropathy) the vascular system (stroke transient ischemic attack or peripheral artery disease) or the heart (left ventricular hypertrophy and heart failure) These hypertension complications are known as end organ damage The cardiac and vascular complications are associated with an increased risk of sudden incapacitation and sudden cardiac death (Koren et al 1991) Unfortunately the cardiac complications are frequently asymptomatic and valid screening tests are not fast and are not inexpensive Therefore determining who to screen for cardiac complications (such as echocardiogram for LVH or a measurement of left ventricular ejection fraction for heart failure) should be based on the severity and the duration of HTN
76 Physical Examination The annual physical examination shall include each of the following components
(a) BP shall be measured according to the Joint National Commission (JNC)-7 recommendations
A76(1)(a) BP should be measured with a properly calibrated and validated instrument Patients should be seated quietly for at least 5 minutes in a chair with feet on the floor and arm supported at heart level An appropriate-sized cuff (cuff bladder encircling at least 80 of the arm) should be used to ensure accuracy At least 2 measurements should be made Systolic BP is the point at which the first of 2 or more sounds is heard (phase 1) and diastolic BP is the point before the disappearance of sounds (phase 5) [Chobanian et al 2003]
(2) Head eyes ears nose and throat (HEENT)
34
9420 Uncontrolled Hypertension 94201 Physician Evaluation Severe uncontrolled hypertension [defined as systolic pressure greater than 180 mm Hg diastolic pressure greater than 100 mm Hg or mean systolic blood
pressure ( systolic + diastolic) greater than 120 mm Hg] or malignant hypertension (defined as hypertension with the presence of target organ damage) compromises the members ability to safely perform essential job tasks 1 5 7 9 and 13 and the physician shall report the applicable job limitations to the fire department
Members with Pre-hypertention (systolic 120-139 mmHg or diastolic 80-89 mmHg) Stage 1 hypertension (systolic 140-159 mmHg or diastolic 90-99 mmHg) or Stage 2 hypertension (systolic ge160 mmHg or diastolic ge100 mmHg) should be referred to their primary care physician for evaluation lifestyle modification and treatment
(1) Members with Stage I hypertension should be followed-up not only by their primary care physician but also by the FD physician every 3 to 6 months to ensure their blood pressure is under control and to determine whether screening tests for asymptomatic end organ damage are appropriate
(2) Members with Stage 2 hypertension or with end organ damage (retinopathy nephropathy vascular or cardiac complications) compromises the members ability to safely perform essential job tasks 1 5 7 9 and 130 and the physician shall report the applicable job limitations to the fire department
A94201 Severe uncontrolled hypertension is a significant risk factor for the development of coronary artery disease congestive heart failure and stroke Blood pressure increases as a normal response to exercise This response is further exaggerated by the emotional and physical stress of performing these critical tasks while operating in personal protective clothing at extremes of temperature This normal elevation of blood pressure under these response conditions can lead to life-threatening hypertensive emergencies if a members daily blood pressure is already elevated to high levels In addition hypertension is a progressive illness that when uncontrolled ultimately and inevitably leads to target organ damage Target organs that are sensitive to the effects of elevated blood pressure are the central nervous system vision heart major blood vessels and kidneys
Chronic hypertension can damage the eye (retinopathy) the kidneys (nephropathy) the vascular system (stroke transient ischemic attack or peripheral artery disease) or the heart (left ventricular hypertrophy and heart failure) These hypertension complications are known as end organ damage The cardiac and vascular complications are associated with an increased risk of sudden incapacitation and sudden cardiac death (Koren et al 1991) Fortunately with proper evaluation life style modification and treatment these complications can be avoided Life style modification includes weight reduction DASH eating plan reduction in dietary sodium an increase in aerobic physical activity and moderation in alcohol consumption [Chobanian 2003]
Formatted Font (Default) Times New Roman12 pt Font color Black
Formatted Font (Default) Times New Roman12 pt Font color Black
35
A94201 (1) Members with Stage I hypertension whose BP returns to either pre-hypertenion or normal with lifestyle modification andor treatment can return to an annual medical evaluation For members with long-standing Stage I hypertension whose BP has not been reduced additional evaluation for possible end organ damage should be considered This evaluation could include any or all of the following
a) a compete patient history for symptoms of heart failure (eg shortness of breath upon exertion) or transient ischemic attacks (TIAs)
b) dilated eye examination for retinopathy
c) blood creatinine measurement for nephropathy
d) tests for left ventricular hypertrophy Unfortunately use of the resting EKG to detect left ventricular hypertrophy is very insensitive (eg 5 sensitivity) The echocardiogram is the best test for diagnosing left ventricular hypertrophy
A 94201 (2) Due to the high risk of a sudden cardiovascular event members with Stage 2 hypertension should be restricted until their BP can be brought under control Once the BP is brought under control they should be followed in the same manner as a member with Stage I hypertension
Formatted Font (Default) Times New Roman12 pt
36
D22 Cardiology Gibbons R J GJ Balady J W Beasley et al 1997 ACCAHA guidelines for exercise testing a report of American College of CardiologyAmerican Heart Association Task Force on Practice Guidelines (Committee on Exercise Testing) J Am Coll Cardiol 30260ndash311
Gibbons RJ Balady GJ Bricker JT Chaitman BR Fletcher GF Froelicher VF Mark DB McCallister BD Mooss AN OrsquoReilly MG Winters WL Jr [2002] ACCAHA 2002 guideline update for exercise testing summary article a report of the ACCAHA Task Force on Practice Guidelines (Committee to Update the 1997 Exercise Testing guidelines) J Am Coll Cardiol 401531ndash 40
Chobanian AV Bakris GL Black HR Cushman WC Green LA Izzo JL Jr Jones DW Materson BJ Oparil S Wright JT Jr Roccella EJ the National High Blood Pressure Education Program Coordinating Committee [2003] The seventh report of the Joint National Committee [JNC-7] on Prevention Detection Evaluation and Treatment of High Blood Pressure JAMA 2892560ndash2571
Soteriades ES Kales SN Liarokapis D Christiani DC [2003] Prospective surveillance of hypertension in firefighters J Clin Hypertens 5315-320
Kales SN Tsismenakis AJ Zhang C Soteriades ES [2009] Blood pressure in fire fighters police officers and other emergency responders Am J Hypertens 2211-20
37
NFPA 1582‐ HTN Draft 1
Reason for Revision
1) New classification of BP by the Joint National Commission [Chobanian et al 2002]
2) A high prevalence of FF have either HTN (~20) and Pre‐HTN (~20) [Soteriades et al 2003]
3) Among FF studies have shown a strong association between HTN and a number of adverse
cardiovascular events [Kales et al 2009]
4) A large percentage of on‐duty FF fatalities were found to have left ventricular hypertrophy a
complication of HTN at autopsy
Language in 2007 Edition with draft revisions in Red (Track changes)
611 The medical evaluation of a candidate shall include a medical history examination and any laboratory tests required to detect physical or medical condition(s) that could adversely affect hisher ability to safely perform the essential job tasks outlined in 511 A611 The medical history should include the candidates known health problems such as major illnesses surgeries medication use and allergies Symptom review is also important for detecting early signs of illness A medical history should also include a personal health history a family health history a health habit history an immunization history and a reproductive history
An occupational history should also be obtained to collect information about the persons past occupational and environmental exposures
(a) BP should be measured according to the Joint National Commission (JNC) -7 recommendations BP should be measured with a properly calibrated and validated instrument Patients should be seated quietly for at least 5 minutes in a chair with feet on the floor and arm supported at heart level An appropriate-sized cuff (cuff bladder encircling at least 80 of the arm) should be used to ensure accuracy At least 2 measurements should be made Systolic BP is the point at which the first of 2 or more sounds is heard (phase 1) and diastolic BP is the point before the disappearance of sounds (phase 5) [Chobanian et al 2003]
(2) Head eyes ears nose and throat
38
692 Vascular System 6921 Category A medical conditions shall include the following
(1) Uncontrolled or poorly controlled hypertension
(2) Hypertension with evidence of end organ damage
A6921(1) Uncontrolled or poorly controlled hypertension increases the risk of a sudden cardiac event This sudden cardiac event would cause sudden incapacitation which interferes with the safe performance of essential job tasks Uncontrolled or poorly controlled hypertension can be defined as the presence of end organ damage (see below) or stage 2 hypertension (BP systolic gt160 mmHg or BP diastolic gt100 mmHg) Individuals with pre- stage 1 or stage 2 hypertension should be referred to their primary care physician for evaluation lifestyle modification and treatment [QUESTION FOR GROUP _- WHAT ABOUT HAVING CANDIDATE RETURN IN ONE MONTH UNDER TREATMENT WITH NORMAL BP]
A6921(2)Chronic hypertension can damage the eye (retinopathy) the kidneys (nephropathy) the vascular system (stroke transient ischemic attack or peripheral artery disease) or the heart (left ventricular hypertrophy and heart failure) These hypertension complications are known as end organ damage The cardiac and vascular complications are associated with an increased risk of sudden incapacitation and sudden cardiac death (Koren et al 1991) Unfortunately the cardiac complications are frequently asymptomatic and valid screening tests are not fast and are not inexpensive Therefore determining who to screen for cardiac complications (such as echocardiogram for LVH or a measurement of left ventricular ejection fraction for heart failure) should be based on the severity and the duration of HTN
76 Physical Examination The annual physical examination shall include each of the following components
(a) BP shall be measured according to the Joint National Commission (JNC)-7 recommendations
A76(1)(a) BP should be measured with a properly calibrated and validated instrument Patients should be seated quietly for at least 5 minutes in a chair with feet on the floor and arm supported at heart level An appropriate-sized cuff (cuff bladder encircling at least 80 of the arm) should be used to ensure accuracy At least 2 measurements should be made Systolic BP is the point at which the first of 2 or more sounds is heard (phase 1) and diastolic BP is the point before the disappearance of sounds (phase 5) [Chobanian et al 2003]
(2) Head eyes ears nose and throat9420 Hypertension 94201 Physician Evaluation Members with Pre-hypertention (systolic 120-139 mmHg or diastolic 80-89 mmHg) Stage 1 hypertension (systolic 140-159 mmHg or diastolic 90-99 mmHg) or Stage 2 hypertension (systolic ge160 mmHg or diastolic ge100 mmHg) should be referred to their primary care physician for evaluation lifestyle modification and treatment
39
(1) Members with Stage I hypertension should be followed-up not only by their primary care physician but also by the FD physician every 3 to 6 months to ensure their blood pressure is under control and to determine whether screening tests for asymptomatic end organ damage are appropriate
(2) Members with Stage 2 hypertension or with end organ damage (retinopathy nephropathy vascular or cardiac complications) compromises the members ability to safely perform essential job tasks 1 5 7 9 and 130 and the physician shall report the applicable job limitations to the fire department
A94201 Chronic hypertension can damage the eye (retinopathy) the kidneys (nephropathy) the vascular system (stroke transient ischemic attack or peripheral artery disease) or the heart (left ventricular hypertrophy and heart failure) These hypertension complications are known as end organ damage The cardiac and vascular complications are associated with an increased risk of sudden incapacitation and sudden cardiac death (Koren et al 1991) Fortunately with proper evaluation life style modification and treatment these complications can be avoided Life style modification includes weight reduction DASH eating plan reduction in dietary sodium an increase in aerobic physical activity and moderation in alcohol consumption [Chobanian 2003]
A94201 (1) Members with Stage I hypertension whose BP returns to either pre-hypertenion or normal with lifestyle modification andor treatment can return to an annual medical evaluation For members with long-standing Stage I hypertension whose BP has not been reduced additional evaluation for possible end organ damage should be considered This evaluation could include any or all of the following
a) a compete patient history for symptoms of heart failure (eg shortness of breath upon exertion) or transient ischemic attacks (TIAs)
b) dilated eye examination for retinopathy
c) blood creatinine measurement for nephropathy
d) tests for left ventricular hypertrophy Unfortunately use of the resting EKG to detect left ventricular hypertrophy is very insensitive (eg 5 sensitivity) The echocardiogram is the best test for diagnosing left ventricular hypertrophy
A 94201 (2) Due to the high risk of a sudden cardiovascular event members with Stage 2 hypertension should be restricted until their BP can be brought under control Once the BP is brought under control they should be followed in the same manner as a member with Stage I hypertension
D22 Cardiology
40
Hypertension
Gibbons RJ Balady GJ Bricker JT Chaitman BR Fletcher GF Froelicher VF Mark DB McCallister BD Mooss AN OrsquoReilly MG Winters WL Jr [2002] ACCAHA 2002 guideline update for exercise testing summary article a report of the ACCAHA Task Force on Practice Guidelines (Committee to Update the 1997 Exercise Testing guidelines) J Am Coll Cardiol 401531ndash 40
Chobanian AV Bakris GL Black HR Cushman WC Green LA Izzo JL Jr Jones DW Materson BJ Oparil S Wright JT Jr Roccella EJ the National High Blood Pressure Education Program Coordinating Committee [2003] The seventh report of the Joint National Committee [JNC-7] on Prevention Detection Evaluation and Treatment of High Blood Pressure JAMA 2892560ndash2571
Soteriades ES Kales SN Liarokapis D Christiani DC [2003] Prospective surveillance of hypertension in firefighters J Clin Hypertens 5315-320
Kales SN Tsismenakis AJ Zhang C Soteriades ES [2009] Blood pressure in fire fighters police officers and other emergency responders Am J Hypertens 2211-20
41
NFPA 1582‐ Draft Revisions for CVDHTN
EKG and stress tests
Reason for Revision
1) Change requirement for annual resting EKG to periodically to be more consistent with ACCAHA
recommendation (Schlant et al 1992)
2) Add language to clarify what constitutes a positive ST
3) Make criteria for conducting diagnostic ST in asymptomatic patients consistent with the
ACCAHA
Language in 2007 Edition with draft revisions in Red (Track changes)
776 Electrocardiograms (EKG)) and Stress Tests 7761 A resting EKG shall be performed as part of the baseline medical evaluation and shall be obtained periodically (every 1 to 5 years) annually thereafter
A7761 A baseline resting EKGs shall be conducted Follow-up resting EKGs should be conducted as clinically indicated but at a minimum of every 1 to 5 years The frequency of these follow-up resting EKGs should increase as a members age increases or with increasing number andor severity of coronary heart disease risk factors Members above the age of 40 should have annual resting EKGs (Schlant et al 1992)
7762 The fire department physician or other qualified medical evaluator shall compare EKGs obtained during yearly evaluations with baseline and subsequent EKGs
7763 Stress testing EKG with or without echocardiography or radionuclide scanning shall be performed as clinically indicated by history or symptoms
A7761 Baseline electrocardiography should be conducted (Periodic resting electrocardiograms have not been shown to be useful but can be reasonable as a members agefactors increase)
A7763 No firm guidelines for stress testingelectrocardiography in asymptomatic individuals have been developed Stress testingelectrocardiography as a screening tool is used as part of an evaluation of aerobic capacity during the annual occupational fitness evaluation Submaximal stress testingelectrocardiography testing to 85 percent is commonly used as part of this screening
Submaximal stress electrocardiography testing should not be used for diagnostic purposes Cardiology evaluation with maximal stress testingelectrocardiography together with imaging techniques (eg echocardiography technetium Tc99m sestamibi study andor coronary angiography) is necessary for diagnosticprognostic purposes for the following
42
(1) Fire fighters with positive or questionably positive changes on screening submaximal stress tests
(2) Fire fighters with new onset chest pain or other symptoms suggestive of coronary artery disease (CAD)
(3) Fire fighters with diabetes mellitus who
(a) are gt35 years old or
(b) have type I diabetes for more than 15 years or
(c) have type II diabetes for more than 10 years or
(d) have any other CHD risk factor (see below) or
(e) have the presence of microvascular disease (proliferative retinopathy)
(4) Fire fighters over the age of 45 (for men) and 55 (for women) with onetwo or more risk factors for CAD Risk factors for CAD include hypercholesterolemia (total cholesterol greater than 240 mgdL) hypertension (systolic gt140 mmHg or diastolic gt90 mmHg) smoking or family history of premature CAD (heart attack or sudden cardiac death in a first degree relative less than 60 years of age)
as defined below if stress electrocardiography with imaging is negative then repeat as clinically indicated or at least every 5 years
(5) Fire fighters with a Framingham Risk Score gt10 Risk calculator is available at [httphp2010nhlbihinnetatpiiicalculatorasp]
(6) Fire fighters identified in 9431
Negative stress tests should be repeated as clinically indicated or at least every 2 to 5 years
Interpreting stress tests as ldquopositiverdquo or ldquonegativerdquo is beyond the scope of this document However factors that should be taken into consideration should include the individualrsquos exercise capacity symptoms blood pressure response heart rate response EKG changes and the presence of arrhythmias (Gibbon et al 2002)
Risk factors for CAD include hypercholesterolemia (total cholesterol greater than 240 mgdL) hypertension (systolic greater than 140 andor diastolic greater than 90) smoking diabetes mellitus or family history of premature CAD (heart attack or sudden cardiac death in a first degree relative less than 60 years of age)
There are other non-invasive tests to screen for coronary artery disease One of the most promising appears to be coronary artery calcium (CAD) scoring by computed tomography In 2007 an expert committee published an update to their original guidance document The committeersquos consensus was that ldquoit may be reasonable to consider use of CAC measurement in such patients [between 10 and 20 10-year risk of estimated coronary event]helliprdquo The committee did not recommend CAC measurement in low risk patients [lt10 10-year risk of estimated coronary event] or in high risk patients [gt20 10-year risk of estimate coronary event] (Greenland et al 2007]
43
D22 Cardiology
Chobanian AV Bakris GL Black HR Cushman WC Green LA Izzo JL Jr Jones DW Materson BJ Oparil S Wright JT Jr Roccella EJ the National High Blood Pressure Education Program Coordinating Committee [2003] The seventh report of the Joint National Committee [JNC-7] on Prevention Detection Evaluation and Treatment of High Blood Pressure JAMA 2892560ndash2571
Gibbons RJ Balady GJ Bricker JT Chaitman BR Fletcher GF Froelicher VF Mark DB McCallister BD Mooss AN OrsquoReilly MG Winters WL Jr [2002] ACCAHA 2002 guideline update for exercise testing summary article a report of the ACCAHA Task Force on Practice Guidelines (Committee to Update the 1997 Exercise Testing guidelines) J Am Coll Cardiol 401531ndash 1540
Greenland et al [2007] ACCFAHA 2007 Clinical Expert Consensus Document on Coronary Artery Calcium Scoring By Computed Tomography in Global Cardiovascular Risk Assessment and in Evaluation of Patients With Chest Pain A Report of the American College of Cardiology Foundation Clinical Expert Consensus Task Force (ACCFAHA Writing Committee to Update the 2000 Expert Consensus Document on Electron Beam Computed Tomography) J Am Coll Cardiol 49378-402
Kales SN Tsismenakis AJ Zhang C Soteriades ES [2009] Blood pressure in fire fighters police officers and other emergency responders Am J Hypertens 2211-20
Schlant RC Adolph RJ DiMarco JP Dreifus LS Dunn MI Fisch C Garson A Jr Haywood LJ Levine HJ Murray JA Noble RJ Ronan JA Jr [1992] Guidelines for electrocardiography A report of the American College of CardiologyAmerican Heart Association Task Force on Assessment of Diagnostic and Therapeutic Cardiovascular Procedures (Committee on Electrocardiography) Circulation 85(3)1221-1228
Soteriades ES Kales SN Liarokapis D Christiani DC [2003] Prospective surveillance of hypertension in firefighters J Clin Hypertens 5315-320
Formatted Font Italic
Formatted Line spacing single
Formatted Font Italic
Formatted Font Italic
44
NFPA 1582‐ Draft Revisions for CVDHTN
EKG and stress tests
Reason for Revision
1) Change requirement for annual resting EKG to periodically to be more consistent with ACCAHA
recommendation (Schlant et al 1992)
2) Add language to clarify what constitutes a positive ST
3) Make criteria for conducting diagnostic ST in asymptomatic patients consistent with the
ACCAHA
Language in 2007 Edition with draft revisions in Red (Track changes)
776 Electrocardiograms (EKG) and Stress Tests 7761 A resting EKG shall be performed as part of the baseline medical evaluation and shall be obtained periodically (every 1 to 5 years) thereafter
A7761 A baseline resting EKGs shall be conducted Follow-up resting EKGs should be conducted as clinically indicated but at a minimum of every 1 to 5 years The frequency of these follow-up resting EKGs should increase as a members age increases or with increasing number andor severity of coronary heart disease risk factors Members above the age of 40 should have annual resting EKGs (Schlant et al 1992)
7762 The fire department physician or other qualified medical evaluator shall compare baseline and subsequent EKGs
7763 Stress testing with or without echocardiography or radionuclide scanning shall be performed as clinically indicated by history or symptoms
A7763 No firm guidelines for stress testing in asymptomatic individuals have been developed Stress testing as a screening tool is used as part of an evaluation of aerobic capacity during the annual occupational fitness evaluation Submaximal stress testing testing to 85 percent is commonly used as part of this screening
Submaximal stress testing should not be used for diagnostic purposes Cardiology evaluation with maximal stress testing together with imaging techniques (eg echocardiography technetium Tc99m sestamibi study) is necessary for diagnosticprognostic purposes for the following
(1) Fire fighters with positive or questionably positive changes on screening submaximal stress tests
(2) Fire fighters with new onset chest pain or other symptoms suggestive of coronary artery disease (CAD)
45
(3) Fire fighters with diabetes mellitus who
(a) are gt35 years old or
(b) have type I diabetes for more than 15 years or
(c) have type II diabetes for more than 10 years or
(d) have any other CHD risk factor (see below) or
(e) have the presence of microvascular disease (proliferative retinopathy)
(4) Fire fighters over the age of 45 (for men) and 55 (for women) with one or more risk factors for CAD Risk factors for CAD include hypercholesterolemia (total cholesterol greater than 240 mgdL) hypertension (systolic gt140 mmHg or diastolic gt90 mmHg) smoking or family history of premature CAD (heart attack or sudden cardiac death in a first degree relative less than 60 years of age)
(5) Fire fighters with a Framingham Risk Score gt10 Risk calculator is available at [httphp2010nhlbihinnetatpiiicalculatorasp]
(6) Fire fighters identified in 9431
Negative stress tests should be repeated as clinically indicated or at least every 2 to 5 years
Interpreting stress tests as ldquopositiverdquo or ldquonegativerdquo is beyond the scope of this document However factors that should be taken into consideration should include the individualrsquos exercise capacity symptoms blood pressure response heart rate response EKG changes and the presence of arrhythmias (Gibbon et al 2002)
There are other non-invasive tests to screen for coronary artery disease One of the most promising appears to be coronary artery calcium (CAD) scoring by computed tomography In 2007 an expert committee published an update to their original guidance document The committeersquos consensus was that ldquoit may be reasonable to consider use of CAC measurement in such patients [between 10 and 20 10-year risk of estimated coronary event]helliprdquo The committee did not recommend CAC measurement in low risk patients [lt10 10-year risk of estimated coronary event] or in high risk patients [gt20 10-year risk of estimate coronary event] (Greenland et al 2007]
D22 Cardiology
Resting EKG and Stress Tests
46
Chobanian AV Bakris GL Black HR Cushman WC Green LA Izzo JL Jr Jones DW Materson BJ Oparil S Wright JT Jr Roccella EJ the National High Blood Pressure Education Program Coordinating Committee [2003] The seventh report of the Joint National Committee [JNC-7] on Prevention Detection Evaluation and Treatment of High Blood Pressure JAMA 2892560ndash2571
Gibbons RJ Balady GJ Bricker JT Chaitman BR Fletcher GF Froelicher VF Mark DB McCallister BD Mooss AN OrsquoReilly MG Winters WL Jr [2002] ACCAHA 2002 guideline update for exercise testing summary article a report of the ACCAHA Task Force on Practice Guidelines (Committee to Update the 1997 Exercise Testing guidelines) J Am Coll Cardiol 401531ndash 1540
Greenland et al [2007] ACCFAHA 2007 Clinical Expert Consensus Document on Coronary Artery Calcium Scoring By Computed Tomography in Global Cardiovascular Risk Assessment and in Evaluation of Patients With Chest Pain A Report of the American College of Cardiology Foundation Clinical Expert Consensus Task Force (ACCFAHA Writing Committee to Update the 2000 Expert Consensus Document on Electron Beam Computed Tomography) J Am Coll Cardiol 49378-402
Kales SN Tsismenakis AJ Zhang C Soteriades ES [2009] Blood pressure in fire fighters police officers and other emergency responders Am J Hypertens 2211-20
Schlant RC Adolph RJ DiMarco JP Dreifus LS Dunn MI Fisch C Garson A Jr Haywood LJ Levine HJ Murray JA Noble RJ Ronan JA Jr [1992] Guidelines for electrocardiography A report of the American College of CardiologyAmerican Heart Association Task Force on Assessment of Diagnostic and Therapeutic Cardiovascular Procedures (Committee on Electrocardiography) Circulation 85(3)1221-1228
Soteriades ES Kales SN Liarokapis D Christiani DC [2003] Prospective surveillance of hypertension in firefighters J Clin Hypertens 5315-320
47
ATTACHMENT F
48
1
Current 1582 (2007) language in reference to pregnancy 43 (4) Report to the fire department physician any medical condition that could interfere with the ability of the individual to safely perform essential job tasks such as illness or injury use of prescription or nonprescription drugs and pregnancy 6112 Category B medical conditions shall include the following (1) Pregnancy for its duration A7792 (e) If HIV prophylaxis is to be given the following tests should be done i CBC ii Glucose renal and hepatic chemical function iii Pregnancy test for females B121 Pregnancy and Reproduction Federal regulations as well as many court decisions including the US Supreme Courtrsquos decision in International Union et al v Johnson Controls Inc [499 US 187 111 S Ct 1196 (1991)] have interpreted the requirements of Title VII with respect to pregnancy and reproduction The AHJ should seek the advice of counsel in resolving specific questions concerning these requirements as well as other requirements that can be imposed by state or local laws C211 (4) Review health status with the individual being evaluated Contraindications for evaluations shall be reviewed addressing any changes in the individualrsquos health status since their last medical evaluation that would warrant deferring the evaluation including (g) Pregnancy Recommendations to language enhancement
A female employee who is assigned to regular fire line duty shall report a pregnancy immediately to their respective Supervisor and the fire department physician The employee will then be given the option of a non-hazardous alternative duty position for the duration of her pregnancy (can we say this or is it even appropriate) Any pregnant employee wishing to remain on regular line duty shall be informed of the possible risks and consequences to herself and her fetus that are associated with continued line fire fighting duty Among those risk factors are exposure to teratogens known to have negative effects on the developing fetus such as smoke diesel fumes hazardous chemicals and extreme heat
49
Page 2
appendix It is recommended that the pregnant employee complete a release of liability form signed by herself and her health care provider utilizing NFPArsquos 13 critical tasks as a reference This will inform the health care provider of specific job-related tasks that will need to be performed in order to continue regular line duty These tasks are basic physical standards that any entry level firefighter would have to be able to complete competently The employeersquos health condition will be kept confidential by the department in accordance with HIPAA standards Employees are allowed to remain on active regular duty until they are no longer able to perform their duties in a reasonable manner andor their protective gear no longer fits correctly It is the responsibility of the health care provider to evaluate the pregnant employee If at any time the health care provider feels the pregnant employee can no longer perform the job related tasks this should be reported to the employer by the employee immediately
50
ATTACHMENT G
51
From GLENN BENARICKTo Sawyer SteveSubject RE RE 7743Date Monday August 30 2010 21633 PM
Yes thats my understanding
Glenn P Benarick 211 Winged Elm CircleAiken SC 29803803-644-7093gbenarprodigynet
--- On Mon 83010 Sawyer Steve ltssawyerNFPAorggt wrote
From Sawyer Steve ltssawyerNFPAorggtSubject RE RE 7743To GLENN BENARICK ltgbenarprodigynetgtDate Monday August 30 2010 212 PM
So it should be ldquoorrdquo instead of ldquoandrdquo for now
Steven F Sawyer
Senior Fire Service Specialist
Executive Secretary IFMAFire Service Section
NFPA
1 Batterymarch Park
Quincy MA 02169
6179847423
Fax 6179847056
ssawyernfpaorg
From GLENN BENARICK [mailtogbenarprodigynet] Sent Monday August 30 2010 1202 PMTo Sawyer SteveSubject Fw RE 7743
52
Steve a couple of our docs agree with April Boyer
Glenn P Benarick 211 Winged Elm Circle
Aiken SC 29803
803-644-7093
gbenarprodigynet
--- On Mon 83010 David Prezant ltprezandfdnynycgovgt wrote
From David Prezant ltprezandfdnynycgovgtSubject RE 7743To Thomas R (CDCNIOSHDSHEFS) Hales lttrh1cdcgovgt GLENNBENARICK ltgbenarprodigynetgtCc Sandy Bogucki ltsandyboguckiyaleedugtDate Monday August 30 2010 1004 AM
agree
we should change this to NHANES III rather than Knudson we should alsomodify this to allow not only for predicted cutoffs but all for use of thelower limit of normal cutoff This is important to prevent false-classificationof spirometry as abnormal in older groups and in taller grps The latter ofparticular import to firefighter occupational health surveillance
thanks
David Prezant MDChief Medical Officer Office of Medical AffairsCo-Director WTC Medical Monitoring amp Treatment ProgramsNew York City Fire Department9 Metrotech Center - Rm 4W-1Brooklyn NY 11201Phone 718-999-2696Fax 718-999-0665
Life is full of twists and turns
53
This email may contain confidential information If you are the unintendedrecipient of this email please send it back and delete from your directory
gtgtgt Hales Thomas R (CDCNIOSHDSHEFS) lttrh1cdcgovgt 8302010955 AM gtgtgt
Glen
This seems like a very reasonable comment and illustrates the importance of having clinicians providefeedback on the std Im not familiar with the software program of the various spirometers (NHANES IIIvs KnudsonATS vs both) Given the large role both Dave Prezant and Sandy Bogucki had for thepulmonary section let me forward to them for clarification
Tom
From GLENN BENARICK [mailtogbenarprodigynet] Sent Sunday August 29 2010 456 PMTo Hales Thomas R (CDCNIOSHDSHEFS)Subject FW 7743
Tom is April Boyer correct
Glenn P Benarick 211 Winged Elm Circle
Aiken SC 29803
803-644-7093
gbenarprodigynet
--- On Thu 82610 Sawyer Steve ltssawyerNFPAorggt wrote
From Sawyer Steve ltssawyerNFPAorggtSubject FW 7743To GLENN BENARICK ltgbenarprodigynetgtDate Thursday August 26 2010 925 PM
FYI Do you have any answer She is write
Steven
54
Steven F Sawyer
Senior Fire Service Specialist
Executive Secretary IFMAFire Service Section
NFPA
1 Batterymarch Park
Quincy MA 02169
6179847423
Fax 6179847056
ssawyernfpaorg
From April Boyer [mailtoaboyerbicclinicorg] Sent Thursday August 26 2010 232 PMTo Sawyer SteveCc RobinMWebbmilstateorusSubject 7743
Steven
The spirometry tests cannot be corrected according to both references as the NFPA states because thereferences are contradictory The first part of 7743 states to follow the ATS guidelines and use theKnudsen (we at Basin Immediate Care use the Nhanes III) The second part states to follow the ACOEMguidelines and use the Nhanes III in the occupational setting if available with your unit (which is availableon ours) 7743 does not use the word OR regarding both requirements it uses the word AND whenreferring to the first and second parts thence making 7743 contradictory I realize the NFPA 1582 hasnot been updated since 2007 unless I have just not received an updated version
Our question to you is which part of 7743 do you want us to follow the first or the second part Anyfacility that has an updated computerized spirometry system (as we do) will not be able to follow bothrequired parts for obvious reasons We can either follow the first part of 7743 and use an oldercorrected version of the Knudson by going into our system and changing out of the Nhanes III conversionOR we can follow the second part of 7743 and use the newer corrected version of Nhanes III which ourunit offers too
If you have any questions you may contact me at anytime and I also have many references in regards toboth parts of 7743 if you would like to see them
55
Thank you~
April
Confidentiality NoticeThis message may contain information that isconfidential or privileged
If you are not the intended recipientPlease advise the sender immediately and delete this message
56
ATTACHMENT H
57
NFPA 1582 771(7) Proposed revisions
Why
Preliminary results of two prospective randomized trials on the PSA test were published in 2009 These studies resulted in medical organizations that previously providing guidance to modify their recommendations
Current language
771 Blood Tests Blood tests shall be performed annually and shall include the following
(7) Prostate specific antigen (PSA) after age 40 for positive family history if African American or if otherwise clinically indicated after age 50 for all other male member
Suggested Revision
771 Blood Tests Blood tests shall be performed annually and shall include the following
(7) Prostate specific antigen (PSA) after age 40 for positive family history if African American or if otherwise clinically indicated after age 50 for all other male member
772 Prostate-Specific Antigen (PSA) test At age 50 fire fighters shall have an opportunity to make an informed decision with either the Fire Department physician or their health care provider concerning the PSA test For fire fighters at increased risk of prostate cancer (African-Americans or those with a first degree relative diagnosed with prostate cancer before age 65) shall have the opportunity for this informed decision at age 40
A772 The PSA as a screening test for prostate cancer in asymptomatic men is controversial controversial for two reasons First there is no consensus that PSA screening actually saves lives For example the PSA test may detect small cancers that would never become life threatening Second it is unclear that the benefits of PSA screening outweigh the risks of follow-up diagnostic tests and cancer treatments For example the prostate biopsy used to diagnose prostate cancer may cause bleeding and infection And prostate cancer treatments such as surgery and radiation therapy may cause incontinence (inability to control urine flow) erectile dysfunction (erections inadequate for intercourse) and other complications For these reasons it is important that the benefits and risks of prostate diagnostic procedures and treatment be taken into account when considering the PSA screening test These considerations can be taken account during discussions with the fire department physician or onersquos health care provider
D211 Cancer Screening
Smith R A C J Mettlin K J Davis and H Eyre 2000 ldquoAmerican Cancer Society guidelines for the early detection of cancerrdquo CA J Clin 50(1)34ndash49
Added references
58
Carroll P Albertsen PC Greene K et al [2010] Prostate-specific antigen best practice statement 2009 update Am Urological Assoc Available at httpwwwauanetorgcontentguidelines-and-quality-careclinical-guidelinesmain-reportspsa09pdf Date accessed September 2010
Ferrini R Woolf SH [2009] Screening for prostate cancer in American men American College of Preventive Medicine Practice Policy Statement Available at httpwwwacpmorgprostatehtm Date accessed September 2010
National Cancer Institute [2009] Prostate-specific antigen test National Cancer Institute Fact Sheet Available at httpwwwcancergovcancertopicsfactsheetDetectionPSA Date accessed September 2010
Wolf AMD Wender RC Etzioni RB et al [2010] American Cancer Society guideline for the early detection of prostate cancer Update 2010 Available at httpcaonlineamcancersocorgcgicontentfullcaac20066v1 Date accessed September 2010
Urine microalbumincreatinine ratio _________________
III Treating Physician Statement
The above named individual meets all of the criteria provided on this form
Yes No ndash not recommended for position
No but IS recommended for position (letter of explanation attached)
It is my opinion that the above named individual is well-educated and well-motivated in diabetes self-management and has
achieved a level of diabetes management to be capable of safe and effective job performance as a law enforcement officer
I have reached this opinion after careful review of the above criteria
___________________________________________________________ ___________________________Signature of Physician Date
______________________________________________________________ ___________________________Printed or Typed Name of Physician Telephone Number
10 ACOEM Guidance for the Medical Evaluation of Law Enforcement Officers
43 ndash DIABETES MELLITUS
29
439 ndash REFERENCES
1 American Diabetes Association Diagnosis and classification of diabetes mellitus Diabetes Care 200427 Suppl
1S5-S10 See httpcarediabetesjournalsorgcgicontentfull27suppl_1s5
2 American Diabetes Association Continuous subcutaneous insulin infusion Diabetes Care 200427 Suppl 1S110
See httpcarediabetesjournalsorgcgicontentfull27suppl_1s110
3 Mensing C Boucher J Cypress M et al National standards for diabetes self-management education Diabetes
Care 200528 Suppl 1S72-9 See httpcarediabetesjournalsorgcgicontentfull28suppl_1s72
4 Goldstein DE Little RR Lorenz RA Malone JI Nathan DM Peterson CM American Diabetes Association Tests
of glycemia in diabetes Diabetes Care 200427 Suppl 1S91-3
See httpcarediabetesjournalsorgcgicontentfull27suppl_1s91
5 The Diabetes Control and Complications Trial Research Group Hypoglycemia in the Diabetes Control and
Complications Trial Diabetes 199746(2)271-86 See wwwncbinlmnihgovpubmed9000705 for abstract
6 American Diabetes Association Hypoglycemia and employmentlicensure Diabetes Care 200528 Suppl 1S61
See httpcarediabetesjournalsorgcgicontentfull28suppl_1s61
7 Viswanath K McGavin DD Diabetic Retinopathy Clinical Findings and Management J Comm Eye Health
200316(46)21-4 See wwwcehjournalorg0953-683316jceh_16_46_021html
8 Michigan Diabetes Research and Training Center University of Michigan Health System How to use the Michigan
Neuropathy Screening Instrument See wwwmedumichedumdrtcprofsdocumentssviMNSI_howtopdf
9 Bradley JG Davis KA Orthostatic hypotension Am Fam Physician 200368(12)2393-8
See wwwaafporgafp200312152393html
10 Gibbons RJ Balady GJ Bricker JT et al ACCAHA 2002 guideline update for exercise testing a report of the
American College of CardiologyAmerican Heart Association Task Force on Practice Guidelines (Committee on
Exercise Testing) J Am Coll Cardiol 200240(8)1531-40
See wwwaccorgqualityandscienceclinicalguidelinesexerciseexercise_cleanpdf
11 American Diabetes Association Standards of medical care in diabetes Diabetes Care 200528 Suppl 1S4-S36
Erratum in Diabetes Care 200528(4)990 See httpcarediabetesjournalsorgcgicontentfull28suppl_1s4
12 Molitch ME DeFronzo RA Franz MJ et al American Diabetes Association Nephropathy in diabetes Diabetes
Care 200427 Suppl 1S79-83 See httpcarediabetesjournalsorgcgicontentfull27suppl_1s79
13 Kitabchi AE Umpierrez GE Murphy MB et al American Diabetes Association Hyperglycemic crises in diabetes
Diabetes Care 200427 Suppl 1S94-102 See httpcarediabetesjournalsorgcgicontentfull27suppl_1s94
14 US Centers for Disease Control and Prevention National Diabetes Fact Sheet 2007
See wwwcdcgovdiabetespubspdfndfs_2007pdf
ACOEM Guidance for the Medical Evaluation of Law Enforcement Officers 11
43 ndash DIABETES MELLITUS
30
ATTACHMENT E
31
Typos A6921(2) 7th line down test should be plural 94201 Paragraph 2 target organ damage is used though end organ damage was defined earlier and in the appendix for that paragraph
A94201 Para A (1) d Id suggest deleting the phrases in brackets Im not sure either are predictably true or politically wise
a) tests for left ventricular hypertrophy Unfortunately use of the EKG to detect left ventricular hypertrophy is very insensitive (eg 5 sensitivity) The echocardiogram is the best test for diagnosing left ventricular hypertrophy but [it is relatively expensive and not readily available in small rural communities ] conducting echocardiograms on asymptomatic fire fighters with Stage 1 hypertension should be reserved only for those with long-standing hypertension
In addition
7761 A resting EKG shall be performed as part of the baseline medical evaluation and shall be obtained periodically thereafter
Changing from annually to periodically is noted has the language in the wellness-fitness initiative been changed as well Our previous decision was that we would support the W-F language since there was no compelling evidence to either support or refute it
Thanks
Sandy
32
NFPA 1582‐ HTN Draft 1
Reason for Revision
1) New classification of BP by the Joint National Commission [Chobanian et al 2002]
2) A high prevalence of FF have either HTN (~20) and Pre‐HTN (~20) [Soteriades et al 2003]
3) Among FF studies have shown a strong association between HTN and a number of adverse
cardiovascular events [Kales et al 2009]
4) A large percentage of on‐duty FF fatalities were found to have left ventricular hypertrophy a
complication of HTN at autopsy
Language in 2007 Edition with draft revisions in Red (Track changes)
611 The medical evaluation of a candidate shall include a medical history examination and any laboratory tests required to detect physical or medical condition(s) that could adversely affect hisher ability to safely perform the essential job tasks outlined in 511 A611 The medical history should include the candidates known health problems such as major illnesses surgeries medication use and allergies Symptom review is also important for detecting early signs of illness A medical history should also include a personal health history a family health history a health habit history an immunization history and a reproductive history
An occupational history should also be obtained to collect information about the persons past occupational and environmental exposures
(a) BP should be measured according to the Joint National Commission (JNC) -7 recommendations BP should be measured with a properly calibrated and validated instrument Patients should be seated quietly for at least 5 minutes in a chair with feet on the floor and arm supported at heart level An appropriate-sized cuff (cuff bladder encircling at least 80 of the arm) should be used to ensure accuracy At least 2 measurements should be made Systolic BP is the point at which the first of 2 or more sounds is heard (phase 1) and diastolic BP is the point before the disappearance of sounds (phase 5) [Chobanian et al 2003]
(2) Head eyes ears nose and throat (HEENT)
Formatted Font (Default) Times New RomanFont color Black
33
692 Vascular System 6921 Category A medical conditions shall include the following
(1) Uncontrolled or poorly controlled hypertension
(2) Hypertension with evidence of end organ damage
or not controlled by approved medications
A6921(1) Uncontrolled or poorly controlled hHypertension increases the risk of a sudden cardiac event This sudden cardiac event would cause sudden incapacitation which that is uncontrolled poorly controlled or requires medication likely to interferes with the safe performance of essential job tasks Uncontrolled or poorly controlled hypertension can be defined as the presence of end organ damage (see below) or stage 2 hypertension (BP systolic gt160 mmHg or BP diastolic gt100 mmHg) is an illness that can lead to functional impairment and potential for sudden incapacitation Individuals with pre- stage 1 or stage 2 hypertension should be referred to their primary care physician for evaluation lifestyle modification and treatment [QUESTION FOR GROUP _- WHAT ABOUT HAVING CANDIDATE RETURN IN ONE MONTH UNDER TREATMENT WITH NORMAL BP]
A6921(2)
Chronic hypertension can damage the eye (retinopathy) the kidneys (nephropathy) the vascular system (stroke transient ischemic attack or peripheral artery disease) or the heart (left ventricular hypertrophy and heart failure) These hypertension complications are known as end organ damage The cardiac and vascular complications are associated with an increased risk of sudden incapacitation and sudden cardiac death (Koren et al 1991) Unfortunately the cardiac complications are frequently asymptomatic and valid screening tests are not fast and are not inexpensive Therefore determining who to screen for cardiac complications (such as echocardiogram for LVH or a measurement of left ventricular ejection fraction for heart failure) should be based on the severity and the duration of HTN
76 Physical Examination The annual physical examination shall include each of the following components
(a) BP shall be measured according to the Joint National Commission (JNC)-7 recommendations
A76(1)(a) BP should be measured with a properly calibrated and validated instrument Patients should be seated quietly for at least 5 minutes in a chair with feet on the floor and arm supported at heart level An appropriate-sized cuff (cuff bladder encircling at least 80 of the arm) should be used to ensure accuracy At least 2 measurements should be made Systolic BP is the point at which the first of 2 or more sounds is heard (phase 1) and diastolic BP is the point before the disappearance of sounds (phase 5) [Chobanian et al 2003]
(2) Head eyes ears nose and throat (HEENT)
34
9420 Uncontrolled Hypertension 94201 Physician Evaluation Severe uncontrolled hypertension [defined as systolic pressure greater than 180 mm Hg diastolic pressure greater than 100 mm Hg or mean systolic blood
pressure ( systolic + diastolic) greater than 120 mm Hg] or malignant hypertension (defined as hypertension with the presence of target organ damage) compromises the members ability to safely perform essential job tasks 1 5 7 9 and 13 and the physician shall report the applicable job limitations to the fire department
Members with Pre-hypertention (systolic 120-139 mmHg or diastolic 80-89 mmHg) Stage 1 hypertension (systolic 140-159 mmHg or diastolic 90-99 mmHg) or Stage 2 hypertension (systolic ge160 mmHg or diastolic ge100 mmHg) should be referred to their primary care physician for evaluation lifestyle modification and treatment
(1) Members with Stage I hypertension should be followed-up not only by their primary care physician but also by the FD physician every 3 to 6 months to ensure their blood pressure is under control and to determine whether screening tests for asymptomatic end organ damage are appropriate
(2) Members with Stage 2 hypertension or with end organ damage (retinopathy nephropathy vascular or cardiac complications) compromises the members ability to safely perform essential job tasks 1 5 7 9 and 130 and the physician shall report the applicable job limitations to the fire department
A94201 Severe uncontrolled hypertension is a significant risk factor for the development of coronary artery disease congestive heart failure and stroke Blood pressure increases as a normal response to exercise This response is further exaggerated by the emotional and physical stress of performing these critical tasks while operating in personal protective clothing at extremes of temperature This normal elevation of blood pressure under these response conditions can lead to life-threatening hypertensive emergencies if a members daily blood pressure is already elevated to high levels In addition hypertension is a progressive illness that when uncontrolled ultimately and inevitably leads to target organ damage Target organs that are sensitive to the effects of elevated blood pressure are the central nervous system vision heart major blood vessels and kidneys
Chronic hypertension can damage the eye (retinopathy) the kidneys (nephropathy) the vascular system (stroke transient ischemic attack or peripheral artery disease) or the heart (left ventricular hypertrophy and heart failure) These hypertension complications are known as end organ damage The cardiac and vascular complications are associated with an increased risk of sudden incapacitation and sudden cardiac death (Koren et al 1991) Fortunately with proper evaluation life style modification and treatment these complications can be avoided Life style modification includes weight reduction DASH eating plan reduction in dietary sodium an increase in aerobic physical activity and moderation in alcohol consumption [Chobanian 2003]
Formatted Font (Default) Times New Roman12 pt Font color Black
Formatted Font (Default) Times New Roman12 pt Font color Black
35
A94201 (1) Members with Stage I hypertension whose BP returns to either pre-hypertenion or normal with lifestyle modification andor treatment can return to an annual medical evaluation For members with long-standing Stage I hypertension whose BP has not been reduced additional evaluation for possible end organ damage should be considered This evaluation could include any or all of the following
a) a compete patient history for symptoms of heart failure (eg shortness of breath upon exertion) or transient ischemic attacks (TIAs)
b) dilated eye examination for retinopathy
c) blood creatinine measurement for nephropathy
d) tests for left ventricular hypertrophy Unfortunately use of the resting EKG to detect left ventricular hypertrophy is very insensitive (eg 5 sensitivity) The echocardiogram is the best test for diagnosing left ventricular hypertrophy
A 94201 (2) Due to the high risk of a sudden cardiovascular event members with Stage 2 hypertension should be restricted until their BP can be brought under control Once the BP is brought under control they should be followed in the same manner as a member with Stage I hypertension
Formatted Font (Default) Times New Roman12 pt
36
D22 Cardiology Gibbons R J GJ Balady J W Beasley et al 1997 ACCAHA guidelines for exercise testing a report of American College of CardiologyAmerican Heart Association Task Force on Practice Guidelines (Committee on Exercise Testing) J Am Coll Cardiol 30260ndash311
Gibbons RJ Balady GJ Bricker JT Chaitman BR Fletcher GF Froelicher VF Mark DB McCallister BD Mooss AN OrsquoReilly MG Winters WL Jr [2002] ACCAHA 2002 guideline update for exercise testing summary article a report of the ACCAHA Task Force on Practice Guidelines (Committee to Update the 1997 Exercise Testing guidelines) J Am Coll Cardiol 401531ndash 40
Chobanian AV Bakris GL Black HR Cushman WC Green LA Izzo JL Jr Jones DW Materson BJ Oparil S Wright JT Jr Roccella EJ the National High Blood Pressure Education Program Coordinating Committee [2003] The seventh report of the Joint National Committee [JNC-7] on Prevention Detection Evaluation and Treatment of High Blood Pressure JAMA 2892560ndash2571
Soteriades ES Kales SN Liarokapis D Christiani DC [2003] Prospective surveillance of hypertension in firefighters J Clin Hypertens 5315-320
Kales SN Tsismenakis AJ Zhang C Soteriades ES [2009] Blood pressure in fire fighters police officers and other emergency responders Am J Hypertens 2211-20
37
NFPA 1582‐ HTN Draft 1
Reason for Revision
1) New classification of BP by the Joint National Commission [Chobanian et al 2002]
2) A high prevalence of FF have either HTN (~20) and Pre‐HTN (~20) [Soteriades et al 2003]
3) Among FF studies have shown a strong association between HTN and a number of adverse
cardiovascular events [Kales et al 2009]
4) A large percentage of on‐duty FF fatalities were found to have left ventricular hypertrophy a
complication of HTN at autopsy
Language in 2007 Edition with draft revisions in Red (Track changes)
611 The medical evaluation of a candidate shall include a medical history examination and any laboratory tests required to detect physical or medical condition(s) that could adversely affect hisher ability to safely perform the essential job tasks outlined in 511 A611 The medical history should include the candidates known health problems such as major illnesses surgeries medication use and allergies Symptom review is also important for detecting early signs of illness A medical history should also include a personal health history a family health history a health habit history an immunization history and a reproductive history
An occupational history should also be obtained to collect information about the persons past occupational and environmental exposures
(a) BP should be measured according to the Joint National Commission (JNC) -7 recommendations BP should be measured with a properly calibrated and validated instrument Patients should be seated quietly for at least 5 minutes in a chair with feet on the floor and arm supported at heart level An appropriate-sized cuff (cuff bladder encircling at least 80 of the arm) should be used to ensure accuracy At least 2 measurements should be made Systolic BP is the point at which the first of 2 or more sounds is heard (phase 1) and diastolic BP is the point before the disappearance of sounds (phase 5) [Chobanian et al 2003]
(2) Head eyes ears nose and throat
38
692 Vascular System 6921 Category A medical conditions shall include the following
(1) Uncontrolled or poorly controlled hypertension
(2) Hypertension with evidence of end organ damage
A6921(1) Uncontrolled or poorly controlled hypertension increases the risk of a sudden cardiac event This sudden cardiac event would cause sudden incapacitation which interferes with the safe performance of essential job tasks Uncontrolled or poorly controlled hypertension can be defined as the presence of end organ damage (see below) or stage 2 hypertension (BP systolic gt160 mmHg or BP diastolic gt100 mmHg) Individuals with pre- stage 1 or stage 2 hypertension should be referred to their primary care physician for evaluation lifestyle modification and treatment [QUESTION FOR GROUP _- WHAT ABOUT HAVING CANDIDATE RETURN IN ONE MONTH UNDER TREATMENT WITH NORMAL BP]
A6921(2)Chronic hypertension can damage the eye (retinopathy) the kidneys (nephropathy) the vascular system (stroke transient ischemic attack or peripheral artery disease) or the heart (left ventricular hypertrophy and heart failure) These hypertension complications are known as end organ damage The cardiac and vascular complications are associated with an increased risk of sudden incapacitation and sudden cardiac death (Koren et al 1991) Unfortunately the cardiac complications are frequently asymptomatic and valid screening tests are not fast and are not inexpensive Therefore determining who to screen for cardiac complications (such as echocardiogram for LVH or a measurement of left ventricular ejection fraction for heart failure) should be based on the severity and the duration of HTN
76 Physical Examination The annual physical examination shall include each of the following components
(a) BP shall be measured according to the Joint National Commission (JNC)-7 recommendations
A76(1)(a) BP should be measured with a properly calibrated and validated instrument Patients should be seated quietly for at least 5 minutes in a chair with feet on the floor and arm supported at heart level An appropriate-sized cuff (cuff bladder encircling at least 80 of the arm) should be used to ensure accuracy At least 2 measurements should be made Systolic BP is the point at which the first of 2 or more sounds is heard (phase 1) and diastolic BP is the point before the disappearance of sounds (phase 5) [Chobanian et al 2003]
(2) Head eyes ears nose and throat9420 Hypertension 94201 Physician Evaluation Members with Pre-hypertention (systolic 120-139 mmHg or diastolic 80-89 mmHg) Stage 1 hypertension (systolic 140-159 mmHg or diastolic 90-99 mmHg) or Stage 2 hypertension (systolic ge160 mmHg or diastolic ge100 mmHg) should be referred to their primary care physician for evaluation lifestyle modification and treatment
39
(1) Members with Stage I hypertension should be followed-up not only by their primary care physician but also by the FD physician every 3 to 6 months to ensure their blood pressure is under control and to determine whether screening tests for asymptomatic end organ damage are appropriate
(2) Members with Stage 2 hypertension or with end organ damage (retinopathy nephropathy vascular or cardiac complications) compromises the members ability to safely perform essential job tasks 1 5 7 9 and 130 and the physician shall report the applicable job limitations to the fire department
A94201 Chronic hypertension can damage the eye (retinopathy) the kidneys (nephropathy) the vascular system (stroke transient ischemic attack or peripheral artery disease) or the heart (left ventricular hypertrophy and heart failure) These hypertension complications are known as end organ damage The cardiac and vascular complications are associated with an increased risk of sudden incapacitation and sudden cardiac death (Koren et al 1991) Fortunately with proper evaluation life style modification and treatment these complications can be avoided Life style modification includes weight reduction DASH eating plan reduction in dietary sodium an increase in aerobic physical activity and moderation in alcohol consumption [Chobanian 2003]
A94201 (1) Members with Stage I hypertension whose BP returns to either pre-hypertenion or normal with lifestyle modification andor treatment can return to an annual medical evaluation For members with long-standing Stage I hypertension whose BP has not been reduced additional evaluation for possible end organ damage should be considered This evaluation could include any or all of the following
a) a compete patient history for symptoms of heart failure (eg shortness of breath upon exertion) or transient ischemic attacks (TIAs)
b) dilated eye examination for retinopathy
c) blood creatinine measurement for nephropathy
d) tests for left ventricular hypertrophy Unfortunately use of the resting EKG to detect left ventricular hypertrophy is very insensitive (eg 5 sensitivity) The echocardiogram is the best test for diagnosing left ventricular hypertrophy
A 94201 (2) Due to the high risk of a sudden cardiovascular event members with Stage 2 hypertension should be restricted until their BP can be brought under control Once the BP is brought under control they should be followed in the same manner as a member with Stage I hypertension
D22 Cardiology
40
Hypertension
Gibbons RJ Balady GJ Bricker JT Chaitman BR Fletcher GF Froelicher VF Mark DB McCallister BD Mooss AN OrsquoReilly MG Winters WL Jr [2002] ACCAHA 2002 guideline update for exercise testing summary article a report of the ACCAHA Task Force on Practice Guidelines (Committee to Update the 1997 Exercise Testing guidelines) J Am Coll Cardiol 401531ndash 40
Chobanian AV Bakris GL Black HR Cushman WC Green LA Izzo JL Jr Jones DW Materson BJ Oparil S Wright JT Jr Roccella EJ the National High Blood Pressure Education Program Coordinating Committee [2003] The seventh report of the Joint National Committee [JNC-7] on Prevention Detection Evaluation and Treatment of High Blood Pressure JAMA 2892560ndash2571
Soteriades ES Kales SN Liarokapis D Christiani DC [2003] Prospective surveillance of hypertension in firefighters J Clin Hypertens 5315-320
Kales SN Tsismenakis AJ Zhang C Soteriades ES [2009] Blood pressure in fire fighters police officers and other emergency responders Am J Hypertens 2211-20
41
NFPA 1582‐ Draft Revisions for CVDHTN
EKG and stress tests
Reason for Revision
1) Change requirement for annual resting EKG to periodically to be more consistent with ACCAHA
recommendation (Schlant et al 1992)
2) Add language to clarify what constitutes a positive ST
3) Make criteria for conducting diagnostic ST in asymptomatic patients consistent with the
ACCAHA
Language in 2007 Edition with draft revisions in Red (Track changes)
776 Electrocardiograms (EKG)) and Stress Tests 7761 A resting EKG shall be performed as part of the baseline medical evaluation and shall be obtained periodically (every 1 to 5 years) annually thereafter
A7761 A baseline resting EKGs shall be conducted Follow-up resting EKGs should be conducted as clinically indicated but at a minimum of every 1 to 5 years The frequency of these follow-up resting EKGs should increase as a members age increases or with increasing number andor severity of coronary heart disease risk factors Members above the age of 40 should have annual resting EKGs (Schlant et al 1992)
7762 The fire department physician or other qualified medical evaluator shall compare EKGs obtained during yearly evaluations with baseline and subsequent EKGs
7763 Stress testing EKG with or without echocardiography or radionuclide scanning shall be performed as clinically indicated by history or symptoms
A7761 Baseline electrocardiography should be conducted (Periodic resting electrocardiograms have not been shown to be useful but can be reasonable as a members agefactors increase)
A7763 No firm guidelines for stress testingelectrocardiography in asymptomatic individuals have been developed Stress testingelectrocardiography as a screening tool is used as part of an evaluation of aerobic capacity during the annual occupational fitness evaluation Submaximal stress testingelectrocardiography testing to 85 percent is commonly used as part of this screening
Submaximal stress electrocardiography testing should not be used for diagnostic purposes Cardiology evaluation with maximal stress testingelectrocardiography together with imaging techniques (eg echocardiography technetium Tc99m sestamibi study andor coronary angiography) is necessary for diagnosticprognostic purposes for the following
42
(1) Fire fighters with positive or questionably positive changes on screening submaximal stress tests
(2) Fire fighters with new onset chest pain or other symptoms suggestive of coronary artery disease (CAD)
(3) Fire fighters with diabetes mellitus who
(a) are gt35 years old or
(b) have type I diabetes for more than 15 years or
(c) have type II diabetes for more than 10 years or
(d) have any other CHD risk factor (see below) or
(e) have the presence of microvascular disease (proliferative retinopathy)
(4) Fire fighters over the age of 45 (for men) and 55 (for women) with onetwo or more risk factors for CAD Risk factors for CAD include hypercholesterolemia (total cholesterol greater than 240 mgdL) hypertension (systolic gt140 mmHg or diastolic gt90 mmHg) smoking or family history of premature CAD (heart attack or sudden cardiac death in a first degree relative less than 60 years of age)
as defined below if stress electrocardiography with imaging is negative then repeat as clinically indicated or at least every 5 years
(5) Fire fighters with a Framingham Risk Score gt10 Risk calculator is available at [httphp2010nhlbihinnetatpiiicalculatorasp]
(6) Fire fighters identified in 9431
Negative stress tests should be repeated as clinically indicated or at least every 2 to 5 years
Interpreting stress tests as ldquopositiverdquo or ldquonegativerdquo is beyond the scope of this document However factors that should be taken into consideration should include the individualrsquos exercise capacity symptoms blood pressure response heart rate response EKG changes and the presence of arrhythmias (Gibbon et al 2002)
Risk factors for CAD include hypercholesterolemia (total cholesterol greater than 240 mgdL) hypertension (systolic greater than 140 andor diastolic greater than 90) smoking diabetes mellitus or family history of premature CAD (heart attack or sudden cardiac death in a first degree relative less than 60 years of age)
There are other non-invasive tests to screen for coronary artery disease One of the most promising appears to be coronary artery calcium (CAD) scoring by computed tomography In 2007 an expert committee published an update to their original guidance document The committeersquos consensus was that ldquoit may be reasonable to consider use of CAC measurement in such patients [between 10 and 20 10-year risk of estimated coronary event]helliprdquo The committee did not recommend CAC measurement in low risk patients [lt10 10-year risk of estimated coronary event] or in high risk patients [gt20 10-year risk of estimate coronary event] (Greenland et al 2007]
43
D22 Cardiology
Chobanian AV Bakris GL Black HR Cushman WC Green LA Izzo JL Jr Jones DW Materson BJ Oparil S Wright JT Jr Roccella EJ the National High Blood Pressure Education Program Coordinating Committee [2003] The seventh report of the Joint National Committee [JNC-7] on Prevention Detection Evaluation and Treatment of High Blood Pressure JAMA 2892560ndash2571
Gibbons RJ Balady GJ Bricker JT Chaitman BR Fletcher GF Froelicher VF Mark DB McCallister BD Mooss AN OrsquoReilly MG Winters WL Jr [2002] ACCAHA 2002 guideline update for exercise testing summary article a report of the ACCAHA Task Force on Practice Guidelines (Committee to Update the 1997 Exercise Testing guidelines) J Am Coll Cardiol 401531ndash 1540
Greenland et al [2007] ACCFAHA 2007 Clinical Expert Consensus Document on Coronary Artery Calcium Scoring By Computed Tomography in Global Cardiovascular Risk Assessment and in Evaluation of Patients With Chest Pain A Report of the American College of Cardiology Foundation Clinical Expert Consensus Task Force (ACCFAHA Writing Committee to Update the 2000 Expert Consensus Document on Electron Beam Computed Tomography) J Am Coll Cardiol 49378-402
Kales SN Tsismenakis AJ Zhang C Soteriades ES [2009] Blood pressure in fire fighters police officers and other emergency responders Am J Hypertens 2211-20
Schlant RC Adolph RJ DiMarco JP Dreifus LS Dunn MI Fisch C Garson A Jr Haywood LJ Levine HJ Murray JA Noble RJ Ronan JA Jr [1992] Guidelines for electrocardiography A report of the American College of CardiologyAmerican Heart Association Task Force on Assessment of Diagnostic and Therapeutic Cardiovascular Procedures (Committee on Electrocardiography) Circulation 85(3)1221-1228
Soteriades ES Kales SN Liarokapis D Christiani DC [2003] Prospective surveillance of hypertension in firefighters J Clin Hypertens 5315-320
Formatted Font Italic
Formatted Line spacing single
Formatted Font Italic
Formatted Font Italic
44
NFPA 1582‐ Draft Revisions for CVDHTN
EKG and stress tests
Reason for Revision
1) Change requirement for annual resting EKG to periodically to be more consistent with ACCAHA
recommendation (Schlant et al 1992)
2) Add language to clarify what constitutes a positive ST
3) Make criteria for conducting diagnostic ST in asymptomatic patients consistent with the
ACCAHA
Language in 2007 Edition with draft revisions in Red (Track changes)
776 Electrocardiograms (EKG) and Stress Tests 7761 A resting EKG shall be performed as part of the baseline medical evaluation and shall be obtained periodically (every 1 to 5 years) thereafter
A7761 A baseline resting EKGs shall be conducted Follow-up resting EKGs should be conducted as clinically indicated but at a minimum of every 1 to 5 years The frequency of these follow-up resting EKGs should increase as a members age increases or with increasing number andor severity of coronary heart disease risk factors Members above the age of 40 should have annual resting EKGs (Schlant et al 1992)
7762 The fire department physician or other qualified medical evaluator shall compare baseline and subsequent EKGs
7763 Stress testing with or without echocardiography or radionuclide scanning shall be performed as clinically indicated by history or symptoms
A7763 No firm guidelines for stress testing in asymptomatic individuals have been developed Stress testing as a screening tool is used as part of an evaluation of aerobic capacity during the annual occupational fitness evaluation Submaximal stress testing testing to 85 percent is commonly used as part of this screening
Submaximal stress testing should not be used for diagnostic purposes Cardiology evaluation with maximal stress testing together with imaging techniques (eg echocardiography technetium Tc99m sestamibi study) is necessary for diagnosticprognostic purposes for the following
(1) Fire fighters with positive or questionably positive changes on screening submaximal stress tests
(2) Fire fighters with new onset chest pain or other symptoms suggestive of coronary artery disease (CAD)
45
(3) Fire fighters with diabetes mellitus who
(a) are gt35 years old or
(b) have type I diabetes for more than 15 years or
(c) have type II diabetes for more than 10 years or
(d) have any other CHD risk factor (see below) or
(e) have the presence of microvascular disease (proliferative retinopathy)
(4) Fire fighters over the age of 45 (for men) and 55 (for women) with one or more risk factors for CAD Risk factors for CAD include hypercholesterolemia (total cholesterol greater than 240 mgdL) hypertension (systolic gt140 mmHg or diastolic gt90 mmHg) smoking or family history of premature CAD (heart attack or sudden cardiac death in a first degree relative less than 60 years of age)
(5) Fire fighters with a Framingham Risk Score gt10 Risk calculator is available at [httphp2010nhlbihinnetatpiiicalculatorasp]
(6) Fire fighters identified in 9431
Negative stress tests should be repeated as clinically indicated or at least every 2 to 5 years
Interpreting stress tests as ldquopositiverdquo or ldquonegativerdquo is beyond the scope of this document However factors that should be taken into consideration should include the individualrsquos exercise capacity symptoms blood pressure response heart rate response EKG changes and the presence of arrhythmias (Gibbon et al 2002)
There are other non-invasive tests to screen for coronary artery disease One of the most promising appears to be coronary artery calcium (CAD) scoring by computed tomography In 2007 an expert committee published an update to their original guidance document The committeersquos consensus was that ldquoit may be reasonable to consider use of CAC measurement in such patients [between 10 and 20 10-year risk of estimated coronary event]helliprdquo The committee did not recommend CAC measurement in low risk patients [lt10 10-year risk of estimated coronary event] or in high risk patients [gt20 10-year risk of estimate coronary event] (Greenland et al 2007]
D22 Cardiology
Resting EKG and Stress Tests
46
Chobanian AV Bakris GL Black HR Cushman WC Green LA Izzo JL Jr Jones DW Materson BJ Oparil S Wright JT Jr Roccella EJ the National High Blood Pressure Education Program Coordinating Committee [2003] The seventh report of the Joint National Committee [JNC-7] on Prevention Detection Evaluation and Treatment of High Blood Pressure JAMA 2892560ndash2571
Gibbons RJ Balady GJ Bricker JT Chaitman BR Fletcher GF Froelicher VF Mark DB McCallister BD Mooss AN OrsquoReilly MG Winters WL Jr [2002] ACCAHA 2002 guideline update for exercise testing summary article a report of the ACCAHA Task Force on Practice Guidelines (Committee to Update the 1997 Exercise Testing guidelines) J Am Coll Cardiol 401531ndash 1540
Greenland et al [2007] ACCFAHA 2007 Clinical Expert Consensus Document on Coronary Artery Calcium Scoring By Computed Tomography in Global Cardiovascular Risk Assessment and in Evaluation of Patients With Chest Pain A Report of the American College of Cardiology Foundation Clinical Expert Consensus Task Force (ACCFAHA Writing Committee to Update the 2000 Expert Consensus Document on Electron Beam Computed Tomography) J Am Coll Cardiol 49378-402
Kales SN Tsismenakis AJ Zhang C Soteriades ES [2009] Blood pressure in fire fighters police officers and other emergency responders Am J Hypertens 2211-20
Schlant RC Adolph RJ DiMarco JP Dreifus LS Dunn MI Fisch C Garson A Jr Haywood LJ Levine HJ Murray JA Noble RJ Ronan JA Jr [1992] Guidelines for electrocardiography A report of the American College of CardiologyAmerican Heart Association Task Force on Assessment of Diagnostic and Therapeutic Cardiovascular Procedures (Committee on Electrocardiography) Circulation 85(3)1221-1228
Soteriades ES Kales SN Liarokapis D Christiani DC [2003] Prospective surveillance of hypertension in firefighters J Clin Hypertens 5315-320
47
ATTACHMENT F
48
1
Current 1582 (2007) language in reference to pregnancy 43 (4) Report to the fire department physician any medical condition that could interfere with the ability of the individual to safely perform essential job tasks such as illness or injury use of prescription or nonprescription drugs and pregnancy 6112 Category B medical conditions shall include the following (1) Pregnancy for its duration A7792 (e) If HIV prophylaxis is to be given the following tests should be done i CBC ii Glucose renal and hepatic chemical function iii Pregnancy test for females B121 Pregnancy and Reproduction Federal regulations as well as many court decisions including the US Supreme Courtrsquos decision in International Union et al v Johnson Controls Inc [499 US 187 111 S Ct 1196 (1991)] have interpreted the requirements of Title VII with respect to pregnancy and reproduction The AHJ should seek the advice of counsel in resolving specific questions concerning these requirements as well as other requirements that can be imposed by state or local laws C211 (4) Review health status with the individual being evaluated Contraindications for evaluations shall be reviewed addressing any changes in the individualrsquos health status since their last medical evaluation that would warrant deferring the evaluation including (g) Pregnancy Recommendations to language enhancement
A female employee who is assigned to regular fire line duty shall report a pregnancy immediately to their respective Supervisor and the fire department physician The employee will then be given the option of a non-hazardous alternative duty position for the duration of her pregnancy (can we say this or is it even appropriate) Any pregnant employee wishing to remain on regular line duty shall be informed of the possible risks and consequences to herself and her fetus that are associated with continued line fire fighting duty Among those risk factors are exposure to teratogens known to have negative effects on the developing fetus such as smoke diesel fumes hazardous chemicals and extreme heat
49
Page 2
appendix It is recommended that the pregnant employee complete a release of liability form signed by herself and her health care provider utilizing NFPArsquos 13 critical tasks as a reference This will inform the health care provider of specific job-related tasks that will need to be performed in order to continue regular line duty These tasks are basic physical standards that any entry level firefighter would have to be able to complete competently The employeersquos health condition will be kept confidential by the department in accordance with HIPAA standards Employees are allowed to remain on active regular duty until they are no longer able to perform their duties in a reasonable manner andor their protective gear no longer fits correctly It is the responsibility of the health care provider to evaluate the pregnant employee If at any time the health care provider feels the pregnant employee can no longer perform the job related tasks this should be reported to the employer by the employee immediately
50
ATTACHMENT G
51
From GLENN BENARICKTo Sawyer SteveSubject RE RE 7743Date Monday August 30 2010 21633 PM
Yes thats my understanding
Glenn P Benarick 211 Winged Elm CircleAiken SC 29803803-644-7093gbenarprodigynet
--- On Mon 83010 Sawyer Steve ltssawyerNFPAorggt wrote
From Sawyer Steve ltssawyerNFPAorggtSubject RE RE 7743To GLENN BENARICK ltgbenarprodigynetgtDate Monday August 30 2010 212 PM
So it should be ldquoorrdquo instead of ldquoandrdquo for now
Steven F Sawyer
Senior Fire Service Specialist
Executive Secretary IFMAFire Service Section
NFPA
1 Batterymarch Park
Quincy MA 02169
6179847423
Fax 6179847056
ssawyernfpaorg
From GLENN BENARICK [mailtogbenarprodigynet] Sent Monday August 30 2010 1202 PMTo Sawyer SteveSubject Fw RE 7743
52
Steve a couple of our docs agree with April Boyer
Glenn P Benarick 211 Winged Elm Circle
Aiken SC 29803
803-644-7093
gbenarprodigynet
--- On Mon 83010 David Prezant ltprezandfdnynycgovgt wrote
From David Prezant ltprezandfdnynycgovgtSubject RE 7743To Thomas R (CDCNIOSHDSHEFS) Hales lttrh1cdcgovgt GLENNBENARICK ltgbenarprodigynetgtCc Sandy Bogucki ltsandyboguckiyaleedugtDate Monday August 30 2010 1004 AM
agree
we should change this to NHANES III rather than Knudson we should alsomodify this to allow not only for predicted cutoffs but all for use of thelower limit of normal cutoff This is important to prevent false-classificationof spirometry as abnormal in older groups and in taller grps The latter ofparticular import to firefighter occupational health surveillance
thanks
David Prezant MDChief Medical Officer Office of Medical AffairsCo-Director WTC Medical Monitoring amp Treatment ProgramsNew York City Fire Department9 Metrotech Center - Rm 4W-1Brooklyn NY 11201Phone 718-999-2696Fax 718-999-0665
Life is full of twists and turns
53
This email may contain confidential information If you are the unintendedrecipient of this email please send it back and delete from your directory
gtgtgt Hales Thomas R (CDCNIOSHDSHEFS) lttrh1cdcgovgt 8302010955 AM gtgtgt
Glen
This seems like a very reasonable comment and illustrates the importance of having clinicians providefeedback on the std Im not familiar with the software program of the various spirometers (NHANES IIIvs KnudsonATS vs both) Given the large role both Dave Prezant and Sandy Bogucki had for thepulmonary section let me forward to them for clarification
Tom
From GLENN BENARICK [mailtogbenarprodigynet] Sent Sunday August 29 2010 456 PMTo Hales Thomas R (CDCNIOSHDSHEFS)Subject FW 7743
Tom is April Boyer correct
Glenn P Benarick 211 Winged Elm Circle
Aiken SC 29803
803-644-7093
gbenarprodigynet
--- On Thu 82610 Sawyer Steve ltssawyerNFPAorggt wrote
From Sawyer Steve ltssawyerNFPAorggtSubject FW 7743To GLENN BENARICK ltgbenarprodigynetgtDate Thursday August 26 2010 925 PM
FYI Do you have any answer She is write
Steven
54
Steven F Sawyer
Senior Fire Service Specialist
Executive Secretary IFMAFire Service Section
NFPA
1 Batterymarch Park
Quincy MA 02169
6179847423
Fax 6179847056
ssawyernfpaorg
From April Boyer [mailtoaboyerbicclinicorg] Sent Thursday August 26 2010 232 PMTo Sawyer SteveCc RobinMWebbmilstateorusSubject 7743
Steven
The spirometry tests cannot be corrected according to both references as the NFPA states because thereferences are contradictory The first part of 7743 states to follow the ATS guidelines and use theKnudsen (we at Basin Immediate Care use the Nhanes III) The second part states to follow the ACOEMguidelines and use the Nhanes III in the occupational setting if available with your unit (which is availableon ours) 7743 does not use the word OR regarding both requirements it uses the word AND whenreferring to the first and second parts thence making 7743 contradictory I realize the NFPA 1582 hasnot been updated since 2007 unless I have just not received an updated version
Our question to you is which part of 7743 do you want us to follow the first or the second part Anyfacility that has an updated computerized spirometry system (as we do) will not be able to follow bothrequired parts for obvious reasons We can either follow the first part of 7743 and use an oldercorrected version of the Knudson by going into our system and changing out of the Nhanes III conversionOR we can follow the second part of 7743 and use the newer corrected version of Nhanes III which ourunit offers too
If you have any questions you may contact me at anytime and I also have many references in regards toboth parts of 7743 if you would like to see them
55
Thank you~
April
Confidentiality NoticeThis message may contain information that isconfidential or privileged
If you are not the intended recipientPlease advise the sender immediately and delete this message
56
ATTACHMENT H
57
NFPA 1582 771(7) Proposed revisions
Why
Preliminary results of two prospective randomized trials on the PSA test were published in 2009 These studies resulted in medical organizations that previously providing guidance to modify their recommendations
Current language
771 Blood Tests Blood tests shall be performed annually and shall include the following
(7) Prostate specific antigen (PSA) after age 40 for positive family history if African American or if otherwise clinically indicated after age 50 for all other male member
Suggested Revision
771 Blood Tests Blood tests shall be performed annually and shall include the following
(7) Prostate specific antigen (PSA) after age 40 for positive family history if African American or if otherwise clinically indicated after age 50 for all other male member
772 Prostate-Specific Antigen (PSA) test At age 50 fire fighters shall have an opportunity to make an informed decision with either the Fire Department physician or their health care provider concerning the PSA test For fire fighters at increased risk of prostate cancer (African-Americans or those with a first degree relative diagnosed with prostate cancer before age 65) shall have the opportunity for this informed decision at age 40
A772 The PSA as a screening test for prostate cancer in asymptomatic men is controversial controversial for two reasons First there is no consensus that PSA screening actually saves lives For example the PSA test may detect small cancers that would never become life threatening Second it is unclear that the benefits of PSA screening outweigh the risks of follow-up diagnostic tests and cancer treatments For example the prostate biopsy used to diagnose prostate cancer may cause bleeding and infection And prostate cancer treatments such as surgery and radiation therapy may cause incontinence (inability to control urine flow) erectile dysfunction (erections inadequate for intercourse) and other complications For these reasons it is important that the benefits and risks of prostate diagnostic procedures and treatment be taken into account when considering the PSA screening test These considerations can be taken account during discussions with the fire department physician or onersquos health care provider
D211 Cancer Screening
Smith R A C J Mettlin K J Davis and H Eyre 2000 ldquoAmerican Cancer Society guidelines for the early detection of cancerrdquo CA J Clin 50(1)34ndash49
Added references
58
Carroll P Albertsen PC Greene K et al [2010] Prostate-specific antigen best practice statement 2009 update Am Urological Assoc Available at httpwwwauanetorgcontentguidelines-and-quality-careclinical-guidelinesmain-reportspsa09pdf Date accessed September 2010
Ferrini R Woolf SH [2009] Screening for prostate cancer in American men American College of Preventive Medicine Practice Policy Statement Available at httpwwwacpmorgprostatehtm Date accessed September 2010
National Cancer Institute [2009] Prostate-specific antigen test National Cancer Institute Fact Sheet Available at httpwwwcancergovcancertopicsfactsheetDetectionPSA Date accessed September 2010
Wolf AMD Wender RC Etzioni RB et al [2010] American Cancer Society guideline for the early detection of prostate cancer Update 2010 Available at httpcaonlineamcancersocorgcgicontentfullcaac20066v1 Date accessed September 2010
59
5 Has been educated in diabetes and its management and thoroughly informed of and understands the procedures that
must be followed to monitor and manage hisher diabetes and what procedures should be followed if complications
arise
The individual has completed the following diabetes education (include year of completion)
Urine microalbumincreatinine ratio _________________
III Treating Physician Statement
The above named individual meets all of the criteria provided on this form
Yes No ndash not recommended for position
No but IS recommended for position (letter of explanation attached)
It is my opinion that the above named individual is well-educated and well-motivated in diabetes self-management and has
achieved a level of diabetes management to be capable of safe and effective job performance as a law enforcement officer
I have reached this opinion after careful review of the above criteria
___________________________________________________________ ___________________________Signature of Physician Date
______________________________________________________________ ___________________________Printed or Typed Name of Physician Telephone Number
10 ACOEM Guidance for the Medical Evaluation of Law Enforcement Officers
43 ndash DIABETES MELLITUS
29
439 ndash REFERENCES
1 American Diabetes Association Diagnosis and classification of diabetes mellitus Diabetes Care 200427 Suppl
1S5-S10 See httpcarediabetesjournalsorgcgicontentfull27suppl_1s5
2 American Diabetes Association Continuous subcutaneous insulin infusion Diabetes Care 200427 Suppl 1S110
See httpcarediabetesjournalsorgcgicontentfull27suppl_1s110
3 Mensing C Boucher J Cypress M et al National standards for diabetes self-management education Diabetes
Care 200528 Suppl 1S72-9 See httpcarediabetesjournalsorgcgicontentfull28suppl_1s72
4 Goldstein DE Little RR Lorenz RA Malone JI Nathan DM Peterson CM American Diabetes Association Tests
of glycemia in diabetes Diabetes Care 200427 Suppl 1S91-3
See httpcarediabetesjournalsorgcgicontentfull27suppl_1s91
5 The Diabetes Control and Complications Trial Research Group Hypoglycemia in the Diabetes Control and
Complications Trial Diabetes 199746(2)271-86 See wwwncbinlmnihgovpubmed9000705 for abstract
6 American Diabetes Association Hypoglycemia and employmentlicensure Diabetes Care 200528 Suppl 1S61
See httpcarediabetesjournalsorgcgicontentfull28suppl_1s61
7 Viswanath K McGavin DD Diabetic Retinopathy Clinical Findings and Management J Comm Eye Health
200316(46)21-4 See wwwcehjournalorg0953-683316jceh_16_46_021html
8 Michigan Diabetes Research and Training Center University of Michigan Health System How to use the Michigan
Neuropathy Screening Instrument See wwwmedumichedumdrtcprofsdocumentssviMNSI_howtopdf
9 Bradley JG Davis KA Orthostatic hypotension Am Fam Physician 200368(12)2393-8
See wwwaafporgafp200312152393html
10 Gibbons RJ Balady GJ Bricker JT et al ACCAHA 2002 guideline update for exercise testing a report of the
American College of CardiologyAmerican Heart Association Task Force on Practice Guidelines (Committee on
Exercise Testing) J Am Coll Cardiol 200240(8)1531-40
See wwwaccorgqualityandscienceclinicalguidelinesexerciseexercise_cleanpdf
11 American Diabetes Association Standards of medical care in diabetes Diabetes Care 200528 Suppl 1S4-S36
Erratum in Diabetes Care 200528(4)990 See httpcarediabetesjournalsorgcgicontentfull28suppl_1s4
12 Molitch ME DeFronzo RA Franz MJ et al American Diabetes Association Nephropathy in diabetes Diabetes
Care 200427 Suppl 1S79-83 See httpcarediabetesjournalsorgcgicontentfull27suppl_1s79
13 Kitabchi AE Umpierrez GE Murphy MB et al American Diabetes Association Hyperglycemic crises in diabetes
Diabetes Care 200427 Suppl 1S94-102 See httpcarediabetesjournalsorgcgicontentfull27suppl_1s94
14 US Centers for Disease Control and Prevention National Diabetes Fact Sheet 2007
See wwwcdcgovdiabetespubspdfndfs_2007pdf
ACOEM Guidance for the Medical Evaluation of Law Enforcement Officers 11
43 ndash DIABETES MELLITUS
30
ATTACHMENT E
31
Typos A6921(2) 7th line down test should be plural 94201 Paragraph 2 target organ damage is used though end organ damage was defined earlier and in the appendix for that paragraph
A94201 Para A (1) d Id suggest deleting the phrases in brackets Im not sure either are predictably true or politically wise
a) tests for left ventricular hypertrophy Unfortunately use of the EKG to detect left ventricular hypertrophy is very insensitive (eg 5 sensitivity) The echocardiogram is the best test for diagnosing left ventricular hypertrophy but [it is relatively expensive and not readily available in small rural communities ] conducting echocardiograms on asymptomatic fire fighters with Stage 1 hypertension should be reserved only for those with long-standing hypertension
In addition
7761 A resting EKG shall be performed as part of the baseline medical evaluation and shall be obtained periodically thereafter
Changing from annually to periodically is noted has the language in the wellness-fitness initiative been changed as well Our previous decision was that we would support the W-F language since there was no compelling evidence to either support or refute it
Thanks
Sandy
32
NFPA 1582‐ HTN Draft 1
Reason for Revision
1) New classification of BP by the Joint National Commission [Chobanian et al 2002]
2) A high prevalence of FF have either HTN (~20) and Pre‐HTN (~20) [Soteriades et al 2003]
3) Among FF studies have shown a strong association between HTN and a number of adverse
cardiovascular events [Kales et al 2009]
4) A large percentage of on‐duty FF fatalities were found to have left ventricular hypertrophy a
complication of HTN at autopsy
Language in 2007 Edition with draft revisions in Red (Track changes)
611 The medical evaluation of a candidate shall include a medical history examination and any laboratory tests required to detect physical or medical condition(s) that could adversely affect hisher ability to safely perform the essential job tasks outlined in 511 A611 The medical history should include the candidates known health problems such as major illnesses surgeries medication use and allergies Symptom review is also important for detecting early signs of illness A medical history should also include a personal health history a family health history a health habit history an immunization history and a reproductive history
An occupational history should also be obtained to collect information about the persons past occupational and environmental exposures
(a) BP should be measured according to the Joint National Commission (JNC) -7 recommendations BP should be measured with a properly calibrated and validated instrument Patients should be seated quietly for at least 5 minutes in a chair with feet on the floor and arm supported at heart level An appropriate-sized cuff (cuff bladder encircling at least 80 of the arm) should be used to ensure accuracy At least 2 measurements should be made Systolic BP is the point at which the first of 2 or more sounds is heard (phase 1) and diastolic BP is the point before the disappearance of sounds (phase 5) [Chobanian et al 2003]
(2) Head eyes ears nose and throat (HEENT)
Formatted Font (Default) Times New RomanFont color Black
33
692 Vascular System 6921 Category A medical conditions shall include the following
(1) Uncontrolled or poorly controlled hypertension
(2) Hypertension with evidence of end organ damage
or not controlled by approved medications
A6921(1) Uncontrolled or poorly controlled hHypertension increases the risk of a sudden cardiac event This sudden cardiac event would cause sudden incapacitation which that is uncontrolled poorly controlled or requires medication likely to interferes with the safe performance of essential job tasks Uncontrolled or poorly controlled hypertension can be defined as the presence of end organ damage (see below) or stage 2 hypertension (BP systolic gt160 mmHg or BP diastolic gt100 mmHg) is an illness that can lead to functional impairment and potential for sudden incapacitation Individuals with pre- stage 1 or stage 2 hypertension should be referred to their primary care physician for evaluation lifestyle modification and treatment [QUESTION FOR GROUP _- WHAT ABOUT HAVING CANDIDATE RETURN IN ONE MONTH UNDER TREATMENT WITH NORMAL BP]
A6921(2)
Chronic hypertension can damage the eye (retinopathy) the kidneys (nephropathy) the vascular system (stroke transient ischemic attack or peripheral artery disease) or the heart (left ventricular hypertrophy and heart failure) These hypertension complications are known as end organ damage The cardiac and vascular complications are associated with an increased risk of sudden incapacitation and sudden cardiac death (Koren et al 1991) Unfortunately the cardiac complications are frequently asymptomatic and valid screening tests are not fast and are not inexpensive Therefore determining who to screen for cardiac complications (such as echocardiogram for LVH or a measurement of left ventricular ejection fraction for heart failure) should be based on the severity and the duration of HTN
76 Physical Examination The annual physical examination shall include each of the following components
(a) BP shall be measured according to the Joint National Commission (JNC)-7 recommendations
A76(1)(a) BP should be measured with a properly calibrated and validated instrument Patients should be seated quietly for at least 5 minutes in a chair with feet on the floor and arm supported at heart level An appropriate-sized cuff (cuff bladder encircling at least 80 of the arm) should be used to ensure accuracy At least 2 measurements should be made Systolic BP is the point at which the first of 2 or more sounds is heard (phase 1) and diastolic BP is the point before the disappearance of sounds (phase 5) [Chobanian et al 2003]
(2) Head eyes ears nose and throat (HEENT)
34
9420 Uncontrolled Hypertension 94201 Physician Evaluation Severe uncontrolled hypertension [defined as systolic pressure greater than 180 mm Hg diastolic pressure greater than 100 mm Hg or mean systolic blood
pressure ( systolic + diastolic) greater than 120 mm Hg] or malignant hypertension (defined as hypertension with the presence of target organ damage) compromises the members ability to safely perform essential job tasks 1 5 7 9 and 13 and the physician shall report the applicable job limitations to the fire department
Members with Pre-hypertention (systolic 120-139 mmHg or diastolic 80-89 mmHg) Stage 1 hypertension (systolic 140-159 mmHg or diastolic 90-99 mmHg) or Stage 2 hypertension (systolic ge160 mmHg or diastolic ge100 mmHg) should be referred to their primary care physician for evaluation lifestyle modification and treatment
(1) Members with Stage I hypertension should be followed-up not only by their primary care physician but also by the FD physician every 3 to 6 months to ensure their blood pressure is under control and to determine whether screening tests for asymptomatic end organ damage are appropriate
(2) Members with Stage 2 hypertension or with end organ damage (retinopathy nephropathy vascular or cardiac complications) compromises the members ability to safely perform essential job tasks 1 5 7 9 and 130 and the physician shall report the applicable job limitations to the fire department
A94201 Severe uncontrolled hypertension is a significant risk factor for the development of coronary artery disease congestive heart failure and stroke Blood pressure increases as a normal response to exercise This response is further exaggerated by the emotional and physical stress of performing these critical tasks while operating in personal protective clothing at extremes of temperature This normal elevation of blood pressure under these response conditions can lead to life-threatening hypertensive emergencies if a members daily blood pressure is already elevated to high levels In addition hypertension is a progressive illness that when uncontrolled ultimately and inevitably leads to target organ damage Target organs that are sensitive to the effects of elevated blood pressure are the central nervous system vision heart major blood vessels and kidneys
Chronic hypertension can damage the eye (retinopathy) the kidneys (nephropathy) the vascular system (stroke transient ischemic attack or peripheral artery disease) or the heart (left ventricular hypertrophy and heart failure) These hypertension complications are known as end organ damage The cardiac and vascular complications are associated with an increased risk of sudden incapacitation and sudden cardiac death (Koren et al 1991) Fortunately with proper evaluation life style modification and treatment these complications can be avoided Life style modification includes weight reduction DASH eating plan reduction in dietary sodium an increase in aerobic physical activity and moderation in alcohol consumption [Chobanian 2003]
Formatted Font (Default) Times New Roman12 pt Font color Black
Formatted Font (Default) Times New Roman12 pt Font color Black
35
A94201 (1) Members with Stage I hypertension whose BP returns to either pre-hypertenion or normal with lifestyle modification andor treatment can return to an annual medical evaluation For members with long-standing Stage I hypertension whose BP has not been reduced additional evaluation for possible end organ damage should be considered This evaluation could include any or all of the following
a) a compete patient history for symptoms of heart failure (eg shortness of breath upon exertion) or transient ischemic attacks (TIAs)
b) dilated eye examination for retinopathy
c) blood creatinine measurement for nephropathy
d) tests for left ventricular hypertrophy Unfortunately use of the resting EKG to detect left ventricular hypertrophy is very insensitive (eg 5 sensitivity) The echocardiogram is the best test for diagnosing left ventricular hypertrophy
A 94201 (2) Due to the high risk of a sudden cardiovascular event members with Stage 2 hypertension should be restricted until their BP can be brought under control Once the BP is brought under control they should be followed in the same manner as a member with Stage I hypertension
Formatted Font (Default) Times New Roman12 pt
36
D22 Cardiology Gibbons R J GJ Balady J W Beasley et al 1997 ACCAHA guidelines for exercise testing a report of American College of CardiologyAmerican Heart Association Task Force on Practice Guidelines (Committee on Exercise Testing) J Am Coll Cardiol 30260ndash311
Gibbons RJ Balady GJ Bricker JT Chaitman BR Fletcher GF Froelicher VF Mark DB McCallister BD Mooss AN OrsquoReilly MG Winters WL Jr [2002] ACCAHA 2002 guideline update for exercise testing summary article a report of the ACCAHA Task Force on Practice Guidelines (Committee to Update the 1997 Exercise Testing guidelines) J Am Coll Cardiol 401531ndash 40
Chobanian AV Bakris GL Black HR Cushman WC Green LA Izzo JL Jr Jones DW Materson BJ Oparil S Wright JT Jr Roccella EJ the National High Blood Pressure Education Program Coordinating Committee [2003] The seventh report of the Joint National Committee [JNC-7] on Prevention Detection Evaluation and Treatment of High Blood Pressure JAMA 2892560ndash2571
Soteriades ES Kales SN Liarokapis D Christiani DC [2003] Prospective surveillance of hypertension in firefighters J Clin Hypertens 5315-320
Kales SN Tsismenakis AJ Zhang C Soteriades ES [2009] Blood pressure in fire fighters police officers and other emergency responders Am J Hypertens 2211-20
37
NFPA 1582‐ HTN Draft 1
Reason for Revision
1) New classification of BP by the Joint National Commission [Chobanian et al 2002]
2) A high prevalence of FF have either HTN (~20) and Pre‐HTN (~20) [Soteriades et al 2003]
3) Among FF studies have shown a strong association between HTN and a number of adverse
cardiovascular events [Kales et al 2009]
4) A large percentage of on‐duty FF fatalities were found to have left ventricular hypertrophy a
complication of HTN at autopsy
Language in 2007 Edition with draft revisions in Red (Track changes)
611 The medical evaluation of a candidate shall include a medical history examination and any laboratory tests required to detect physical or medical condition(s) that could adversely affect hisher ability to safely perform the essential job tasks outlined in 511 A611 The medical history should include the candidates known health problems such as major illnesses surgeries medication use and allergies Symptom review is also important for detecting early signs of illness A medical history should also include a personal health history a family health history a health habit history an immunization history and a reproductive history
An occupational history should also be obtained to collect information about the persons past occupational and environmental exposures
(a) BP should be measured according to the Joint National Commission (JNC) -7 recommendations BP should be measured with a properly calibrated and validated instrument Patients should be seated quietly for at least 5 minutes in a chair with feet on the floor and arm supported at heart level An appropriate-sized cuff (cuff bladder encircling at least 80 of the arm) should be used to ensure accuracy At least 2 measurements should be made Systolic BP is the point at which the first of 2 or more sounds is heard (phase 1) and diastolic BP is the point before the disappearance of sounds (phase 5) [Chobanian et al 2003]
(2) Head eyes ears nose and throat
38
692 Vascular System 6921 Category A medical conditions shall include the following
(1) Uncontrolled or poorly controlled hypertension
(2) Hypertension with evidence of end organ damage
A6921(1) Uncontrolled or poorly controlled hypertension increases the risk of a sudden cardiac event This sudden cardiac event would cause sudden incapacitation which interferes with the safe performance of essential job tasks Uncontrolled or poorly controlled hypertension can be defined as the presence of end organ damage (see below) or stage 2 hypertension (BP systolic gt160 mmHg or BP diastolic gt100 mmHg) Individuals with pre- stage 1 or stage 2 hypertension should be referred to their primary care physician for evaluation lifestyle modification and treatment [QUESTION FOR GROUP _- WHAT ABOUT HAVING CANDIDATE RETURN IN ONE MONTH UNDER TREATMENT WITH NORMAL BP]
A6921(2)Chronic hypertension can damage the eye (retinopathy) the kidneys (nephropathy) the vascular system (stroke transient ischemic attack or peripheral artery disease) or the heart (left ventricular hypertrophy and heart failure) These hypertension complications are known as end organ damage The cardiac and vascular complications are associated with an increased risk of sudden incapacitation and sudden cardiac death (Koren et al 1991) Unfortunately the cardiac complications are frequently asymptomatic and valid screening tests are not fast and are not inexpensive Therefore determining who to screen for cardiac complications (such as echocardiogram for LVH or a measurement of left ventricular ejection fraction for heart failure) should be based on the severity and the duration of HTN
76 Physical Examination The annual physical examination shall include each of the following components
(a) BP shall be measured according to the Joint National Commission (JNC)-7 recommendations
A76(1)(a) BP should be measured with a properly calibrated and validated instrument Patients should be seated quietly for at least 5 minutes in a chair with feet on the floor and arm supported at heart level An appropriate-sized cuff (cuff bladder encircling at least 80 of the arm) should be used to ensure accuracy At least 2 measurements should be made Systolic BP is the point at which the first of 2 or more sounds is heard (phase 1) and diastolic BP is the point before the disappearance of sounds (phase 5) [Chobanian et al 2003]
(2) Head eyes ears nose and throat9420 Hypertension 94201 Physician Evaluation Members with Pre-hypertention (systolic 120-139 mmHg or diastolic 80-89 mmHg) Stage 1 hypertension (systolic 140-159 mmHg or diastolic 90-99 mmHg) or Stage 2 hypertension (systolic ge160 mmHg or diastolic ge100 mmHg) should be referred to their primary care physician for evaluation lifestyle modification and treatment
39
(1) Members with Stage I hypertension should be followed-up not only by their primary care physician but also by the FD physician every 3 to 6 months to ensure their blood pressure is under control and to determine whether screening tests for asymptomatic end organ damage are appropriate
(2) Members with Stage 2 hypertension or with end organ damage (retinopathy nephropathy vascular or cardiac complications) compromises the members ability to safely perform essential job tasks 1 5 7 9 and 130 and the physician shall report the applicable job limitations to the fire department
A94201 Chronic hypertension can damage the eye (retinopathy) the kidneys (nephropathy) the vascular system (stroke transient ischemic attack or peripheral artery disease) or the heart (left ventricular hypertrophy and heart failure) These hypertension complications are known as end organ damage The cardiac and vascular complications are associated with an increased risk of sudden incapacitation and sudden cardiac death (Koren et al 1991) Fortunately with proper evaluation life style modification and treatment these complications can be avoided Life style modification includes weight reduction DASH eating plan reduction in dietary sodium an increase in aerobic physical activity and moderation in alcohol consumption [Chobanian 2003]
A94201 (1) Members with Stage I hypertension whose BP returns to either pre-hypertenion or normal with lifestyle modification andor treatment can return to an annual medical evaluation For members with long-standing Stage I hypertension whose BP has not been reduced additional evaluation for possible end organ damage should be considered This evaluation could include any or all of the following
a) a compete patient history for symptoms of heart failure (eg shortness of breath upon exertion) or transient ischemic attacks (TIAs)
b) dilated eye examination for retinopathy
c) blood creatinine measurement for nephropathy
d) tests for left ventricular hypertrophy Unfortunately use of the resting EKG to detect left ventricular hypertrophy is very insensitive (eg 5 sensitivity) The echocardiogram is the best test for diagnosing left ventricular hypertrophy
A 94201 (2) Due to the high risk of a sudden cardiovascular event members with Stage 2 hypertension should be restricted until their BP can be brought under control Once the BP is brought under control they should be followed in the same manner as a member with Stage I hypertension
D22 Cardiology
40
Hypertension
Gibbons RJ Balady GJ Bricker JT Chaitman BR Fletcher GF Froelicher VF Mark DB McCallister BD Mooss AN OrsquoReilly MG Winters WL Jr [2002] ACCAHA 2002 guideline update for exercise testing summary article a report of the ACCAHA Task Force on Practice Guidelines (Committee to Update the 1997 Exercise Testing guidelines) J Am Coll Cardiol 401531ndash 40
Chobanian AV Bakris GL Black HR Cushman WC Green LA Izzo JL Jr Jones DW Materson BJ Oparil S Wright JT Jr Roccella EJ the National High Blood Pressure Education Program Coordinating Committee [2003] The seventh report of the Joint National Committee [JNC-7] on Prevention Detection Evaluation and Treatment of High Blood Pressure JAMA 2892560ndash2571
Soteriades ES Kales SN Liarokapis D Christiani DC [2003] Prospective surveillance of hypertension in firefighters J Clin Hypertens 5315-320
Kales SN Tsismenakis AJ Zhang C Soteriades ES [2009] Blood pressure in fire fighters police officers and other emergency responders Am J Hypertens 2211-20
41
NFPA 1582‐ Draft Revisions for CVDHTN
EKG and stress tests
Reason for Revision
1) Change requirement for annual resting EKG to periodically to be more consistent with ACCAHA
recommendation (Schlant et al 1992)
2) Add language to clarify what constitutes a positive ST
3) Make criteria for conducting diagnostic ST in asymptomatic patients consistent with the
ACCAHA
Language in 2007 Edition with draft revisions in Red (Track changes)
776 Electrocardiograms (EKG)) and Stress Tests 7761 A resting EKG shall be performed as part of the baseline medical evaluation and shall be obtained periodically (every 1 to 5 years) annually thereafter
A7761 A baseline resting EKGs shall be conducted Follow-up resting EKGs should be conducted as clinically indicated but at a minimum of every 1 to 5 years The frequency of these follow-up resting EKGs should increase as a members age increases or with increasing number andor severity of coronary heart disease risk factors Members above the age of 40 should have annual resting EKGs (Schlant et al 1992)
7762 The fire department physician or other qualified medical evaluator shall compare EKGs obtained during yearly evaluations with baseline and subsequent EKGs
7763 Stress testing EKG with or without echocardiography or radionuclide scanning shall be performed as clinically indicated by history or symptoms
A7761 Baseline electrocardiography should be conducted (Periodic resting electrocardiograms have not been shown to be useful but can be reasonable as a members agefactors increase)
A7763 No firm guidelines for stress testingelectrocardiography in asymptomatic individuals have been developed Stress testingelectrocardiography as a screening tool is used as part of an evaluation of aerobic capacity during the annual occupational fitness evaluation Submaximal stress testingelectrocardiography testing to 85 percent is commonly used as part of this screening
Submaximal stress electrocardiography testing should not be used for diagnostic purposes Cardiology evaluation with maximal stress testingelectrocardiography together with imaging techniques (eg echocardiography technetium Tc99m sestamibi study andor coronary angiography) is necessary for diagnosticprognostic purposes for the following
42
(1) Fire fighters with positive or questionably positive changes on screening submaximal stress tests
(2) Fire fighters with new onset chest pain or other symptoms suggestive of coronary artery disease (CAD)
(3) Fire fighters with diabetes mellitus who
(a) are gt35 years old or
(b) have type I diabetes for more than 15 years or
(c) have type II diabetes for more than 10 years or
(d) have any other CHD risk factor (see below) or
(e) have the presence of microvascular disease (proliferative retinopathy)
(4) Fire fighters over the age of 45 (for men) and 55 (for women) with onetwo or more risk factors for CAD Risk factors for CAD include hypercholesterolemia (total cholesterol greater than 240 mgdL) hypertension (systolic gt140 mmHg or diastolic gt90 mmHg) smoking or family history of premature CAD (heart attack or sudden cardiac death in a first degree relative less than 60 years of age)
as defined below if stress electrocardiography with imaging is negative then repeat as clinically indicated or at least every 5 years
(5) Fire fighters with a Framingham Risk Score gt10 Risk calculator is available at [httphp2010nhlbihinnetatpiiicalculatorasp]
(6) Fire fighters identified in 9431
Negative stress tests should be repeated as clinically indicated or at least every 2 to 5 years
Interpreting stress tests as ldquopositiverdquo or ldquonegativerdquo is beyond the scope of this document However factors that should be taken into consideration should include the individualrsquos exercise capacity symptoms blood pressure response heart rate response EKG changes and the presence of arrhythmias (Gibbon et al 2002)
Risk factors for CAD include hypercholesterolemia (total cholesterol greater than 240 mgdL) hypertension (systolic greater than 140 andor diastolic greater than 90) smoking diabetes mellitus or family history of premature CAD (heart attack or sudden cardiac death in a first degree relative less than 60 years of age)
There are other non-invasive tests to screen for coronary artery disease One of the most promising appears to be coronary artery calcium (CAD) scoring by computed tomography In 2007 an expert committee published an update to their original guidance document The committeersquos consensus was that ldquoit may be reasonable to consider use of CAC measurement in such patients [between 10 and 20 10-year risk of estimated coronary event]helliprdquo The committee did not recommend CAC measurement in low risk patients [lt10 10-year risk of estimated coronary event] or in high risk patients [gt20 10-year risk of estimate coronary event] (Greenland et al 2007]
43
D22 Cardiology
Chobanian AV Bakris GL Black HR Cushman WC Green LA Izzo JL Jr Jones DW Materson BJ Oparil S Wright JT Jr Roccella EJ the National High Blood Pressure Education Program Coordinating Committee [2003] The seventh report of the Joint National Committee [JNC-7] on Prevention Detection Evaluation and Treatment of High Blood Pressure JAMA 2892560ndash2571
Gibbons RJ Balady GJ Bricker JT Chaitman BR Fletcher GF Froelicher VF Mark DB McCallister BD Mooss AN OrsquoReilly MG Winters WL Jr [2002] ACCAHA 2002 guideline update for exercise testing summary article a report of the ACCAHA Task Force on Practice Guidelines (Committee to Update the 1997 Exercise Testing guidelines) J Am Coll Cardiol 401531ndash 1540
Greenland et al [2007] ACCFAHA 2007 Clinical Expert Consensus Document on Coronary Artery Calcium Scoring By Computed Tomography in Global Cardiovascular Risk Assessment and in Evaluation of Patients With Chest Pain A Report of the American College of Cardiology Foundation Clinical Expert Consensus Task Force (ACCFAHA Writing Committee to Update the 2000 Expert Consensus Document on Electron Beam Computed Tomography) J Am Coll Cardiol 49378-402
Kales SN Tsismenakis AJ Zhang C Soteriades ES [2009] Blood pressure in fire fighters police officers and other emergency responders Am J Hypertens 2211-20
Schlant RC Adolph RJ DiMarco JP Dreifus LS Dunn MI Fisch C Garson A Jr Haywood LJ Levine HJ Murray JA Noble RJ Ronan JA Jr [1992] Guidelines for electrocardiography A report of the American College of CardiologyAmerican Heart Association Task Force on Assessment of Diagnostic and Therapeutic Cardiovascular Procedures (Committee on Electrocardiography) Circulation 85(3)1221-1228
Soteriades ES Kales SN Liarokapis D Christiani DC [2003] Prospective surveillance of hypertension in firefighters J Clin Hypertens 5315-320
Formatted Font Italic
Formatted Line spacing single
Formatted Font Italic
Formatted Font Italic
44
NFPA 1582‐ Draft Revisions for CVDHTN
EKG and stress tests
Reason for Revision
1) Change requirement for annual resting EKG to periodically to be more consistent with ACCAHA
recommendation (Schlant et al 1992)
2) Add language to clarify what constitutes a positive ST
3) Make criteria for conducting diagnostic ST in asymptomatic patients consistent with the
ACCAHA
Language in 2007 Edition with draft revisions in Red (Track changes)
776 Electrocardiograms (EKG) and Stress Tests 7761 A resting EKG shall be performed as part of the baseline medical evaluation and shall be obtained periodically (every 1 to 5 years) thereafter
A7761 A baseline resting EKGs shall be conducted Follow-up resting EKGs should be conducted as clinically indicated but at a minimum of every 1 to 5 years The frequency of these follow-up resting EKGs should increase as a members age increases or with increasing number andor severity of coronary heart disease risk factors Members above the age of 40 should have annual resting EKGs (Schlant et al 1992)
7762 The fire department physician or other qualified medical evaluator shall compare baseline and subsequent EKGs
7763 Stress testing with or without echocardiography or radionuclide scanning shall be performed as clinically indicated by history or symptoms
A7763 No firm guidelines for stress testing in asymptomatic individuals have been developed Stress testing as a screening tool is used as part of an evaluation of aerobic capacity during the annual occupational fitness evaluation Submaximal stress testing testing to 85 percent is commonly used as part of this screening
Submaximal stress testing should not be used for diagnostic purposes Cardiology evaluation with maximal stress testing together with imaging techniques (eg echocardiography technetium Tc99m sestamibi study) is necessary for diagnosticprognostic purposes for the following
(1) Fire fighters with positive or questionably positive changes on screening submaximal stress tests
(2) Fire fighters with new onset chest pain or other symptoms suggestive of coronary artery disease (CAD)
45
(3) Fire fighters with diabetes mellitus who
(a) are gt35 years old or
(b) have type I diabetes for more than 15 years or
(c) have type II diabetes for more than 10 years or
(d) have any other CHD risk factor (see below) or
(e) have the presence of microvascular disease (proliferative retinopathy)
(4) Fire fighters over the age of 45 (for men) and 55 (for women) with one or more risk factors for CAD Risk factors for CAD include hypercholesterolemia (total cholesterol greater than 240 mgdL) hypertension (systolic gt140 mmHg or diastolic gt90 mmHg) smoking or family history of premature CAD (heart attack or sudden cardiac death in a first degree relative less than 60 years of age)
(5) Fire fighters with a Framingham Risk Score gt10 Risk calculator is available at [httphp2010nhlbihinnetatpiiicalculatorasp]
(6) Fire fighters identified in 9431
Negative stress tests should be repeated as clinically indicated or at least every 2 to 5 years
Interpreting stress tests as ldquopositiverdquo or ldquonegativerdquo is beyond the scope of this document However factors that should be taken into consideration should include the individualrsquos exercise capacity symptoms blood pressure response heart rate response EKG changes and the presence of arrhythmias (Gibbon et al 2002)
There are other non-invasive tests to screen for coronary artery disease One of the most promising appears to be coronary artery calcium (CAD) scoring by computed tomography In 2007 an expert committee published an update to their original guidance document The committeersquos consensus was that ldquoit may be reasonable to consider use of CAC measurement in such patients [between 10 and 20 10-year risk of estimated coronary event]helliprdquo The committee did not recommend CAC measurement in low risk patients [lt10 10-year risk of estimated coronary event] or in high risk patients [gt20 10-year risk of estimate coronary event] (Greenland et al 2007]
D22 Cardiology
Resting EKG and Stress Tests
46
Chobanian AV Bakris GL Black HR Cushman WC Green LA Izzo JL Jr Jones DW Materson BJ Oparil S Wright JT Jr Roccella EJ the National High Blood Pressure Education Program Coordinating Committee [2003] The seventh report of the Joint National Committee [JNC-7] on Prevention Detection Evaluation and Treatment of High Blood Pressure JAMA 2892560ndash2571
Gibbons RJ Balady GJ Bricker JT Chaitman BR Fletcher GF Froelicher VF Mark DB McCallister BD Mooss AN OrsquoReilly MG Winters WL Jr [2002] ACCAHA 2002 guideline update for exercise testing summary article a report of the ACCAHA Task Force on Practice Guidelines (Committee to Update the 1997 Exercise Testing guidelines) J Am Coll Cardiol 401531ndash 1540
Greenland et al [2007] ACCFAHA 2007 Clinical Expert Consensus Document on Coronary Artery Calcium Scoring By Computed Tomography in Global Cardiovascular Risk Assessment and in Evaluation of Patients With Chest Pain A Report of the American College of Cardiology Foundation Clinical Expert Consensus Task Force (ACCFAHA Writing Committee to Update the 2000 Expert Consensus Document on Electron Beam Computed Tomography) J Am Coll Cardiol 49378-402
Kales SN Tsismenakis AJ Zhang C Soteriades ES [2009] Blood pressure in fire fighters police officers and other emergency responders Am J Hypertens 2211-20
Schlant RC Adolph RJ DiMarco JP Dreifus LS Dunn MI Fisch C Garson A Jr Haywood LJ Levine HJ Murray JA Noble RJ Ronan JA Jr [1992] Guidelines for electrocardiography A report of the American College of CardiologyAmerican Heart Association Task Force on Assessment of Diagnostic and Therapeutic Cardiovascular Procedures (Committee on Electrocardiography) Circulation 85(3)1221-1228
Soteriades ES Kales SN Liarokapis D Christiani DC [2003] Prospective surveillance of hypertension in firefighters J Clin Hypertens 5315-320
47
ATTACHMENT F
48
1
Current 1582 (2007) language in reference to pregnancy 43 (4) Report to the fire department physician any medical condition that could interfere with the ability of the individual to safely perform essential job tasks such as illness or injury use of prescription or nonprescription drugs and pregnancy 6112 Category B medical conditions shall include the following (1) Pregnancy for its duration A7792 (e) If HIV prophylaxis is to be given the following tests should be done i CBC ii Glucose renal and hepatic chemical function iii Pregnancy test for females B121 Pregnancy and Reproduction Federal regulations as well as many court decisions including the US Supreme Courtrsquos decision in International Union et al v Johnson Controls Inc [499 US 187 111 S Ct 1196 (1991)] have interpreted the requirements of Title VII with respect to pregnancy and reproduction The AHJ should seek the advice of counsel in resolving specific questions concerning these requirements as well as other requirements that can be imposed by state or local laws C211 (4) Review health status with the individual being evaluated Contraindications for evaluations shall be reviewed addressing any changes in the individualrsquos health status since their last medical evaluation that would warrant deferring the evaluation including (g) Pregnancy Recommendations to language enhancement
A female employee who is assigned to regular fire line duty shall report a pregnancy immediately to their respective Supervisor and the fire department physician The employee will then be given the option of a non-hazardous alternative duty position for the duration of her pregnancy (can we say this or is it even appropriate) Any pregnant employee wishing to remain on regular line duty shall be informed of the possible risks and consequences to herself and her fetus that are associated with continued line fire fighting duty Among those risk factors are exposure to teratogens known to have negative effects on the developing fetus such as smoke diesel fumes hazardous chemicals and extreme heat
49
Page 2
appendix It is recommended that the pregnant employee complete a release of liability form signed by herself and her health care provider utilizing NFPArsquos 13 critical tasks as a reference This will inform the health care provider of specific job-related tasks that will need to be performed in order to continue regular line duty These tasks are basic physical standards that any entry level firefighter would have to be able to complete competently The employeersquos health condition will be kept confidential by the department in accordance with HIPAA standards Employees are allowed to remain on active regular duty until they are no longer able to perform their duties in a reasonable manner andor their protective gear no longer fits correctly It is the responsibility of the health care provider to evaluate the pregnant employee If at any time the health care provider feels the pregnant employee can no longer perform the job related tasks this should be reported to the employer by the employee immediately
50
ATTACHMENT G
51
From GLENN BENARICKTo Sawyer SteveSubject RE RE 7743Date Monday August 30 2010 21633 PM
Yes thats my understanding
Glenn P Benarick 211 Winged Elm CircleAiken SC 29803803-644-7093gbenarprodigynet
--- On Mon 83010 Sawyer Steve ltssawyerNFPAorggt wrote
From Sawyer Steve ltssawyerNFPAorggtSubject RE RE 7743To GLENN BENARICK ltgbenarprodigynetgtDate Monday August 30 2010 212 PM
So it should be ldquoorrdquo instead of ldquoandrdquo for now
Steven F Sawyer
Senior Fire Service Specialist
Executive Secretary IFMAFire Service Section
NFPA
1 Batterymarch Park
Quincy MA 02169
6179847423
Fax 6179847056
ssawyernfpaorg
From GLENN BENARICK [mailtogbenarprodigynet] Sent Monday August 30 2010 1202 PMTo Sawyer SteveSubject Fw RE 7743
52
Steve a couple of our docs agree with April Boyer
Glenn P Benarick 211 Winged Elm Circle
Aiken SC 29803
803-644-7093
gbenarprodigynet
--- On Mon 83010 David Prezant ltprezandfdnynycgovgt wrote
From David Prezant ltprezandfdnynycgovgtSubject RE 7743To Thomas R (CDCNIOSHDSHEFS) Hales lttrh1cdcgovgt GLENNBENARICK ltgbenarprodigynetgtCc Sandy Bogucki ltsandyboguckiyaleedugtDate Monday August 30 2010 1004 AM
agree
we should change this to NHANES III rather than Knudson we should alsomodify this to allow not only for predicted cutoffs but all for use of thelower limit of normal cutoff This is important to prevent false-classificationof spirometry as abnormal in older groups and in taller grps The latter ofparticular import to firefighter occupational health surveillance
thanks
David Prezant MDChief Medical Officer Office of Medical AffairsCo-Director WTC Medical Monitoring amp Treatment ProgramsNew York City Fire Department9 Metrotech Center - Rm 4W-1Brooklyn NY 11201Phone 718-999-2696Fax 718-999-0665
Life is full of twists and turns
53
This email may contain confidential information If you are the unintendedrecipient of this email please send it back and delete from your directory
gtgtgt Hales Thomas R (CDCNIOSHDSHEFS) lttrh1cdcgovgt 8302010955 AM gtgtgt
Glen
This seems like a very reasonable comment and illustrates the importance of having clinicians providefeedback on the std Im not familiar with the software program of the various spirometers (NHANES IIIvs KnudsonATS vs both) Given the large role both Dave Prezant and Sandy Bogucki had for thepulmonary section let me forward to them for clarification
Tom
From GLENN BENARICK [mailtogbenarprodigynet] Sent Sunday August 29 2010 456 PMTo Hales Thomas R (CDCNIOSHDSHEFS)Subject FW 7743
Tom is April Boyer correct
Glenn P Benarick 211 Winged Elm Circle
Aiken SC 29803
803-644-7093
gbenarprodigynet
--- On Thu 82610 Sawyer Steve ltssawyerNFPAorggt wrote
From Sawyer Steve ltssawyerNFPAorggtSubject FW 7743To GLENN BENARICK ltgbenarprodigynetgtDate Thursday August 26 2010 925 PM
FYI Do you have any answer She is write
Steven
54
Steven F Sawyer
Senior Fire Service Specialist
Executive Secretary IFMAFire Service Section
NFPA
1 Batterymarch Park
Quincy MA 02169
6179847423
Fax 6179847056
ssawyernfpaorg
From April Boyer [mailtoaboyerbicclinicorg] Sent Thursday August 26 2010 232 PMTo Sawyer SteveCc RobinMWebbmilstateorusSubject 7743
Steven
The spirometry tests cannot be corrected according to both references as the NFPA states because thereferences are contradictory The first part of 7743 states to follow the ATS guidelines and use theKnudsen (we at Basin Immediate Care use the Nhanes III) The second part states to follow the ACOEMguidelines and use the Nhanes III in the occupational setting if available with your unit (which is availableon ours) 7743 does not use the word OR regarding both requirements it uses the word AND whenreferring to the first and second parts thence making 7743 contradictory I realize the NFPA 1582 hasnot been updated since 2007 unless I have just not received an updated version
Our question to you is which part of 7743 do you want us to follow the first or the second part Anyfacility that has an updated computerized spirometry system (as we do) will not be able to follow bothrequired parts for obvious reasons We can either follow the first part of 7743 and use an oldercorrected version of the Knudson by going into our system and changing out of the Nhanes III conversionOR we can follow the second part of 7743 and use the newer corrected version of Nhanes III which ourunit offers too
If you have any questions you may contact me at anytime and I also have many references in regards toboth parts of 7743 if you would like to see them
55
Thank you~
April
Confidentiality NoticeThis message may contain information that isconfidential or privileged
If you are not the intended recipientPlease advise the sender immediately and delete this message
56
ATTACHMENT H
57
NFPA 1582 771(7) Proposed revisions
Why
Preliminary results of two prospective randomized trials on the PSA test were published in 2009 These studies resulted in medical organizations that previously providing guidance to modify their recommendations
Current language
771 Blood Tests Blood tests shall be performed annually and shall include the following
(7) Prostate specific antigen (PSA) after age 40 for positive family history if African American or if otherwise clinically indicated after age 50 for all other male member
Suggested Revision
771 Blood Tests Blood tests shall be performed annually and shall include the following
(7) Prostate specific antigen (PSA) after age 40 for positive family history if African American or if otherwise clinically indicated after age 50 for all other male member
772 Prostate-Specific Antigen (PSA) test At age 50 fire fighters shall have an opportunity to make an informed decision with either the Fire Department physician or their health care provider concerning the PSA test For fire fighters at increased risk of prostate cancer (African-Americans or those with a first degree relative diagnosed with prostate cancer before age 65) shall have the opportunity for this informed decision at age 40
A772 The PSA as a screening test for prostate cancer in asymptomatic men is controversial controversial for two reasons First there is no consensus that PSA screening actually saves lives For example the PSA test may detect small cancers that would never become life threatening Second it is unclear that the benefits of PSA screening outweigh the risks of follow-up diagnostic tests and cancer treatments For example the prostate biopsy used to diagnose prostate cancer may cause bleeding and infection And prostate cancer treatments such as surgery and radiation therapy may cause incontinence (inability to control urine flow) erectile dysfunction (erections inadequate for intercourse) and other complications For these reasons it is important that the benefits and risks of prostate diagnostic procedures and treatment be taken into account when considering the PSA screening test These considerations can be taken account during discussions with the fire department physician or onersquos health care provider
D211 Cancer Screening
Smith R A C J Mettlin K J Davis and H Eyre 2000 ldquoAmerican Cancer Society guidelines for the early detection of cancerrdquo CA J Clin 50(1)34ndash49
Added references
58
Carroll P Albertsen PC Greene K et al [2010] Prostate-specific antigen best practice statement 2009 update Am Urological Assoc Available at httpwwwauanetorgcontentguidelines-and-quality-careclinical-guidelinesmain-reportspsa09pdf Date accessed September 2010
Ferrini R Woolf SH [2009] Screening for prostate cancer in American men American College of Preventive Medicine Practice Policy Statement Available at httpwwwacpmorgprostatehtm Date accessed September 2010
National Cancer Institute [2009] Prostate-specific antigen test National Cancer Institute Fact Sheet Available at httpwwwcancergovcancertopicsfactsheetDetectionPSA Date accessed September 2010
Wolf AMD Wender RC Etzioni RB et al [2010] American Cancer Society guideline for the early detection of prostate cancer Update 2010 Available at httpcaonlineamcancersocorgcgicontentfullcaac20066v1 Date accessed September 2010
59
9 Has had a complete eye exam by a qualified ophthalmologist or optometrist including a dilated retinal exam
demonstrating no more than mild background diabetic retinopathy
Copy of ophthalmology or optometry report is attached
Yes No ndash please explain_______________________________________________________
10 Has normal vibratory testing with 128 Hz tuning fork has normal testing with 10 gram Semmes-Weinstein
monofilament and normal orthostatic blood pressure and pulse testing
Vibration sensation _____________________
Monofilament _________________________
BP supine ____________________________ Pulse supine ______________
BP standing ___________________________ Pulse standing _____________
11 Has normal cardiac physical exam and normal cardiac stress testing to at least 12 METS Annual cardiac stress
testing should begin when any of the following criteria are met
age greater than 35 years
Type 1 DM greater than 15 years duration
Type 2 DM greater than 10 years duration
signs of target organ damage (eyes kidneys autonomic cardiac)
any other coronary artery disease risk factors
Copy of stress test report performed within the last 12 months is attached
Yes No ndash please explain ________________________________________________________
12 Has normal renal function based on albumincreatinine ratio 301 and measured or calculated creatinine
Urine microalbumincreatinine ratio _________________
III Treating Physician Statement
The above named individual meets all of the criteria provided on this form
Yes No ndash not recommended for position
No but IS recommended for position (letter of explanation attached)
It is my opinion that the above named individual is well-educated and well-motivated in diabetes self-management and has
achieved a level of diabetes management to be capable of safe and effective job performance as a law enforcement officer
I have reached this opinion after careful review of the above criteria
___________________________________________________________ ___________________________Signature of Physician Date
______________________________________________________________ ___________________________Printed or Typed Name of Physician Telephone Number
10 ACOEM Guidance for the Medical Evaluation of Law Enforcement Officers
43 ndash DIABETES MELLITUS
29
439 ndash REFERENCES
1 American Diabetes Association Diagnosis and classification of diabetes mellitus Diabetes Care 200427 Suppl
1S5-S10 See httpcarediabetesjournalsorgcgicontentfull27suppl_1s5
2 American Diabetes Association Continuous subcutaneous insulin infusion Diabetes Care 200427 Suppl 1S110
See httpcarediabetesjournalsorgcgicontentfull27suppl_1s110
3 Mensing C Boucher J Cypress M et al National standards for diabetes self-management education Diabetes
Care 200528 Suppl 1S72-9 See httpcarediabetesjournalsorgcgicontentfull28suppl_1s72
4 Goldstein DE Little RR Lorenz RA Malone JI Nathan DM Peterson CM American Diabetes Association Tests
of glycemia in diabetes Diabetes Care 200427 Suppl 1S91-3
See httpcarediabetesjournalsorgcgicontentfull27suppl_1s91
5 The Diabetes Control and Complications Trial Research Group Hypoglycemia in the Diabetes Control and
Complications Trial Diabetes 199746(2)271-86 See wwwncbinlmnihgovpubmed9000705 for abstract
6 American Diabetes Association Hypoglycemia and employmentlicensure Diabetes Care 200528 Suppl 1S61
See httpcarediabetesjournalsorgcgicontentfull28suppl_1s61
7 Viswanath K McGavin DD Diabetic Retinopathy Clinical Findings and Management J Comm Eye Health
200316(46)21-4 See wwwcehjournalorg0953-683316jceh_16_46_021html
8 Michigan Diabetes Research and Training Center University of Michigan Health System How to use the Michigan
Neuropathy Screening Instrument See wwwmedumichedumdrtcprofsdocumentssviMNSI_howtopdf
9 Bradley JG Davis KA Orthostatic hypotension Am Fam Physician 200368(12)2393-8
See wwwaafporgafp200312152393html
10 Gibbons RJ Balady GJ Bricker JT et al ACCAHA 2002 guideline update for exercise testing a report of the
American College of CardiologyAmerican Heart Association Task Force on Practice Guidelines (Committee on
Exercise Testing) J Am Coll Cardiol 200240(8)1531-40
See wwwaccorgqualityandscienceclinicalguidelinesexerciseexercise_cleanpdf
11 American Diabetes Association Standards of medical care in diabetes Diabetes Care 200528 Suppl 1S4-S36
Erratum in Diabetes Care 200528(4)990 See httpcarediabetesjournalsorgcgicontentfull28suppl_1s4
12 Molitch ME DeFronzo RA Franz MJ et al American Diabetes Association Nephropathy in diabetes Diabetes
Care 200427 Suppl 1S79-83 See httpcarediabetesjournalsorgcgicontentfull27suppl_1s79
13 Kitabchi AE Umpierrez GE Murphy MB et al American Diabetes Association Hyperglycemic crises in diabetes
Diabetes Care 200427 Suppl 1S94-102 See httpcarediabetesjournalsorgcgicontentfull27suppl_1s94
14 US Centers for Disease Control and Prevention National Diabetes Fact Sheet 2007
See wwwcdcgovdiabetespubspdfndfs_2007pdf
ACOEM Guidance for the Medical Evaluation of Law Enforcement Officers 11
43 ndash DIABETES MELLITUS
30
ATTACHMENT E
31
Typos A6921(2) 7th line down test should be plural 94201 Paragraph 2 target organ damage is used though end organ damage was defined earlier and in the appendix for that paragraph
A94201 Para A (1) d Id suggest deleting the phrases in brackets Im not sure either are predictably true or politically wise
a) tests for left ventricular hypertrophy Unfortunately use of the EKG to detect left ventricular hypertrophy is very insensitive (eg 5 sensitivity) The echocardiogram is the best test for diagnosing left ventricular hypertrophy but [it is relatively expensive and not readily available in small rural communities ] conducting echocardiograms on asymptomatic fire fighters with Stage 1 hypertension should be reserved only for those with long-standing hypertension
In addition
7761 A resting EKG shall be performed as part of the baseline medical evaluation and shall be obtained periodically thereafter
Changing from annually to periodically is noted has the language in the wellness-fitness initiative been changed as well Our previous decision was that we would support the W-F language since there was no compelling evidence to either support or refute it
Thanks
Sandy
32
NFPA 1582‐ HTN Draft 1
Reason for Revision
1) New classification of BP by the Joint National Commission [Chobanian et al 2002]
2) A high prevalence of FF have either HTN (~20) and Pre‐HTN (~20) [Soteriades et al 2003]
3) Among FF studies have shown a strong association between HTN and a number of adverse
cardiovascular events [Kales et al 2009]
4) A large percentage of on‐duty FF fatalities were found to have left ventricular hypertrophy a
complication of HTN at autopsy
Language in 2007 Edition with draft revisions in Red (Track changes)
611 The medical evaluation of a candidate shall include a medical history examination and any laboratory tests required to detect physical or medical condition(s) that could adversely affect hisher ability to safely perform the essential job tasks outlined in 511 A611 The medical history should include the candidates known health problems such as major illnesses surgeries medication use and allergies Symptom review is also important for detecting early signs of illness A medical history should also include a personal health history a family health history a health habit history an immunization history and a reproductive history
An occupational history should also be obtained to collect information about the persons past occupational and environmental exposures
(a) BP should be measured according to the Joint National Commission (JNC) -7 recommendations BP should be measured with a properly calibrated and validated instrument Patients should be seated quietly for at least 5 minutes in a chair with feet on the floor and arm supported at heart level An appropriate-sized cuff (cuff bladder encircling at least 80 of the arm) should be used to ensure accuracy At least 2 measurements should be made Systolic BP is the point at which the first of 2 or more sounds is heard (phase 1) and diastolic BP is the point before the disappearance of sounds (phase 5) [Chobanian et al 2003]
(2) Head eyes ears nose and throat (HEENT)
Formatted Font (Default) Times New RomanFont color Black
33
692 Vascular System 6921 Category A medical conditions shall include the following
(1) Uncontrolled or poorly controlled hypertension
(2) Hypertension with evidence of end organ damage
or not controlled by approved medications
A6921(1) Uncontrolled or poorly controlled hHypertension increases the risk of a sudden cardiac event This sudden cardiac event would cause sudden incapacitation which that is uncontrolled poorly controlled or requires medication likely to interferes with the safe performance of essential job tasks Uncontrolled or poorly controlled hypertension can be defined as the presence of end organ damage (see below) or stage 2 hypertension (BP systolic gt160 mmHg or BP diastolic gt100 mmHg) is an illness that can lead to functional impairment and potential for sudden incapacitation Individuals with pre- stage 1 or stage 2 hypertension should be referred to their primary care physician for evaluation lifestyle modification and treatment [QUESTION FOR GROUP _- WHAT ABOUT HAVING CANDIDATE RETURN IN ONE MONTH UNDER TREATMENT WITH NORMAL BP]
A6921(2)
Chronic hypertension can damage the eye (retinopathy) the kidneys (nephropathy) the vascular system (stroke transient ischemic attack or peripheral artery disease) or the heart (left ventricular hypertrophy and heart failure) These hypertension complications are known as end organ damage The cardiac and vascular complications are associated with an increased risk of sudden incapacitation and sudden cardiac death (Koren et al 1991) Unfortunately the cardiac complications are frequently asymptomatic and valid screening tests are not fast and are not inexpensive Therefore determining who to screen for cardiac complications (such as echocardiogram for LVH or a measurement of left ventricular ejection fraction for heart failure) should be based on the severity and the duration of HTN
76 Physical Examination The annual physical examination shall include each of the following components
(a) BP shall be measured according to the Joint National Commission (JNC)-7 recommendations
A76(1)(a) BP should be measured with a properly calibrated and validated instrument Patients should be seated quietly for at least 5 minutes in a chair with feet on the floor and arm supported at heart level An appropriate-sized cuff (cuff bladder encircling at least 80 of the arm) should be used to ensure accuracy At least 2 measurements should be made Systolic BP is the point at which the first of 2 or more sounds is heard (phase 1) and diastolic BP is the point before the disappearance of sounds (phase 5) [Chobanian et al 2003]
(2) Head eyes ears nose and throat (HEENT)
34
9420 Uncontrolled Hypertension 94201 Physician Evaluation Severe uncontrolled hypertension [defined as systolic pressure greater than 180 mm Hg diastolic pressure greater than 100 mm Hg or mean systolic blood
pressure ( systolic + diastolic) greater than 120 mm Hg] or malignant hypertension (defined as hypertension with the presence of target organ damage) compromises the members ability to safely perform essential job tasks 1 5 7 9 and 13 and the physician shall report the applicable job limitations to the fire department
Members with Pre-hypertention (systolic 120-139 mmHg or diastolic 80-89 mmHg) Stage 1 hypertension (systolic 140-159 mmHg or diastolic 90-99 mmHg) or Stage 2 hypertension (systolic ge160 mmHg or diastolic ge100 mmHg) should be referred to their primary care physician for evaluation lifestyle modification and treatment
(1) Members with Stage I hypertension should be followed-up not only by their primary care physician but also by the FD physician every 3 to 6 months to ensure their blood pressure is under control and to determine whether screening tests for asymptomatic end organ damage are appropriate
(2) Members with Stage 2 hypertension or with end organ damage (retinopathy nephropathy vascular or cardiac complications) compromises the members ability to safely perform essential job tasks 1 5 7 9 and 130 and the physician shall report the applicable job limitations to the fire department
A94201 Severe uncontrolled hypertension is a significant risk factor for the development of coronary artery disease congestive heart failure and stroke Blood pressure increases as a normal response to exercise This response is further exaggerated by the emotional and physical stress of performing these critical tasks while operating in personal protective clothing at extremes of temperature This normal elevation of blood pressure under these response conditions can lead to life-threatening hypertensive emergencies if a members daily blood pressure is already elevated to high levels In addition hypertension is a progressive illness that when uncontrolled ultimately and inevitably leads to target organ damage Target organs that are sensitive to the effects of elevated blood pressure are the central nervous system vision heart major blood vessels and kidneys
Chronic hypertension can damage the eye (retinopathy) the kidneys (nephropathy) the vascular system (stroke transient ischemic attack or peripheral artery disease) or the heart (left ventricular hypertrophy and heart failure) These hypertension complications are known as end organ damage The cardiac and vascular complications are associated with an increased risk of sudden incapacitation and sudden cardiac death (Koren et al 1991) Fortunately with proper evaluation life style modification and treatment these complications can be avoided Life style modification includes weight reduction DASH eating plan reduction in dietary sodium an increase in aerobic physical activity and moderation in alcohol consumption [Chobanian 2003]
Formatted Font (Default) Times New Roman12 pt Font color Black
Formatted Font (Default) Times New Roman12 pt Font color Black
35
A94201 (1) Members with Stage I hypertension whose BP returns to either pre-hypertenion or normal with lifestyle modification andor treatment can return to an annual medical evaluation For members with long-standing Stage I hypertension whose BP has not been reduced additional evaluation for possible end organ damage should be considered This evaluation could include any or all of the following
a) a compete patient history for symptoms of heart failure (eg shortness of breath upon exertion) or transient ischemic attacks (TIAs)
b) dilated eye examination for retinopathy
c) blood creatinine measurement for nephropathy
d) tests for left ventricular hypertrophy Unfortunately use of the resting EKG to detect left ventricular hypertrophy is very insensitive (eg 5 sensitivity) The echocardiogram is the best test for diagnosing left ventricular hypertrophy
A 94201 (2) Due to the high risk of a sudden cardiovascular event members with Stage 2 hypertension should be restricted until their BP can be brought under control Once the BP is brought under control they should be followed in the same manner as a member with Stage I hypertension
Formatted Font (Default) Times New Roman12 pt
36
D22 Cardiology Gibbons R J GJ Balady J W Beasley et al 1997 ACCAHA guidelines for exercise testing a report of American College of CardiologyAmerican Heart Association Task Force on Practice Guidelines (Committee on Exercise Testing) J Am Coll Cardiol 30260ndash311
Gibbons RJ Balady GJ Bricker JT Chaitman BR Fletcher GF Froelicher VF Mark DB McCallister BD Mooss AN OrsquoReilly MG Winters WL Jr [2002] ACCAHA 2002 guideline update for exercise testing summary article a report of the ACCAHA Task Force on Practice Guidelines (Committee to Update the 1997 Exercise Testing guidelines) J Am Coll Cardiol 401531ndash 40
Chobanian AV Bakris GL Black HR Cushman WC Green LA Izzo JL Jr Jones DW Materson BJ Oparil S Wright JT Jr Roccella EJ the National High Blood Pressure Education Program Coordinating Committee [2003] The seventh report of the Joint National Committee [JNC-7] on Prevention Detection Evaluation and Treatment of High Blood Pressure JAMA 2892560ndash2571
Soteriades ES Kales SN Liarokapis D Christiani DC [2003] Prospective surveillance of hypertension in firefighters J Clin Hypertens 5315-320
Kales SN Tsismenakis AJ Zhang C Soteriades ES [2009] Blood pressure in fire fighters police officers and other emergency responders Am J Hypertens 2211-20
37
NFPA 1582‐ HTN Draft 1
Reason for Revision
1) New classification of BP by the Joint National Commission [Chobanian et al 2002]
2) A high prevalence of FF have either HTN (~20) and Pre‐HTN (~20) [Soteriades et al 2003]
3) Among FF studies have shown a strong association between HTN and a number of adverse
cardiovascular events [Kales et al 2009]
4) A large percentage of on‐duty FF fatalities were found to have left ventricular hypertrophy a
complication of HTN at autopsy
Language in 2007 Edition with draft revisions in Red (Track changes)
611 The medical evaluation of a candidate shall include a medical history examination and any laboratory tests required to detect physical or medical condition(s) that could adversely affect hisher ability to safely perform the essential job tasks outlined in 511 A611 The medical history should include the candidates known health problems such as major illnesses surgeries medication use and allergies Symptom review is also important for detecting early signs of illness A medical history should also include a personal health history a family health history a health habit history an immunization history and a reproductive history
An occupational history should also be obtained to collect information about the persons past occupational and environmental exposures
(a) BP should be measured according to the Joint National Commission (JNC) -7 recommendations BP should be measured with a properly calibrated and validated instrument Patients should be seated quietly for at least 5 minutes in a chair with feet on the floor and arm supported at heart level An appropriate-sized cuff (cuff bladder encircling at least 80 of the arm) should be used to ensure accuracy At least 2 measurements should be made Systolic BP is the point at which the first of 2 or more sounds is heard (phase 1) and diastolic BP is the point before the disappearance of sounds (phase 5) [Chobanian et al 2003]
(2) Head eyes ears nose and throat
38
692 Vascular System 6921 Category A medical conditions shall include the following
(1) Uncontrolled or poorly controlled hypertension
(2) Hypertension with evidence of end organ damage
A6921(1) Uncontrolled or poorly controlled hypertension increases the risk of a sudden cardiac event This sudden cardiac event would cause sudden incapacitation which interferes with the safe performance of essential job tasks Uncontrolled or poorly controlled hypertension can be defined as the presence of end organ damage (see below) or stage 2 hypertension (BP systolic gt160 mmHg or BP diastolic gt100 mmHg) Individuals with pre- stage 1 or stage 2 hypertension should be referred to their primary care physician for evaluation lifestyle modification and treatment [QUESTION FOR GROUP _- WHAT ABOUT HAVING CANDIDATE RETURN IN ONE MONTH UNDER TREATMENT WITH NORMAL BP]
A6921(2)Chronic hypertension can damage the eye (retinopathy) the kidneys (nephropathy) the vascular system (stroke transient ischemic attack or peripheral artery disease) or the heart (left ventricular hypertrophy and heart failure) These hypertension complications are known as end organ damage The cardiac and vascular complications are associated with an increased risk of sudden incapacitation and sudden cardiac death (Koren et al 1991) Unfortunately the cardiac complications are frequently asymptomatic and valid screening tests are not fast and are not inexpensive Therefore determining who to screen for cardiac complications (such as echocardiogram for LVH or a measurement of left ventricular ejection fraction for heart failure) should be based on the severity and the duration of HTN
76 Physical Examination The annual physical examination shall include each of the following components
(a) BP shall be measured according to the Joint National Commission (JNC)-7 recommendations
A76(1)(a) BP should be measured with a properly calibrated and validated instrument Patients should be seated quietly for at least 5 minutes in a chair with feet on the floor and arm supported at heart level An appropriate-sized cuff (cuff bladder encircling at least 80 of the arm) should be used to ensure accuracy At least 2 measurements should be made Systolic BP is the point at which the first of 2 or more sounds is heard (phase 1) and diastolic BP is the point before the disappearance of sounds (phase 5) [Chobanian et al 2003]
(2) Head eyes ears nose and throat9420 Hypertension 94201 Physician Evaluation Members with Pre-hypertention (systolic 120-139 mmHg or diastolic 80-89 mmHg) Stage 1 hypertension (systolic 140-159 mmHg or diastolic 90-99 mmHg) or Stage 2 hypertension (systolic ge160 mmHg or diastolic ge100 mmHg) should be referred to their primary care physician for evaluation lifestyle modification and treatment
39
(1) Members with Stage I hypertension should be followed-up not only by their primary care physician but also by the FD physician every 3 to 6 months to ensure their blood pressure is under control and to determine whether screening tests for asymptomatic end organ damage are appropriate
(2) Members with Stage 2 hypertension or with end organ damage (retinopathy nephropathy vascular or cardiac complications) compromises the members ability to safely perform essential job tasks 1 5 7 9 and 130 and the physician shall report the applicable job limitations to the fire department
A94201 Chronic hypertension can damage the eye (retinopathy) the kidneys (nephropathy) the vascular system (stroke transient ischemic attack or peripheral artery disease) or the heart (left ventricular hypertrophy and heart failure) These hypertension complications are known as end organ damage The cardiac and vascular complications are associated with an increased risk of sudden incapacitation and sudden cardiac death (Koren et al 1991) Fortunately with proper evaluation life style modification and treatment these complications can be avoided Life style modification includes weight reduction DASH eating plan reduction in dietary sodium an increase in aerobic physical activity and moderation in alcohol consumption [Chobanian 2003]
A94201 (1) Members with Stage I hypertension whose BP returns to either pre-hypertenion or normal with lifestyle modification andor treatment can return to an annual medical evaluation For members with long-standing Stage I hypertension whose BP has not been reduced additional evaluation for possible end organ damage should be considered This evaluation could include any or all of the following
a) a compete patient history for symptoms of heart failure (eg shortness of breath upon exertion) or transient ischemic attacks (TIAs)
b) dilated eye examination for retinopathy
c) blood creatinine measurement for nephropathy
d) tests for left ventricular hypertrophy Unfortunately use of the resting EKG to detect left ventricular hypertrophy is very insensitive (eg 5 sensitivity) The echocardiogram is the best test for diagnosing left ventricular hypertrophy
A 94201 (2) Due to the high risk of a sudden cardiovascular event members with Stage 2 hypertension should be restricted until their BP can be brought under control Once the BP is brought under control they should be followed in the same manner as a member with Stage I hypertension
D22 Cardiology
40
Hypertension
Gibbons RJ Balady GJ Bricker JT Chaitman BR Fletcher GF Froelicher VF Mark DB McCallister BD Mooss AN OrsquoReilly MG Winters WL Jr [2002] ACCAHA 2002 guideline update for exercise testing summary article a report of the ACCAHA Task Force on Practice Guidelines (Committee to Update the 1997 Exercise Testing guidelines) J Am Coll Cardiol 401531ndash 40
Chobanian AV Bakris GL Black HR Cushman WC Green LA Izzo JL Jr Jones DW Materson BJ Oparil S Wright JT Jr Roccella EJ the National High Blood Pressure Education Program Coordinating Committee [2003] The seventh report of the Joint National Committee [JNC-7] on Prevention Detection Evaluation and Treatment of High Blood Pressure JAMA 2892560ndash2571
Soteriades ES Kales SN Liarokapis D Christiani DC [2003] Prospective surveillance of hypertension in firefighters J Clin Hypertens 5315-320
Kales SN Tsismenakis AJ Zhang C Soteriades ES [2009] Blood pressure in fire fighters police officers and other emergency responders Am J Hypertens 2211-20
41
NFPA 1582‐ Draft Revisions for CVDHTN
EKG and stress tests
Reason for Revision
1) Change requirement for annual resting EKG to periodically to be more consistent with ACCAHA
recommendation (Schlant et al 1992)
2) Add language to clarify what constitutes a positive ST
3) Make criteria for conducting diagnostic ST in asymptomatic patients consistent with the
ACCAHA
Language in 2007 Edition with draft revisions in Red (Track changes)
776 Electrocardiograms (EKG)) and Stress Tests 7761 A resting EKG shall be performed as part of the baseline medical evaluation and shall be obtained periodically (every 1 to 5 years) annually thereafter
A7761 A baseline resting EKGs shall be conducted Follow-up resting EKGs should be conducted as clinically indicated but at a minimum of every 1 to 5 years The frequency of these follow-up resting EKGs should increase as a members age increases or with increasing number andor severity of coronary heart disease risk factors Members above the age of 40 should have annual resting EKGs (Schlant et al 1992)
7762 The fire department physician or other qualified medical evaluator shall compare EKGs obtained during yearly evaluations with baseline and subsequent EKGs
7763 Stress testing EKG with or without echocardiography or radionuclide scanning shall be performed as clinically indicated by history or symptoms
A7761 Baseline electrocardiography should be conducted (Periodic resting electrocardiograms have not been shown to be useful but can be reasonable as a members agefactors increase)
A7763 No firm guidelines for stress testingelectrocardiography in asymptomatic individuals have been developed Stress testingelectrocardiography as a screening tool is used as part of an evaluation of aerobic capacity during the annual occupational fitness evaluation Submaximal stress testingelectrocardiography testing to 85 percent is commonly used as part of this screening
Submaximal stress electrocardiography testing should not be used for diagnostic purposes Cardiology evaluation with maximal stress testingelectrocardiography together with imaging techniques (eg echocardiography technetium Tc99m sestamibi study andor coronary angiography) is necessary for diagnosticprognostic purposes for the following
42
(1) Fire fighters with positive or questionably positive changes on screening submaximal stress tests
(2) Fire fighters with new onset chest pain or other symptoms suggestive of coronary artery disease (CAD)
(3) Fire fighters with diabetes mellitus who
(a) are gt35 years old or
(b) have type I diabetes for more than 15 years or
(c) have type II diabetes for more than 10 years or
(d) have any other CHD risk factor (see below) or
(e) have the presence of microvascular disease (proliferative retinopathy)
(4) Fire fighters over the age of 45 (for men) and 55 (for women) with onetwo or more risk factors for CAD Risk factors for CAD include hypercholesterolemia (total cholesterol greater than 240 mgdL) hypertension (systolic gt140 mmHg or diastolic gt90 mmHg) smoking or family history of premature CAD (heart attack or sudden cardiac death in a first degree relative less than 60 years of age)
as defined below if stress electrocardiography with imaging is negative then repeat as clinically indicated or at least every 5 years
(5) Fire fighters with a Framingham Risk Score gt10 Risk calculator is available at [httphp2010nhlbihinnetatpiiicalculatorasp]
(6) Fire fighters identified in 9431
Negative stress tests should be repeated as clinically indicated or at least every 2 to 5 years
Interpreting stress tests as ldquopositiverdquo or ldquonegativerdquo is beyond the scope of this document However factors that should be taken into consideration should include the individualrsquos exercise capacity symptoms blood pressure response heart rate response EKG changes and the presence of arrhythmias (Gibbon et al 2002)
Risk factors for CAD include hypercholesterolemia (total cholesterol greater than 240 mgdL) hypertension (systolic greater than 140 andor diastolic greater than 90) smoking diabetes mellitus or family history of premature CAD (heart attack or sudden cardiac death in a first degree relative less than 60 years of age)
There are other non-invasive tests to screen for coronary artery disease One of the most promising appears to be coronary artery calcium (CAD) scoring by computed tomography In 2007 an expert committee published an update to their original guidance document The committeersquos consensus was that ldquoit may be reasonable to consider use of CAC measurement in such patients [between 10 and 20 10-year risk of estimated coronary event]helliprdquo The committee did not recommend CAC measurement in low risk patients [lt10 10-year risk of estimated coronary event] or in high risk patients [gt20 10-year risk of estimate coronary event] (Greenland et al 2007]
43
D22 Cardiology
Chobanian AV Bakris GL Black HR Cushman WC Green LA Izzo JL Jr Jones DW Materson BJ Oparil S Wright JT Jr Roccella EJ the National High Blood Pressure Education Program Coordinating Committee [2003] The seventh report of the Joint National Committee [JNC-7] on Prevention Detection Evaluation and Treatment of High Blood Pressure JAMA 2892560ndash2571
Gibbons RJ Balady GJ Bricker JT Chaitman BR Fletcher GF Froelicher VF Mark DB McCallister BD Mooss AN OrsquoReilly MG Winters WL Jr [2002] ACCAHA 2002 guideline update for exercise testing summary article a report of the ACCAHA Task Force on Practice Guidelines (Committee to Update the 1997 Exercise Testing guidelines) J Am Coll Cardiol 401531ndash 1540
Greenland et al [2007] ACCFAHA 2007 Clinical Expert Consensus Document on Coronary Artery Calcium Scoring By Computed Tomography in Global Cardiovascular Risk Assessment and in Evaluation of Patients With Chest Pain A Report of the American College of Cardiology Foundation Clinical Expert Consensus Task Force (ACCFAHA Writing Committee to Update the 2000 Expert Consensus Document on Electron Beam Computed Tomography) J Am Coll Cardiol 49378-402
Kales SN Tsismenakis AJ Zhang C Soteriades ES [2009] Blood pressure in fire fighters police officers and other emergency responders Am J Hypertens 2211-20
Schlant RC Adolph RJ DiMarco JP Dreifus LS Dunn MI Fisch C Garson A Jr Haywood LJ Levine HJ Murray JA Noble RJ Ronan JA Jr [1992] Guidelines for electrocardiography A report of the American College of CardiologyAmerican Heart Association Task Force on Assessment of Diagnostic and Therapeutic Cardiovascular Procedures (Committee on Electrocardiography) Circulation 85(3)1221-1228
Soteriades ES Kales SN Liarokapis D Christiani DC [2003] Prospective surveillance of hypertension in firefighters J Clin Hypertens 5315-320
Formatted Font Italic
Formatted Line spacing single
Formatted Font Italic
Formatted Font Italic
44
NFPA 1582‐ Draft Revisions for CVDHTN
EKG and stress tests
Reason for Revision
1) Change requirement for annual resting EKG to periodically to be more consistent with ACCAHA
recommendation (Schlant et al 1992)
2) Add language to clarify what constitutes a positive ST
3) Make criteria for conducting diagnostic ST in asymptomatic patients consistent with the
ACCAHA
Language in 2007 Edition with draft revisions in Red (Track changes)
776 Electrocardiograms (EKG) and Stress Tests 7761 A resting EKG shall be performed as part of the baseline medical evaluation and shall be obtained periodically (every 1 to 5 years) thereafter
A7761 A baseline resting EKGs shall be conducted Follow-up resting EKGs should be conducted as clinically indicated but at a minimum of every 1 to 5 years The frequency of these follow-up resting EKGs should increase as a members age increases or with increasing number andor severity of coronary heart disease risk factors Members above the age of 40 should have annual resting EKGs (Schlant et al 1992)
7762 The fire department physician or other qualified medical evaluator shall compare baseline and subsequent EKGs
7763 Stress testing with or without echocardiography or radionuclide scanning shall be performed as clinically indicated by history or symptoms
A7763 No firm guidelines for stress testing in asymptomatic individuals have been developed Stress testing as a screening tool is used as part of an evaluation of aerobic capacity during the annual occupational fitness evaluation Submaximal stress testing testing to 85 percent is commonly used as part of this screening
Submaximal stress testing should not be used for diagnostic purposes Cardiology evaluation with maximal stress testing together with imaging techniques (eg echocardiography technetium Tc99m sestamibi study) is necessary for diagnosticprognostic purposes for the following
(1) Fire fighters with positive or questionably positive changes on screening submaximal stress tests
(2) Fire fighters with new onset chest pain or other symptoms suggestive of coronary artery disease (CAD)
45
(3) Fire fighters with diabetes mellitus who
(a) are gt35 years old or
(b) have type I diabetes for more than 15 years or
(c) have type II diabetes for more than 10 years or
(d) have any other CHD risk factor (see below) or
(e) have the presence of microvascular disease (proliferative retinopathy)
(4) Fire fighters over the age of 45 (for men) and 55 (for women) with one or more risk factors for CAD Risk factors for CAD include hypercholesterolemia (total cholesterol greater than 240 mgdL) hypertension (systolic gt140 mmHg or diastolic gt90 mmHg) smoking or family history of premature CAD (heart attack or sudden cardiac death in a first degree relative less than 60 years of age)
(5) Fire fighters with a Framingham Risk Score gt10 Risk calculator is available at [httphp2010nhlbihinnetatpiiicalculatorasp]
(6) Fire fighters identified in 9431
Negative stress tests should be repeated as clinically indicated or at least every 2 to 5 years
Interpreting stress tests as ldquopositiverdquo or ldquonegativerdquo is beyond the scope of this document However factors that should be taken into consideration should include the individualrsquos exercise capacity symptoms blood pressure response heart rate response EKG changes and the presence of arrhythmias (Gibbon et al 2002)
There are other non-invasive tests to screen for coronary artery disease One of the most promising appears to be coronary artery calcium (CAD) scoring by computed tomography In 2007 an expert committee published an update to their original guidance document The committeersquos consensus was that ldquoit may be reasonable to consider use of CAC measurement in such patients [between 10 and 20 10-year risk of estimated coronary event]helliprdquo The committee did not recommend CAC measurement in low risk patients [lt10 10-year risk of estimated coronary event] or in high risk patients [gt20 10-year risk of estimate coronary event] (Greenland et al 2007]
D22 Cardiology
Resting EKG and Stress Tests
46
Chobanian AV Bakris GL Black HR Cushman WC Green LA Izzo JL Jr Jones DW Materson BJ Oparil S Wright JT Jr Roccella EJ the National High Blood Pressure Education Program Coordinating Committee [2003] The seventh report of the Joint National Committee [JNC-7] on Prevention Detection Evaluation and Treatment of High Blood Pressure JAMA 2892560ndash2571
Gibbons RJ Balady GJ Bricker JT Chaitman BR Fletcher GF Froelicher VF Mark DB McCallister BD Mooss AN OrsquoReilly MG Winters WL Jr [2002] ACCAHA 2002 guideline update for exercise testing summary article a report of the ACCAHA Task Force on Practice Guidelines (Committee to Update the 1997 Exercise Testing guidelines) J Am Coll Cardiol 401531ndash 1540
Greenland et al [2007] ACCFAHA 2007 Clinical Expert Consensus Document on Coronary Artery Calcium Scoring By Computed Tomography in Global Cardiovascular Risk Assessment and in Evaluation of Patients With Chest Pain A Report of the American College of Cardiology Foundation Clinical Expert Consensus Task Force (ACCFAHA Writing Committee to Update the 2000 Expert Consensus Document on Electron Beam Computed Tomography) J Am Coll Cardiol 49378-402
Kales SN Tsismenakis AJ Zhang C Soteriades ES [2009] Blood pressure in fire fighters police officers and other emergency responders Am J Hypertens 2211-20
Schlant RC Adolph RJ DiMarco JP Dreifus LS Dunn MI Fisch C Garson A Jr Haywood LJ Levine HJ Murray JA Noble RJ Ronan JA Jr [1992] Guidelines for electrocardiography A report of the American College of CardiologyAmerican Heart Association Task Force on Assessment of Diagnostic and Therapeutic Cardiovascular Procedures (Committee on Electrocardiography) Circulation 85(3)1221-1228
Soteriades ES Kales SN Liarokapis D Christiani DC [2003] Prospective surveillance of hypertension in firefighters J Clin Hypertens 5315-320
47
ATTACHMENT F
48
1
Current 1582 (2007) language in reference to pregnancy 43 (4) Report to the fire department physician any medical condition that could interfere with the ability of the individual to safely perform essential job tasks such as illness or injury use of prescription or nonprescription drugs and pregnancy 6112 Category B medical conditions shall include the following (1) Pregnancy for its duration A7792 (e) If HIV prophylaxis is to be given the following tests should be done i CBC ii Glucose renal and hepatic chemical function iii Pregnancy test for females B121 Pregnancy and Reproduction Federal regulations as well as many court decisions including the US Supreme Courtrsquos decision in International Union et al v Johnson Controls Inc [499 US 187 111 S Ct 1196 (1991)] have interpreted the requirements of Title VII with respect to pregnancy and reproduction The AHJ should seek the advice of counsel in resolving specific questions concerning these requirements as well as other requirements that can be imposed by state or local laws C211 (4) Review health status with the individual being evaluated Contraindications for evaluations shall be reviewed addressing any changes in the individualrsquos health status since their last medical evaluation that would warrant deferring the evaluation including (g) Pregnancy Recommendations to language enhancement
A female employee who is assigned to regular fire line duty shall report a pregnancy immediately to their respective Supervisor and the fire department physician The employee will then be given the option of a non-hazardous alternative duty position for the duration of her pregnancy (can we say this or is it even appropriate) Any pregnant employee wishing to remain on regular line duty shall be informed of the possible risks and consequences to herself and her fetus that are associated with continued line fire fighting duty Among those risk factors are exposure to teratogens known to have negative effects on the developing fetus such as smoke diesel fumes hazardous chemicals and extreme heat
49
Page 2
appendix It is recommended that the pregnant employee complete a release of liability form signed by herself and her health care provider utilizing NFPArsquos 13 critical tasks as a reference This will inform the health care provider of specific job-related tasks that will need to be performed in order to continue regular line duty These tasks are basic physical standards that any entry level firefighter would have to be able to complete competently The employeersquos health condition will be kept confidential by the department in accordance with HIPAA standards Employees are allowed to remain on active regular duty until they are no longer able to perform their duties in a reasonable manner andor their protective gear no longer fits correctly It is the responsibility of the health care provider to evaluate the pregnant employee If at any time the health care provider feels the pregnant employee can no longer perform the job related tasks this should be reported to the employer by the employee immediately
50
ATTACHMENT G
51
From GLENN BENARICKTo Sawyer SteveSubject RE RE 7743Date Monday August 30 2010 21633 PM
Yes thats my understanding
Glenn P Benarick 211 Winged Elm CircleAiken SC 29803803-644-7093gbenarprodigynet
--- On Mon 83010 Sawyer Steve ltssawyerNFPAorggt wrote
From Sawyer Steve ltssawyerNFPAorggtSubject RE RE 7743To GLENN BENARICK ltgbenarprodigynetgtDate Monday August 30 2010 212 PM
So it should be ldquoorrdquo instead of ldquoandrdquo for now
Steven F Sawyer
Senior Fire Service Specialist
Executive Secretary IFMAFire Service Section
NFPA
1 Batterymarch Park
Quincy MA 02169
6179847423
Fax 6179847056
ssawyernfpaorg
From GLENN BENARICK [mailtogbenarprodigynet] Sent Monday August 30 2010 1202 PMTo Sawyer SteveSubject Fw RE 7743
52
Steve a couple of our docs agree with April Boyer
Glenn P Benarick 211 Winged Elm Circle
Aiken SC 29803
803-644-7093
gbenarprodigynet
--- On Mon 83010 David Prezant ltprezandfdnynycgovgt wrote
From David Prezant ltprezandfdnynycgovgtSubject RE 7743To Thomas R (CDCNIOSHDSHEFS) Hales lttrh1cdcgovgt GLENNBENARICK ltgbenarprodigynetgtCc Sandy Bogucki ltsandyboguckiyaleedugtDate Monday August 30 2010 1004 AM
agree
we should change this to NHANES III rather than Knudson we should alsomodify this to allow not only for predicted cutoffs but all for use of thelower limit of normal cutoff This is important to prevent false-classificationof spirometry as abnormal in older groups and in taller grps The latter ofparticular import to firefighter occupational health surveillance
thanks
David Prezant MDChief Medical Officer Office of Medical AffairsCo-Director WTC Medical Monitoring amp Treatment ProgramsNew York City Fire Department9 Metrotech Center - Rm 4W-1Brooklyn NY 11201Phone 718-999-2696Fax 718-999-0665
Life is full of twists and turns
53
This email may contain confidential information If you are the unintendedrecipient of this email please send it back and delete from your directory
gtgtgt Hales Thomas R (CDCNIOSHDSHEFS) lttrh1cdcgovgt 8302010955 AM gtgtgt
Glen
This seems like a very reasonable comment and illustrates the importance of having clinicians providefeedback on the std Im not familiar with the software program of the various spirometers (NHANES IIIvs KnudsonATS vs both) Given the large role both Dave Prezant and Sandy Bogucki had for thepulmonary section let me forward to them for clarification
Tom
From GLENN BENARICK [mailtogbenarprodigynet] Sent Sunday August 29 2010 456 PMTo Hales Thomas R (CDCNIOSHDSHEFS)Subject FW 7743
Tom is April Boyer correct
Glenn P Benarick 211 Winged Elm Circle
Aiken SC 29803
803-644-7093
gbenarprodigynet
--- On Thu 82610 Sawyer Steve ltssawyerNFPAorggt wrote
From Sawyer Steve ltssawyerNFPAorggtSubject FW 7743To GLENN BENARICK ltgbenarprodigynetgtDate Thursday August 26 2010 925 PM
FYI Do you have any answer She is write
Steven
54
Steven F Sawyer
Senior Fire Service Specialist
Executive Secretary IFMAFire Service Section
NFPA
1 Batterymarch Park
Quincy MA 02169
6179847423
Fax 6179847056
ssawyernfpaorg
From April Boyer [mailtoaboyerbicclinicorg] Sent Thursday August 26 2010 232 PMTo Sawyer SteveCc RobinMWebbmilstateorusSubject 7743
Steven
The spirometry tests cannot be corrected according to both references as the NFPA states because thereferences are contradictory The first part of 7743 states to follow the ATS guidelines and use theKnudsen (we at Basin Immediate Care use the Nhanes III) The second part states to follow the ACOEMguidelines and use the Nhanes III in the occupational setting if available with your unit (which is availableon ours) 7743 does not use the word OR regarding both requirements it uses the word AND whenreferring to the first and second parts thence making 7743 contradictory I realize the NFPA 1582 hasnot been updated since 2007 unless I have just not received an updated version
Our question to you is which part of 7743 do you want us to follow the first or the second part Anyfacility that has an updated computerized spirometry system (as we do) will not be able to follow bothrequired parts for obvious reasons We can either follow the first part of 7743 and use an oldercorrected version of the Knudson by going into our system and changing out of the Nhanes III conversionOR we can follow the second part of 7743 and use the newer corrected version of Nhanes III which ourunit offers too
If you have any questions you may contact me at anytime and I also have many references in regards toboth parts of 7743 if you would like to see them
55
Thank you~
April
Confidentiality NoticeThis message may contain information that isconfidential or privileged
If you are not the intended recipientPlease advise the sender immediately and delete this message
56
ATTACHMENT H
57
NFPA 1582 771(7) Proposed revisions
Why
Preliminary results of two prospective randomized trials on the PSA test were published in 2009 These studies resulted in medical organizations that previously providing guidance to modify their recommendations
Current language
771 Blood Tests Blood tests shall be performed annually and shall include the following
(7) Prostate specific antigen (PSA) after age 40 for positive family history if African American or if otherwise clinically indicated after age 50 for all other male member
Suggested Revision
771 Blood Tests Blood tests shall be performed annually and shall include the following
(7) Prostate specific antigen (PSA) after age 40 for positive family history if African American or if otherwise clinically indicated after age 50 for all other male member
772 Prostate-Specific Antigen (PSA) test At age 50 fire fighters shall have an opportunity to make an informed decision with either the Fire Department physician or their health care provider concerning the PSA test For fire fighters at increased risk of prostate cancer (African-Americans or those with a first degree relative diagnosed with prostate cancer before age 65) shall have the opportunity for this informed decision at age 40
A772 The PSA as a screening test for prostate cancer in asymptomatic men is controversial controversial for two reasons First there is no consensus that PSA screening actually saves lives For example the PSA test may detect small cancers that would never become life threatening Second it is unclear that the benefits of PSA screening outweigh the risks of follow-up diagnostic tests and cancer treatments For example the prostate biopsy used to diagnose prostate cancer may cause bleeding and infection And prostate cancer treatments such as surgery and radiation therapy may cause incontinence (inability to control urine flow) erectile dysfunction (erections inadequate for intercourse) and other complications For these reasons it is important that the benefits and risks of prostate diagnostic procedures and treatment be taken into account when considering the PSA screening test These considerations can be taken account during discussions with the fire department physician or onersquos health care provider
D211 Cancer Screening
Smith R A C J Mettlin K J Davis and H Eyre 2000 ldquoAmerican Cancer Society guidelines for the early detection of cancerrdquo CA J Clin 50(1)34ndash49
Added references
58
Carroll P Albertsen PC Greene K et al [2010] Prostate-specific antigen best practice statement 2009 update Am Urological Assoc Available at httpwwwauanetorgcontentguidelines-and-quality-careclinical-guidelinesmain-reportspsa09pdf Date accessed September 2010
Ferrini R Woolf SH [2009] Screening for prostate cancer in American men American College of Preventive Medicine Practice Policy Statement Available at httpwwwacpmorgprostatehtm Date accessed September 2010
National Cancer Institute [2009] Prostate-specific antigen test National Cancer Institute Fact Sheet Available at httpwwwcancergovcancertopicsfactsheetDetectionPSA Date accessed September 2010
Wolf AMD Wender RC Etzioni RB et al [2010] American Cancer Society guideline for the early detection of prostate cancer Update 2010 Available at httpcaonlineamcancersocorgcgicontentfullcaac20066v1 Date accessed September 2010
59
439 ndash REFERENCES
1 American Diabetes Association Diagnosis and classification of diabetes mellitus Diabetes Care 200427 Suppl
1S5-S10 See httpcarediabetesjournalsorgcgicontentfull27suppl_1s5
2 American Diabetes Association Continuous subcutaneous insulin infusion Diabetes Care 200427 Suppl 1S110
See httpcarediabetesjournalsorgcgicontentfull27suppl_1s110
3 Mensing C Boucher J Cypress M et al National standards for diabetes self-management education Diabetes
Care 200528 Suppl 1S72-9 See httpcarediabetesjournalsorgcgicontentfull28suppl_1s72
4 Goldstein DE Little RR Lorenz RA Malone JI Nathan DM Peterson CM American Diabetes Association Tests
of glycemia in diabetes Diabetes Care 200427 Suppl 1S91-3
See httpcarediabetesjournalsorgcgicontentfull27suppl_1s91
5 The Diabetes Control and Complications Trial Research Group Hypoglycemia in the Diabetes Control and
Complications Trial Diabetes 199746(2)271-86 See wwwncbinlmnihgovpubmed9000705 for abstract
6 American Diabetes Association Hypoglycemia and employmentlicensure Diabetes Care 200528 Suppl 1S61
See httpcarediabetesjournalsorgcgicontentfull28suppl_1s61
7 Viswanath K McGavin DD Diabetic Retinopathy Clinical Findings and Management J Comm Eye Health
200316(46)21-4 See wwwcehjournalorg0953-683316jceh_16_46_021html
8 Michigan Diabetes Research and Training Center University of Michigan Health System How to use the Michigan
Neuropathy Screening Instrument See wwwmedumichedumdrtcprofsdocumentssviMNSI_howtopdf
9 Bradley JG Davis KA Orthostatic hypotension Am Fam Physician 200368(12)2393-8
See wwwaafporgafp200312152393html
10 Gibbons RJ Balady GJ Bricker JT et al ACCAHA 2002 guideline update for exercise testing a report of the
American College of CardiologyAmerican Heart Association Task Force on Practice Guidelines (Committee on
Exercise Testing) J Am Coll Cardiol 200240(8)1531-40
See wwwaccorgqualityandscienceclinicalguidelinesexerciseexercise_cleanpdf
11 American Diabetes Association Standards of medical care in diabetes Diabetes Care 200528 Suppl 1S4-S36
Erratum in Diabetes Care 200528(4)990 See httpcarediabetesjournalsorgcgicontentfull28suppl_1s4
12 Molitch ME DeFronzo RA Franz MJ et al American Diabetes Association Nephropathy in diabetes Diabetes
Care 200427 Suppl 1S79-83 See httpcarediabetesjournalsorgcgicontentfull27suppl_1s79
13 Kitabchi AE Umpierrez GE Murphy MB et al American Diabetes Association Hyperglycemic crises in diabetes
Diabetes Care 200427 Suppl 1S94-102 See httpcarediabetesjournalsorgcgicontentfull27suppl_1s94
14 US Centers for Disease Control and Prevention National Diabetes Fact Sheet 2007
See wwwcdcgovdiabetespubspdfndfs_2007pdf
ACOEM Guidance for the Medical Evaluation of Law Enforcement Officers 11
43 ndash DIABETES MELLITUS
30
ATTACHMENT E
31
Typos A6921(2) 7th line down test should be plural 94201 Paragraph 2 target organ damage is used though end organ damage was defined earlier and in the appendix for that paragraph
A94201 Para A (1) d Id suggest deleting the phrases in brackets Im not sure either are predictably true or politically wise
a) tests for left ventricular hypertrophy Unfortunately use of the EKG to detect left ventricular hypertrophy is very insensitive (eg 5 sensitivity) The echocardiogram is the best test for diagnosing left ventricular hypertrophy but [it is relatively expensive and not readily available in small rural communities ] conducting echocardiograms on asymptomatic fire fighters with Stage 1 hypertension should be reserved only for those with long-standing hypertension
In addition
7761 A resting EKG shall be performed as part of the baseline medical evaluation and shall be obtained periodically thereafter
Changing from annually to periodically is noted has the language in the wellness-fitness initiative been changed as well Our previous decision was that we would support the W-F language since there was no compelling evidence to either support or refute it
Thanks
Sandy
32
NFPA 1582‐ HTN Draft 1
Reason for Revision
1) New classification of BP by the Joint National Commission [Chobanian et al 2002]
2) A high prevalence of FF have either HTN (~20) and Pre‐HTN (~20) [Soteriades et al 2003]
3) Among FF studies have shown a strong association between HTN and a number of adverse
cardiovascular events [Kales et al 2009]
4) A large percentage of on‐duty FF fatalities were found to have left ventricular hypertrophy a
complication of HTN at autopsy
Language in 2007 Edition with draft revisions in Red (Track changes)
611 The medical evaluation of a candidate shall include a medical history examination and any laboratory tests required to detect physical or medical condition(s) that could adversely affect hisher ability to safely perform the essential job tasks outlined in 511 A611 The medical history should include the candidates known health problems such as major illnesses surgeries medication use and allergies Symptom review is also important for detecting early signs of illness A medical history should also include a personal health history a family health history a health habit history an immunization history and a reproductive history
An occupational history should also be obtained to collect information about the persons past occupational and environmental exposures
(a) BP should be measured according to the Joint National Commission (JNC) -7 recommendations BP should be measured with a properly calibrated and validated instrument Patients should be seated quietly for at least 5 minutes in a chair with feet on the floor and arm supported at heart level An appropriate-sized cuff (cuff bladder encircling at least 80 of the arm) should be used to ensure accuracy At least 2 measurements should be made Systolic BP is the point at which the first of 2 or more sounds is heard (phase 1) and diastolic BP is the point before the disappearance of sounds (phase 5) [Chobanian et al 2003]
(2) Head eyes ears nose and throat (HEENT)
Formatted Font (Default) Times New RomanFont color Black
33
692 Vascular System 6921 Category A medical conditions shall include the following
(1) Uncontrolled or poorly controlled hypertension
(2) Hypertension with evidence of end organ damage
or not controlled by approved medications
A6921(1) Uncontrolled or poorly controlled hHypertension increases the risk of a sudden cardiac event This sudden cardiac event would cause sudden incapacitation which that is uncontrolled poorly controlled or requires medication likely to interferes with the safe performance of essential job tasks Uncontrolled or poorly controlled hypertension can be defined as the presence of end organ damage (see below) or stage 2 hypertension (BP systolic gt160 mmHg or BP diastolic gt100 mmHg) is an illness that can lead to functional impairment and potential for sudden incapacitation Individuals with pre- stage 1 or stage 2 hypertension should be referred to their primary care physician for evaluation lifestyle modification and treatment [QUESTION FOR GROUP _- WHAT ABOUT HAVING CANDIDATE RETURN IN ONE MONTH UNDER TREATMENT WITH NORMAL BP]
A6921(2)
Chronic hypertension can damage the eye (retinopathy) the kidneys (nephropathy) the vascular system (stroke transient ischemic attack or peripheral artery disease) or the heart (left ventricular hypertrophy and heart failure) These hypertension complications are known as end organ damage The cardiac and vascular complications are associated with an increased risk of sudden incapacitation and sudden cardiac death (Koren et al 1991) Unfortunately the cardiac complications are frequently asymptomatic and valid screening tests are not fast and are not inexpensive Therefore determining who to screen for cardiac complications (such as echocardiogram for LVH or a measurement of left ventricular ejection fraction for heart failure) should be based on the severity and the duration of HTN
76 Physical Examination The annual physical examination shall include each of the following components
(a) BP shall be measured according to the Joint National Commission (JNC)-7 recommendations
A76(1)(a) BP should be measured with a properly calibrated and validated instrument Patients should be seated quietly for at least 5 minutes in a chair with feet on the floor and arm supported at heart level An appropriate-sized cuff (cuff bladder encircling at least 80 of the arm) should be used to ensure accuracy At least 2 measurements should be made Systolic BP is the point at which the first of 2 or more sounds is heard (phase 1) and diastolic BP is the point before the disappearance of sounds (phase 5) [Chobanian et al 2003]
(2) Head eyes ears nose and throat (HEENT)
34
9420 Uncontrolled Hypertension 94201 Physician Evaluation Severe uncontrolled hypertension [defined as systolic pressure greater than 180 mm Hg diastolic pressure greater than 100 mm Hg or mean systolic blood
pressure ( systolic + diastolic) greater than 120 mm Hg] or malignant hypertension (defined as hypertension with the presence of target organ damage) compromises the members ability to safely perform essential job tasks 1 5 7 9 and 13 and the physician shall report the applicable job limitations to the fire department
Members with Pre-hypertention (systolic 120-139 mmHg or diastolic 80-89 mmHg) Stage 1 hypertension (systolic 140-159 mmHg or diastolic 90-99 mmHg) or Stage 2 hypertension (systolic ge160 mmHg or diastolic ge100 mmHg) should be referred to their primary care physician for evaluation lifestyle modification and treatment
(1) Members with Stage I hypertension should be followed-up not only by their primary care physician but also by the FD physician every 3 to 6 months to ensure their blood pressure is under control and to determine whether screening tests for asymptomatic end organ damage are appropriate
(2) Members with Stage 2 hypertension or with end organ damage (retinopathy nephropathy vascular or cardiac complications) compromises the members ability to safely perform essential job tasks 1 5 7 9 and 130 and the physician shall report the applicable job limitations to the fire department
A94201 Severe uncontrolled hypertension is a significant risk factor for the development of coronary artery disease congestive heart failure and stroke Blood pressure increases as a normal response to exercise This response is further exaggerated by the emotional and physical stress of performing these critical tasks while operating in personal protective clothing at extremes of temperature This normal elevation of blood pressure under these response conditions can lead to life-threatening hypertensive emergencies if a members daily blood pressure is already elevated to high levels In addition hypertension is a progressive illness that when uncontrolled ultimately and inevitably leads to target organ damage Target organs that are sensitive to the effects of elevated blood pressure are the central nervous system vision heart major blood vessels and kidneys
Chronic hypertension can damage the eye (retinopathy) the kidneys (nephropathy) the vascular system (stroke transient ischemic attack or peripheral artery disease) or the heart (left ventricular hypertrophy and heart failure) These hypertension complications are known as end organ damage The cardiac and vascular complications are associated with an increased risk of sudden incapacitation and sudden cardiac death (Koren et al 1991) Fortunately with proper evaluation life style modification and treatment these complications can be avoided Life style modification includes weight reduction DASH eating plan reduction in dietary sodium an increase in aerobic physical activity and moderation in alcohol consumption [Chobanian 2003]
Formatted Font (Default) Times New Roman12 pt Font color Black
Formatted Font (Default) Times New Roman12 pt Font color Black
35
A94201 (1) Members with Stage I hypertension whose BP returns to either pre-hypertenion or normal with lifestyle modification andor treatment can return to an annual medical evaluation For members with long-standing Stage I hypertension whose BP has not been reduced additional evaluation for possible end organ damage should be considered This evaluation could include any or all of the following
a) a compete patient history for symptoms of heart failure (eg shortness of breath upon exertion) or transient ischemic attacks (TIAs)
b) dilated eye examination for retinopathy
c) blood creatinine measurement for nephropathy
d) tests for left ventricular hypertrophy Unfortunately use of the resting EKG to detect left ventricular hypertrophy is very insensitive (eg 5 sensitivity) The echocardiogram is the best test for diagnosing left ventricular hypertrophy
A 94201 (2) Due to the high risk of a sudden cardiovascular event members with Stage 2 hypertension should be restricted until their BP can be brought under control Once the BP is brought under control they should be followed in the same manner as a member with Stage I hypertension
Formatted Font (Default) Times New Roman12 pt
36
D22 Cardiology Gibbons R J GJ Balady J W Beasley et al 1997 ACCAHA guidelines for exercise testing a report of American College of CardiologyAmerican Heart Association Task Force on Practice Guidelines (Committee on Exercise Testing) J Am Coll Cardiol 30260ndash311
Gibbons RJ Balady GJ Bricker JT Chaitman BR Fletcher GF Froelicher VF Mark DB McCallister BD Mooss AN OrsquoReilly MG Winters WL Jr [2002] ACCAHA 2002 guideline update for exercise testing summary article a report of the ACCAHA Task Force on Practice Guidelines (Committee to Update the 1997 Exercise Testing guidelines) J Am Coll Cardiol 401531ndash 40
Chobanian AV Bakris GL Black HR Cushman WC Green LA Izzo JL Jr Jones DW Materson BJ Oparil S Wright JT Jr Roccella EJ the National High Blood Pressure Education Program Coordinating Committee [2003] The seventh report of the Joint National Committee [JNC-7] on Prevention Detection Evaluation and Treatment of High Blood Pressure JAMA 2892560ndash2571
Soteriades ES Kales SN Liarokapis D Christiani DC [2003] Prospective surveillance of hypertension in firefighters J Clin Hypertens 5315-320
Kales SN Tsismenakis AJ Zhang C Soteriades ES [2009] Blood pressure in fire fighters police officers and other emergency responders Am J Hypertens 2211-20
37
NFPA 1582‐ HTN Draft 1
Reason for Revision
1) New classification of BP by the Joint National Commission [Chobanian et al 2002]
2) A high prevalence of FF have either HTN (~20) and Pre‐HTN (~20) [Soteriades et al 2003]
3) Among FF studies have shown a strong association between HTN and a number of adverse
cardiovascular events [Kales et al 2009]
4) A large percentage of on‐duty FF fatalities were found to have left ventricular hypertrophy a
complication of HTN at autopsy
Language in 2007 Edition with draft revisions in Red (Track changes)
611 The medical evaluation of a candidate shall include a medical history examination and any laboratory tests required to detect physical or medical condition(s) that could adversely affect hisher ability to safely perform the essential job tasks outlined in 511 A611 The medical history should include the candidates known health problems such as major illnesses surgeries medication use and allergies Symptom review is also important for detecting early signs of illness A medical history should also include a personal health history a family health history a health habit history an immunization history and a reproductive history
An occupational history should also be obtained to collect information about the persons past occupational and environmental exposures
(a) BP should be measured according to the Joint National Commission (JNC) -7 recommendations BP should be measured with a properly calibrated and validated instrument Patients should be seated quietly for at least 5 minutes in a chair with feet on the floor and arm supported at heart level An appropriate-sized cuff (cuff bladder encircling at least 80 of the arm) should be used to ensure accuracy At least 2 measurements should be made Systolic BP is the point at which the first of 2 or more sounds is heard (phase 1) and diastolic BP is the point before the disappearance of sounds (phase 5) [Chobanian et al 2003]
(2) Head eyes ears nose and throat
38
692 Vascular System 6921 Category A medical conditions shall include the following
(1) Uncontrolled or poorly controlled hypertension
(2) Hypertension with evidence of end organ damage
A6921(1) Uncontrolled or poorly controlled hypertension increases the risk of a sudden cardiac event This sudden cardiac event would cause sudden incapacitation which interferes with the safe performance of essential job tasks Uncontrolled or poorly controlled hypertension can be defined as the presence of end organ damage (see below) or stage 2 hypertension (BP systolic gt160 mmHg or BP diastolic gt100 mmHg) Individuals with pre- stage 1 or stage 2 hypertension should be referred to their primary care physician for evaluation lifestyle modification and treatment [QUESTION FOR GROUP _- WHAT ABOUT HAVING CANDIDATE RETURN IN ONE MONTH UNDER TREATMENT WITH NORMAL BP]
A6921(2)Chronic hypertension can damage the eye (retinopathy) the kidneys (nephropathy) the vascular system (stroke transient ischemic attack or peripheral artery disease) or the heart (left ventricular hypertrophy and heart failure) These hypertension complications are known as end organ damage The cardiac and vascular complications are associated with an increased risk of sudden incapacitation and sudden cardiac death (Koren et al 1991) Unfortunately the cardiac complications are frequently asymptomatic and valid screening tests are not fast and are not inexpensive Therefore determining who to screen for cardiac complications (such as echocardiogram for LVH or a measurement of left ventricular ejection fraction for heart failure) should be based on the severity and the duration of HTN
76 Physical Examination The annual physical examination shall include each of the following components
(a) BP shall be measured according to the Joint National Commission (JNC)-7 recommendations
A76(1)(a) BP should be measured with a properly calibrated and validated instrument Patients should be seated quietly for at least 5 minutes in a chair with feet on the floor and arm supported at heart level An appropriate-sized cuff (cuff bladder encircling at least 80 of the arm) should be used to ensure accuracy At least 2 measurements should be made Systolic BP is the point at which the first of 2 or more sounds is heard (phase 1) and diastolic BP is the point before the disappearance of sounds (phase 5) [Chobanian et al 2003]
(2) Head eyes ears nose and throat9420 Hypertension 94201 Physician Evaluation Members with Pre-hypertention (systolic 120-139 mmHg or diastolic 80-89 mmHg) Stage 1 hypertension (systolic 140-159 mmHg or diastolic 90-99 mmHg) or Stage 2 hypertension (systolic ge160 mmHg or diastolic ge100 mmHg) should be referred to their primary care physician for evaluation lifestyle modification and treatment
39
(1) Members with Stage I hypertension should be followed-up not only by their primary care physician but also by the FD physician every 3 to 6 months to ensure their blood pressure is under control and to determine whether screening tests for asymptomatic end organ damage are appropriate
(2) Members with Stage 2 hypertension or with end organ damage (retinopathy nephropathy vascular or cardiac complications) compromises the members ability to safely perform essential job tasks 1 5 7 9 and 130 and the physician shall report the applicable job limitations to the fire department
A94201 Chronic hypertension can damage the eye (retinopathy) the kidneys (nephropathy) the vascular system (stroke transient ischemic attack or peripheral artery disease) or the heart (left ventricular hypertrophy and heart failure) These hypertension complications are known as end organ damage The cardiac and vascular complications are associated with an increased risk of sudden incapacitation and sudden cardiac death (Koren et al 1991) Fortunately with proper evaluation life style modification and treatment these complications can be avoided Life style modification includes weight reduction DASH eating plan reduction in dietary sodium an increase in aerobic physical activity and moderation in alcohol consumption [Chobanian 2003]
A94201 (1) Members with Stage I hypertension whose BP returns to either pre-hypertenion or normal with lifestyle modification andor treatment can return to an annual medical evaluation For members with long-standing Stage I hypertension whose BP has not been reduced additional evaluation for possible end organ damage should be considered This evaluation could include any or all of the following
a) a compete patient history for symptoms of heart failure (eg shortness of breath upon exertion) or transient ischemic attacks (TIAs)
b) dilated eye examination for retinopathy
c) blood creatinine measurement for nephropathy
d) tests for left ventricular hypertrophy Unfortunately use of the resting EKG to detect left ventricular hypertrophy is very insensitive (eg 5 sensitivity) The echocardiogram is the best test for diagnosing left ventricular hypertrophy
A 94201 (2) Due to the high risk of a sudden cardiovascular event members with Stage 2 hypertension should be restricted until their BP can be brought under control Once the BP is brought under control they should be followed in the same manner as a member with Stage I hypertension
D22 Cardiology
40
Hypertension
Gibbons RJ Balady GJ Bricker JT Chaitman BR Fletcher GF Froelicher VF Mark DB McCallister BD Mooss AN OrsquoReilly MG Winters WL Jr [2002] ACCAHA 2002 guideline update for exercise testing summary article a report of the ACCAHA Task Force on Practice Guidelines (Committee to Update the 1997 Exercise Testing guidelines) J Am Coll Cardiol 401531ndash 40
Chobanian AV Bakris GL Black HR Cushman WC Green LA Izzo JL Jr Jones DW Materson BJ Oparil S Wright JT Jr Roccella EJ the National High Blood Pressure Education Program Coordinating Committee [2003] The seventh report of the Joint National Committee [JNC-7] on Prevention Detection Evaluation and Treatment of High Blood Pressure JAMA 2892560ndash2571
Soteriades ES Kales SN Liarokapis D Christiani DC [2003] Prospective surveillance of hypertension in firefighters J Clin Hypertens 5315-320
Kales SN Tsismenakis AJ Zhang C Soteriades ES [2009] Blood pressure in fire fighters police officers and other emergency responders Am J Hypertens 2211-20
41
NFPA 1582‐ Draft Revisions for CVDHTN
EKG and stress tests
Reason for Revision
1) Change requirement for annual resting EKG to periodically to be more consistent with ACCAHA
recommendation (Schlant et al 1992)
2) Add language to clarify what constitutes a positive ST
3) Make criteria for conducting diagnostic ST in asymptomatic patients consistent with the
ACCAHA
Language in 2007 Edition with draft revisions in Red (Track changes)
776 Electrocardiograms (EKG)) and Stress Tests 7761 A resting EKG shall be performed as part of the baseline medical evaluation and shall be obtained periodically (every 1 to 5 years) annually thereafter
A7761 A baseline resting EKGs shall be conducted Follow-up resting EKGs should be conducted as clinically indicated but at a minimum of every 1 to 5 years The frequency of these follow-up resting EKGs should increase as a members age increases or with increasing number andor severity of coronary heart disease risk factors Members above the age of 40 should have annual resting EKGs (Schlant et al 1992)
7762 The fire department physician or other qualified medical evaluator shall compare EKGs obtained during yearly evaluations with baseline and subsequent EKGs
7763 Stress testing EKG with or without echocardiography or radionuclide scanning shall be performed as clinically indicated by history or symptoms
A7761 Baseline electrocardiography should be conducted (Periodic resting electrocardiograms have not been shown to be useful but can be reasonable as a members agefactors increase)
A7763 No firm guidelines for stress testingelectrocardiography in asymptomatic individuals have been developed Stress testingelectrocardiography as a screening tool is used as part of an evaluation of aerobic capacity during the annual occupational fitness evaluation Submaximal stress testingelectrocardiography testing to 85 percent is commonly used as part of this screening
Submaximal stress electrocardiography testing should not be used for diagnostic purposes Cardiology evaluation with maximal stress testingelectrocardiography together with imaging techniques (eg echocardiography technetium Tc99m sestamibi study andor coronary angiography) is necessary for diagnosticprognostic purposes for the following
42
(1) Fire fighters with positive or questionably positive changes on screening submaximal stress tests
(2) Fire fighters with new onset chest pain or other symptoms suggestive of coronary artery disease (CAD)
(3) Fire fighters with diabetes mellitus who
(a) are gt35 years old or
(b) have type I diabetes for more than 15 years or
(c) have type II diabetes for more than 10 years or
(d) have any other CHD risk factor (see below) or
(e) have the presence of microvascular disease (proliferative retinopathy)
(4) Fire fighters over the age of 45 (for men) and 55 (for women) with onetwo or more risk factors for CAD Risk factors for CAD include hypercholesterolemia (total cholesterol greater than 240 mgdL) hypertension (systolic gt140 mmHg or diastolic gt90 mmHg) smoking or family history of premature CAD (heart attack or sudden cardiac death in a first degree relative less than 60 years of age)
as defined below if stress electrocardiography with imaging is negative then repeat as clinically indicated or at least every 5 years
(5) Fire fighters with a Framingham Risk Score gt10 Risk calculator is available at [httphp2010nhlbihinnetatpiiicalculatorasp]
(6) Fire fighters identified in 9431
Negative stress tests should be repeated as clinically indicated or at least every 2 to 5 years
Interpreting stress tests as ldquopositiverdquo or ldquonegativerdquo is beyond the scope of this document However factors that should be taken into consideration should include the individualrsquos exercise capacity symptoms blood pressure response heart rate response EKG changes and the presence of arrhythmias (Gibbon et al 2002)
Risk factors for CAD include hypercholesterolemia (total cholesterol greater than 240 mgdL) hypertension (systolic greater than 140 andor diastolic greater than 90) smoking diabetes mellitus or family history of premature CAD (heart attack or sudden cardiac death in a first degree relative less than 60 years of age)
There are other non-invasive tests to screen for coronary artery disease One of the most promising appears to be coronary artery calcium (CAD) scoring by computed tomography In 2007 an expert committee published an update to their original guidance document The committeersquos consensus was that ldquoit may be reasonable to consider use of CAC measurement in such patients [between 10 and 20 10-year risk of estimated coronary event]helliprdquo The committee did not recommend CAC measurement in low risk patients [lt10 10-year risk of estimated coronary event] or in high risk patients [gt20 10-year risk of estimate coronary event] (Greenland et al 2007]
43
D22 Cardiology
Chobanian AV Bakris GL Black HR Cushman WC Green LA Izzo JL Jr Jones DW Materson BJ Oparil S Wright JT Jr Roccella EJ the National High Blood Pressure Education Program Coordinating Committee [2003] The seventh report of the Joint National Committee [JNC-7] on Prevention Detection Evaluation and Treatment of High Blood Pressure JAMA 2892560ndash2571
Gibbons RJ Balady GJ Bricker JT Chaitman BR Fletcher GF Froelicher VF Mark DB McCallister BD Mooss AN OrsquoReilly MG Winters WL Jr [2002] ACCAHA 2002 guideline update for exercise testing summary article a report of the ACCAHA Task Force on Practice Guidelines (Committee to Update the 1997 Exercise Testing guidelines) J Am Coll Cardiol 401531ndash 1540
Greenland et al [2007] ACCFAHA 2007 Clinical Expert Consensus Document on Coronary Artery Calcium Scoring By Computed Tomography in Global Cardiovascular Risk Assessment and in Evaluation of Patients With Chest Pain A Report of the American College of Cardiology Foundation Clinical Expert Consensus Task Force (ACCFAHA Writing Committee to Update the 2000 Expert Consensus Document on Electron Beam Computed Tomography) J Am Coll Cardiol 49378-402
Kales SN Tsismenakis AJ Zhang C Soteriades ES [2009] Blood pressure in fire fighters police officers and other emergency responders Am J Hypertens 2211-20
Schlant RC Adolph RJ DiMarco JP Dreifus LS Dunn MI Fisch C Garson A Jr Haywood LJ Levine HJ Murray JA Noble RJ Ronan JA Jr [1992] Guidelines for electrocardiography A report of the American College of CardiologyAmerican Heart Association Task Force on Assessment of Diagnostic and Therapeutic Cardiovascular Procedures (Committee on Electrocardiography) Circulation 85(3)1221-1228
Soteriades ES Kales SN Liarokapis D Christiani DC [2003] Prospective surveillance of hypertension in firefighters J Clin Hypertens 5315-320
Formatted Font Italic
Formatted Line spacing single
Formatted Font Italic
Formatted Font Italic
44
NFPA 1582‐ Draft Revisions for CVDHTN
EKG and stress tests
Reason for Revision
1) Change requirement for annual resting EKG to periodically to be more consistent with ACCAHA
recommendation (Schlant et al 1992)
2) Add language to clarify what constitutes a positive ST
3) Make criteria for conducting diagnostic ST in asymptomatic patients consistent with the
ACCAHA
Language in 2007 Edition with draft revisions in Red (Track changes)
776 Electrocardiograms (EKG) and Stress Tests 7761 A resting EKG shall be performed as part of the baseline medical evaluation and shall be obtained periodically (every 1 to 5 years) thereafter
A7761 A baseline resting EKGs shall be conducted Follow-up resting EKGs should be conducted as clinically indicated but at a minimum of every 1 to 5 years The frequency of these follow-up resting EKGs should increase as a members age increases or with increasing number andor severity of coronary heart disease risk factors Members above the age of 40 should have annual resting EKGs (Schlant et al 1992)
7762 The fire department physician or other qualified medical evaluator shall compare baseline and subsequent EKGs
7763 Stress testing with or without echocardiography or radionuclide scanning shall be performed as clinically indicated by history or symptoms
A7763 No firm guidelines for stress testing in asymptomatic individuals have been developed Stress testing as a screening tool is used as part of an evaluation of aerobic capacity during the annual occupational fitness evaluation Submaximal stress testing testing to 85 percent is commonly used as part of this screening
Submaximal stress testing should not be used for diagnostic purposes Cardiology evaluation with maximal stress testing together with imaging techniques (eg echocardiography technetium Tc99m sestamibi study) is necessary for diagnosticprognostic purposes for the following
(1) Fire fighters with positive or questionably positive changes on screening submaximal stress tests
(2) Fire fighters with new onset chest pain or other symptoms suggestive of coronary artery disease (CAD)
45
(3) Fire fighters with diabetes mellitus who
(a) are gt35 years old or
(b) have type I diabetes for more than 15 years or
(c) have type II diabetes for more than 10 years or
(d) have any other CHD risk factor (see below) or
(e) have the presence of microvascular disease (proliferative retinopathy)
(4) Fire fighters over the age of 45 (for men) and 55 (for women) with one or more risk factors for CAD Risk factors for CAD include hypercholesterolemia (total cholesterol greater than 240 mgdL) hypertension (systolic gt140 mmHg or diastolic gt90 mmHg) smoking or family history of premature CAD (heart attack or sudden cardiac death in a first degree relative less than 60 years of age)
(5) Fire fighters with a Framingham Risk Score gt10 Risk calculator is available at [httphp2010nhlbihinnetatpiiicalculatorasp]
(6) Fire fighters identified in 9431
Negative stress tests should be repeated as clinically indicated or at least every 2 to 5 years
Interpreting stress tests as ldquopositiverdquo or ldquonegativerdquo is beyond the scope of this document However factors that should be taken into consideration should include the individualrsquos exercise capacity symptoms blood pressure response heart rate response EKG changes and the presence of arrhythmias (Gibbon et al 2002)
There are other non-invasive tests to screen for coronary artery disease One of the most promising appears to be coronary artery calcium (CAD) scoring by computed tomography In 2007 an expert committee published an update to their original guidance document The committeersquos consensus was that ldquoit may be reasonable to consider use of CAC measurement in such patients [between 10 and 20 10-year risk of estimated coronary event]helliprdquo The committee did not recommend CAC measurement in low risk patients [lt10 10-year risk of estimated coronary event] or in high risk patients [gt20 10-year risk of estimate coronary event] (Greenland et al 2007]
D22 Cardiology
Resting EKG and Stress Tests
46
Chobanian AV Bakris GL Black HR Cushman WC Green LA Izzo JL Jr Jones DW Materson BJ Oparil S Wright JT Jr Roccella EJ the National High Blood Pressure Education Program Coordinating Committee [2003] The seventh report of the Joint National Committee [JNC-7] on Prevention Detection Evaluation and Treatment of High Blood Pressure JAMA 2892560ndash2571
Gibbons RJ Balady GJ Bricker JT Chaitman BR Fletcher GF Froelicher VF Mark DB McCallister BD Mooss AN OrsquoReilly MG Winters WL Jr [2002] ACCAHA 2002 guideline update for exercise testing summary article a report of the ACCAHA Task Force on Practice Guidelines (Committee to Update the 1997 Exercise Testing guidelines) J Am Coll Cardiol 401531ndash 1540
Greenland et al [2007] ACCFAHA 2007 Clinical Expert Consensus Document on Coronary Artery Calcium Scoring By Computed Tomography in Global Cardiovascular Risk Assessment and in Evaluation of Patients With Chest Pain A Report of the American College of Cardiology Foundation Clinical Expert Consensus Task Force (ACCFAHA Writing Committee to Update the 2000 Expert Consensus Document on Electron Beam Computed Tomography) J Am Coll Cardiol 49378-402
Kales SN Tsismenakis AJ Zhang C Soteriades ES [2009] Blood pressure in fire fighters police officers and other emergency responders Am J Hypertens 2211-20
Schlant RC Adolph RJ DiMarco JP Dreifus LS Dunn MI Fisch C Garson A Jr Haywood LJ Levine HJ Murray JA Noble RJ Ronan JA Jr [1992] Guidelines for electrocardiography A report of the American College of CardiologyAmerican Heart Association Task Force on Assessment of Diagnostic and Therapeutic Cardiovascular Procedures (Committee on Electrocardiography) Circulation 85(3)1221-1228
Soteriades ES Kales SN Liarokapis D Christiani DC [2003] Prospective surveillance of hypertension in firefighters J Clin Hypertens 5315-320
47
ATTACHMENT F
48
1
Current 1582 (2007) language in reference to pregnancy 43 (4) Report to the fire department physician any medical condition that could interfere with the ability of the individual to safely perform essential job tasks such as illness or injury use of prescription or nonprescription drugs and pregnancy 6112 Category B medical conditions shall include the following (1) Pregnancy for its duration A7792 (e) If HIV prophylaxis is to be given the following tests should be done i CBC ii Glucose renal and hepatic chemical function iii Pregnancy test for females B121 Pregnancy and Reproduction Federal regulations as well as many court decisions including the US Supreme Courtrsquos decision in International Union et al v Johnson Controls Inc [499 US 187 111 S Ct 1196 (1991)] have interpreted the requirements of Title VII with respect to pregnancy and reproduction The AHJ should seek the advice of counsel in resolving specific questions concerning these requirements as well as other requirements that can be imposed by state or local laws C211 (4) Review health status with the individual being evaluated Contraindications for evaluations shall be reviewed addressing any changes in the individualrsquos health status since their last medical evaluation that would warrant deferring the evaluation including (g) Pregnancy Recommendations to language enhancement
A female employee who is assigned to regular fire line duty shall report a pregnancy immediately to their respective Supervisor and the fire department physician The employee will then be given the option of a non-hazardous alternative duty position for the duration of her pregnancy (can we say this or is it even appropriate) Any pregnant employee wishing to remain on regular line duty shall be informed of the possible risks and consequences to herself and her fetus that are associated with continued line fire fighting duty Among those risk factors are exposure to teratogens known to have negative effects on the developing fetus such as smoke diesel fumes hazardous chemicals and extreme heat
49
Page 2
appendix It is recommended that the pregnant employee complete a release of liability form signed by herself and her health care provider utilizing NFPArsquos 13 critical tasks as a reference This will inform the health care provider of specific job-related tasks that will need to be performed in order to continue regular line duty These tasks are basic physical standards that any entry level firefighter would have to be able to complete competently The employeersquos health condition will be kept confidential by the department in accordance with HIPAA standards Employees are allowed to remain on active regular duty until they are no longer able to perform their duties in a reasonable manner andor their protective gear no longer fits correctly It is the responsibility of the health care provider to evaluate the pregnant employee If at any time the health care provider feels the pregnant employee can no longer perform the job related tasks this should be reported to the employer by the employee immediately
50
ATTACHMENT G
51
From GLENN BENARICKTo Sawyer SteveSubject RE RE 7743Date Monday August 30 2010 21633 PM
Yes thats my understanding
Glenn P Benarick 211 Winged Elm CircleAiken SC 29803803-644-7093gbenarprodigynet
--- On Mon 83010 Sawyer Steve ltssawyerNFPAorggt wrote
From Sawyer Steve ltssawyerNFPAorggtSubject RE RE 7743To GLENN BENARICK ltgbenarprodigynetgtDate Monday August 30 2010 212 PM
So it should be ldquoorrdquo instead of ldquoandrdquo for now
Steven F Sawyer
Senior Fire Service Specialist
Executive Secretary IFMAFire Service Section
NFPA
1 Batterymarch Park
Quincy MA 02169
6179847423
Fax 6179847056
ssawyernfpaorg
From GLENN BENARICK [mailtogbenarprodigynet] Sent Monday August 30 2010 1202 PMTo Sawyer SteveSubject Fw RE 7743
52
Steve a couple of our docs agree with April Boyer
Glenn P Benarick 211 Winged Elm Circle
Aiken SC 29803
803-644-7093
gbenarprodigynet
--- On Mon 83010 David Prezant ltprezandfdnynycgovgt wrote
From David Prezant ltprezandfdnynycgovgtSubject RE 7743To Thomas R (CDCNIOSHDSHEFS) Hales lttrh1cdcgovgt GLENNBENARICK ltgbenarprodigynetgtCc Sandy Bogucki ltsandyboguckiyaleedugtDate Monday August 30 2010 1004 AM
agree
we should change this to NHANES III rather than Knudson we should alsomodify this to allow not only for predicted cutoffs but all for use of thelower limit of normal cutoff This is important to prevent false-classificationof spirometry as abnormal in older groups and in taller grps The latter ofparticular import to firefighter occupational health surveillance
thanks
David Prezant MDChief Medical Officer Office of Medical AffairsCo-Director WTC Medical Monitoring amp Treatment ProgramsNew York City Fire Department9 Metrotech Center - Rm 4W-1Brooklyn NY 11201Phone 718-999-2696Fax 718-999-0665
Life is full of twists and turns
53
This email may contain confidential information If you are the unintendedrecipient of this email please send it back and delete from your directory
gtgtgt Hales Thomas R (CDCNIOSHDSHEFS) lttrh1cdcgovgt 8302010955 AM gtgtgt
Glen
This seems like a very reasonable comment and illustrates the importance of having clinicians providefeedback on the std Im not familiar with the software program of the various spirometers (NHANES IIIvs KnudsonATS vs both) Given the large role both Dave Prezant and Sandy Bogucki had for thepulmonary section let me forward to them for clarification
Tom
From GLENN BENARICK [mailtogbenarprodigynet] Sent Sunday August 29 2010 456 PMTo Hales Thomas R (CDCNIOSHDSHEFS)Subject FW 7743
Tom is April Boyer correct
Glenn P Benarick 211 Winged Elm Circle
Aiken SC 29803
803-644-7093
gbenarprodigynet
--- On Thu 82610 Sawyer Steve ltssawyerNFPAorggt wrote
From Sawyer Steve ltssawyerNFPAorggtSubject FW 7743To GLENN BENARICK ltgbenarprodigynetgtDate Thursday August 26 2010 925 PM
FYI Do you have any answer She is write
Steven
54
Steven F Sawyer
Senior Fire Service Specialist
Executive Secretary IFMAFire Service Section
NFPA
1 Batterymarch Park
Quincy MA 02169
6179847423
Fax 6179847056
ssawyernfpaorg
From April Boyer [mailtoaboyerbicclinicorg] Sent Thursday August 26 2010 232 PMTo Sawyer SteveCc RobinMWebbmilstateorusSubject 7743
Steven
The spirometry tests cannot be corrected according to both references as the NFPA states because thereferences are contradictory The first part of 7743 states to follow the ATS guidelines and use theKnudsen (we at Basin Immediate Care use the Nhanes III) The second part states to follow the ACOEMguidelines and use the Nhanes III in the occupational setting if available with your unit (which is availableon ours) 7743 does not use the word OR regarding both requirements it uses the word AND whenreferring to the first and second parts thence making 7743 contradictory I realize the NFPA 1582 hasnot been updated since 2007 unless I have just not received an updated version
Our question to you is which part of 7743 do you want us to follow the first or the second part Anyfacility that has an updated computerized spirometry system (as we do) will not be able to follow bothrequired parts for obvious reasons We can either follow the first part of 7743 and use an oldercorrected version of the Knudson by going into our system and changing out of the Nhanes III conversionOR we can follow the second part of 7743 and use the newer corrected version of Nhanes III which ourunit offers too
If you have any questions you may contact me at anytime and I also have many references in regards toboth parts of 7743 if you would like to see them
55
Thank you~
April
Confidentiality NoticeThis message may contain information that isconfidential or privileged
If you are not the intended recipientPlease advise the sender immediately and delete this message
56
ATTACHMENT H
57
NFPA 1582 771(7) Proposed revisions
Why
Preliminary results of two prospective randomized trials on the PSA test were published in 2009 These studies resulted in medical organizations that previously providing guidance to modify their recommendations
Current language
771 Blood Tests Blood tests shall be performed annually and shall include the following
(7) Prostate specific antigen (PSA) after age 40 for positive family history if African American or if otherwise clinically indicated after age 50 for all other male member
Suggested Revision
771 Blood Tests Blood tests shall be performed annually and shall include the following
(7) Prostate specific antigen (PSA) after age 40 for positive family history if African American or if otherwise clinically indicated after age 50 for all other male member
772 Prostate-Specific Antigen (PSA) test At age 50 fire fighters shall have an opportunity to make an informed decision with either the Fire Department physician or their health care provider concerning the PSA test For fire fighters at increased risk of prostate cancer (African-Americans or those with a first degree relative diagnosed with prostate cancer before age 65) shall have the opportunity for this informed decision at age 40
A772 The PSA as a screening test for prostate cancer in asymptomatic men is controversial controversial for two reasons First there is no consensus that PSA screening actually saves lives For example the PSA test may detect small cancers that would never become life threatening Second it is unclear that the benefits of PSA screening outweigh the risks of follow-up diagnostic tests and cancer treatments For example the prostate biopsy used to diagnose prostate cancer may cause bleeding and infection And prostate cancer treatments such as surgery and radiation therapy may cause incontinence (inability to control urine flow) erectile dysfunction (erections inadequate for intercourse) and other complications For these reasons it is important that the benefits and risks of prostate diagnostic procedures and treatment be taken into account when considering the PSA screening test These considerations can be taken account during discussions with the fire department physician or onersquos health care provider
D211 Cancer Screening
Smith R A C J Mettlin K J Davis and H Eyre 2000 ldquoAmerican Cancer Society guidelines for the early detection of cancerrdquo CA J Clin 50(1)34ndash49
Added references
58
Carroll P Albertsen PC Greene K et al [2010] Prostate-specific antigen best practice statement 2009 update Am Urological Assoc Available at httpwwwauanetorgcontentguidelines-and-quality-careclinical-guidelinesmain-reportspsa09pdf Date accessed September 2010
Ferrini R Woolf SH [2009] Screening for prostate cancer in American men American College of Preventive Medicine Practice Policy Statement Available at httpwwwacpmorgprostatehtm Date accessed September 2010
National Cancer Institute [2009] Prostate-specific antigen test National Cancer Institute Fact Sheet Available at httpwwwcancergovcancertopicsfactsheetDetectionPSA Date accessed September 2010
Wolf AMD Wender RC Etzioni RB et al [2010] American Cancer Society guideline for the early detection of prostate cancer Update 2010 Available at httpcaonlineamcancersocorgcgicontentfullcaac20066v1 Date accessed September 2010
59
ATTACHMENT E
31
Typos A6921(2) 7th line down test should be plural 94201 Paragraph 2 target organ damage is used though end organ damage was defined earlier and in the appendix for that paragraph
A94201 Para A (1) d Id suggest deleting the phrases in brackets Im not sure either are predictably true or politically wise
a) tests for left ventricular hypertrophy Unfortunately use of the EKG to detect left ventricular hypertrophy is very insensitive (eg 5 sensitivity) The echocardiogram is the best test for diagnosing left ventricular hypertrophy but [it is relatively expensive and not readily available in small rural communities ] conducting echocardiograms on asymptomatic fire fighters with Stage 1 hypertension should be reserved only for those with long-standing hypertension
In addition
7761 A resting EKG shall be performed as part of the baseline medical evaluation and shall be obtained periodically thereafter
Changing from annually to periodically is noted has the language in the wellness-fitness initiative been changed as well Our previous decision was that we would support the W-F language since there was no compelling evidence to either support or refute it
Thanks
Sandy
32
NFPA 1582‐ HTN Draft 1
Reason for Revision
1) New classification of BP by the Joint National Commission [Chobanian et al 2002]
2) A high prevalence of FF have either HTN (~20) and Pre‐HTN (~20) [Soteriades et al 2003]
3) Among FF studies have shown a strong association between HTN and a number of adverse
cardiovascular events [Kales et al 2009]
4) A large percentage of on‐duty FF fatalities were found to have left ventricular hypertrophy a
complication of HTN at autopsy
Language in 2007 Edition with draft revisions in Red (Track changes)
611 The medical evaluation of a candidate shall include a medical history examination and any laboratory tests required to detect physical or medical condition(s) that could adversely affect hisher ability to safely perform the essential job tasks outlined in 511 A611 The medical history should include the candidates known health problems such as major illnesses surgeries medication use and allergies Symptom review is also important for detecting early signs of illness A medical history should also include a personal health history a family health history a health habit history an immunization history and a reproductive history
An occupational history should also be obtained to collect information about the persons past occupational and environmental exposures
(a) BP should be measured according to the Joint National Commission (JNC) -7 recommendations BP should be measured with a properly calibrated and validated instrument Patients should be seated quietly for at least 5 minutes in a chair with feet on the floor and arm supported at heart level An appropriate-sized cuff (cuff bladder encircling at least 80 of the arm) should be used to ensure accuracy At least 2 measurements should be made Systolic BP is the point at which the first of 2 or more sounds is heard (phase 1) and diastolic BP is the point before the disappearance of sounds (phase 5) [Chobanian et al 2003]
(2) Head eyes ears nose and throat (HEENT)
Formatted Font (Default) Times New RomanFont color Black
33
692 Vascular System 6921 Category A medical conditions shall include the following
(1) Uncontrolled or poorly controlled hypertension
(2) Hypertension with evidence of end organ damage
or not controlled by approved medications
A6921(1) Uncontrolled or poorly controlled hHypertension increases the risk of a sudden cardiac event This sudden cardiac event would cause sudden incapacitation which that is uncontrolled poorly controlled or requires medication likely to interferes with the safe performance of essential job tasks Uncontrolled or poorly controlled hypertension can be defined as the presence of end organ damage (see below) or stage 2 hypertension (BP systolic gt160 mmHg or BP diastolic gt100 mmHg) is an illness that can lead to functional impairment and potential for sudden incapacitation Individuals with pre- stage 1 or stage 2 hypertension should be referred to their primary care physician for evaluation lifestyle modification and treatment [QUESTION FOR GROUP _- WHAT ABOUT HAVING CANDIDATE RETURN IN ONE MONTH UNDER TREATMENT WITH NORMAL BP]
A6921(2)
Chronic hypertension can damage the eye (retinopathy) the kidneys (nephropathy) the vascular system (stroke transient ischemic attack or peripheral artery disease) or the heart (left ventricular hypertrophy and heart failure) These hypertension complications are known as end organ damage The cardiac and vascular complications are associated with an increased risk of sudden incapacitation and sudden cardiac death (Koren et al 1991) Unfortunately the cardiac complications are frequently asymptomatic and valid screening tests are not fast and are not inexpensive Therefore determining who to screen for cardiac complications (such as echocardiogram for LVH or a measurement of left ventricular ejection fraction for heart failure) should be based on the severity and the duration of HTN
76 Physical Examination The annual physical examination shall include each of the following components
(a) BP shall be measured according to the Joint National Commission (JNC)-7 recommendations
A76(1)(a) BP should be measured with a properly calibrated and validated instrument Patients should be seated quietly for at least 5 minutes in a chair with feet on the floor and arm supported at heart level An appropriate-sized cuff (cuff bladder encircling at least 80 of the arm) should be used to ensure accuracy At least 2 measurements should be made Systolic BP is the point at which the first of 2 or more sounds is heard (phase 1) and diastolic BP is the point before the disappearance of sounds (phase 5) [Chobanian et al 2003]
(2) Head eyes ears nose and throat (HEENT)
34
9420 Uncontrolled Hypertension 94201 Physician Evaluation Severe uncontrolled hypertension [defined as systolic pressure greater than 180 mm Hg diastolic pressure greater than 100 mm Hg or mean systolic blood
pressure ( systolic + diastolic) greater than 120 mm Hg] or malignant hypertension (defined as hypertension with the presence of target organ damage) compromises the members ability to safely perform essential job tasks 1 5 7 9 and 13 and the physician shall report the applicable job limitations to the fire department
Members with Pre-hypertention (systolic 120-139 mmHg or diastolic 80-89 mmHg) Stage 1 hypertension (systolic 140-159 mmHg or diastolic 90-99 mmHg) or Stage 2 hypertension (systolic ge160 mmHg or diastolic ge100 mmHg) should be referred to their primary care physician for evaluation lifestyle modification and treatment
(1) Members with Stage I hypertension should be followed-up not only by their primary care physician but also by the FD physician every 3 to 6 months to ensure their blood pressure is under control and to determine whether screening tests for asymptomatic end organ damage are appropriate
(2) Members with Stage 2 hypertension or with end organ damage (retinopathy nephropathy vascular or cardiac complications) compromises the members ability to safely perform essential job tasks 1 5 7 9 and 130 and the physician shall report the applicable job limitations to the fire department
A94201 Severe uncontrolled hypertension is a significant risk factor for the development of coronary artery disease congestive heart failure and stroke Blood pressure increases as a normal response to exercise This response is further exaggerated by the emotional and physical stress of performing these critical tasks while operating in personal protective clothing at extremes of temperature This normal elevation of blood pressure under these response conditions can lead to life-threatening hypertensive emergencies if a members daily blood pressure is already elevated to high levels In addition hypertension is a progressive illness that when uncontrolled ultimately and inevitably leads to target organ damage Target organs that are sensitive to the effects of elevated blood pressure are the central nervous system vision heart major blood vessels and kidneys
Chronic hypertension can damage the eye (retinopathy) the kidneys (nephropathy) the vascular system (stroke transient ischemic attack or peripheral artery disease) or the heart (left ventricular hypertrophy and heart failure) These hypertension complications are known as end organ damage The cardiac and vascular complications are associated with an increased risk of sudden incapacitation and sudden cardiac death (Koren et al 1991) Fortunately with proper evaluation life style modification and treatment these complications can be avoided Life style modification includes weight reduction DASH eating plan reduction in dietary sodium an increase in aerobic physical activity and moderation in alcohol consumption [Chobanian 2003]
Formatted Font (Default) Times New Roman12 pt Font color Black
Formatted Font (Default) Times New Roman12 pt Font color Black
35
A94201 (1) Members with Stage I hypertension whose BP returns to either pre-hypertenion or normal with lifestyle modification andor treatment can return to an annual medical evaluation For members with long-standing Stage I hypertension whose BP has not been reduced additional evaluation for possible end organ damage should be considered This evaluation could include any or all of the following
a) a compete patient history for symptoms of heart failure (eg shortness of breath upon exertion) or transient ischemic attacks (TIAs)
b) dilated eye examination for retinopathy
c) blood creatinine measurement for nephropathy
d) tests for left ventricular hypertrophy Unfortunately use of the resting EKG to detect left ventricular hypertrophy is very insensitive (eg 5 sensitivity) The echocardiogram is the best test for diagnosing left ventricular hypertrophy
A 94201 (2) Due to the high risk of a sudden cardiovascular event members with Stage 2 hypertension should be restricted until their BP can be brought under control Once the BP is brought under control they should be followed in the same manner as a member with Stage I hypertension
Formatted Font (Default) Times New Roman12 pt
36
D22 Cardiology Gibbons R J GJ Balady J W Beasley et al 1997 ACCAHA guidelines for exercise testing a report of American College of CardiologyAmerican Heart Association Task Force on Practice Guidelines (Committee on Exercise Testing) J Am Coll Cardiol 30260ndash311
Gibbons RJ Balady GJ Bricker JT Chaitman BR Fletcher GF Froelicher VF Mark DB McCallister BD Mooss AN OrsquoReilly MG Winters WL Jr [2002] ACCAHA 2002 guideline update for exercise testing summary article a report of the ACCAHA Task Force on Practice Guidelines (Committee to Update the 1997 Exercise Testing guidelines) J Am Coll Cardiol 401531ndash 40
Chobanian AV Bakris GL Black HR Cushman WC Green LA Izzo JL Jr Jones DW Materson BJ Oparil S Wright JT Jr Roccella EJ the National High Blood Pressure Education Program Coordinating Committee [2003] The seventh report of the Joint National Committee [JNC-7] on Prevention Detection Evaluation and Treatment of High Blood Pressure JAMA 2892560ndash2571
Soteriades ES Kales SN Liarokapis D Christiani DC [2003] Prospective surveillance of hypertension in firefighters J Clin Hypertens 5315-320
Kales SN Tsismenakis AJ Zhang C Soteriades ES [2009] Blood pressure in fire fighters police officers and other emergency responders Am J Hypertens 2211-20
37
NFPA 1582‐ HTN Draft 1
Reason for Revision
1) New classification of BP by the Joint National Commission [Chobanian et al 2002]
2) A high prevalence of FF have either HTN (~20) and Pre‐HTN (~20) [Soteriades et al 2003]
3) Among FF studies have shown a strong association between HTN and a number of adverse
cardiovascular events [Kales et al 2009]
4) A large percentage of on‐duty FF fatalities were found to have left ventricular hypertrophy a
complication of HTN at autopsy
Language in 2007 Edition with draft revisions in Red (Track changes)
611 The medical evaluation of a candidate shall include a medical history examination and any laboratory tests required to detect physical or medical condition(s) that could adversely affect hisher ability to safely perform the essential job tasks outlined in 511 A611 The medical history should include the candidates known health problems such as major illnesses surgeries medication use and allergies Symptom review is also important for detecting early signs of illness A medical history should also include a personal health history a family health history a health habit history an immunization history and a reproductive history
An occupational history should also be obtained to collect information about the persons past occupational and environmental exposures
(a) BP should be measured according to the Joint National Commission (JNC) -7 recommendations BP should be measured with a properly calibrated and validated instrument Patients should be seated quietly for at least 5 minutes in a chair with feet on the floor and arm supported at heart level An appropriate-sized cuff (cuff bladder encircling at least 80 of the arm) should be used to ensure accuracy At least 2 measurements should be made Systolic BP is the point at which the first of 2 or more sounds is heard (phase 1) and diastolic BP is the point before the disappearance of sounds (phase 5) [Chobanian et al 2003]
(2) Head eyes ears nose and throat
38
692 Vascular System 6921 Category A medical conditions shall include the following
(1) Uncontrolled or poorly controlled hypertension
(2) Hypertension with evidence of end organ damage
A6921(1) Uncontrolled or poorly controlled hypertension increases the risk of a sudden cardiac event This sudden cardiac event would cause sudden incapacitation which interferes with the safe performance of essential job tasks Uncontrolled or poorly controlled hypertension can be defined as the presence of end organ damage (see below) or stage 2 hypertension (BP systolic gt160 mmHg or BP diastolic gt100 mmHg) Individuals with pre- stage 1 or stage 2 hypertension should be referred to their primary care physician for evaluation lifestyle modification and treatment [QUESTION FOR GROUP _- WHAT ABOUT HAVING CANDIDATE RETURN IN ONE MONTH UNDER TREATMENT WITH NORMAL BP]
A6921(2)Chronic hypertension can damage the eye (retinopathy) the kidneys (nephropathy) the vascular system (stroke transient ischemic attack or peripheral artery disease) or the heart (left ventricular hypertrophy and heart failure) These hypertension complications are known as end organ damage The cardiac and vascular complications are associated with an increased risk of sudden incapacitation and sudden cardiac death (Koren et al 1991) Unfortunately the cardiac complications are frequently asymptomatic and valid screening tests are not fast and are not inexpensive Therefore determining who to screen for cardiac complications (such as echocardiogram for LVH or a measurement of left ventricular ejection fraction for heart failure) should be based on the severity and the duration of HTN
76 Physical Examination The annual physical examination shall include each of the following components
(a) BP shall be measured according to the Joint National Commission (JNC)-7 recommendations
A76(1)(a) BP should be measured with a properly calibrated and validated instrument Patients should be seated quietly for at least 5 minutes in a chair with feet on the floor and arm supported at heart level An appropriate-sized cuff (cuff bladder encircling at least 80 of the arm) should be used to ensure accuracy At least 2 measurements should be made Systolic BP is the point at which the first of 2 or more sounds is heard (phase 1) and diastolic BP is the point before the disappearance of sounds (phase 5) [Chobanian et al 2003]
(2) Head eyes ears nose and throat9420 Hypertension 94201 Physician Evaluation Members with Pre-hypertention (systolic 120-139 mmHg or diastolic 80-89 mmHg) Stage 1 hypertension (systolic 140-159 mmHg or diastolic 90-99 mmHg) or Stage 2 hypertension (systolic ge160 mmHg or diastolic ge100 mmHg) should be referred to their primary care physician for evaluation lifestyle modification and treatment
39
(1) Members with Stage I hypertension should be followed-up not only by their primary care physician but also by the FD physician every 3 to 6 months to ensure their blood pressure is under control and to determine whether screening tests for asymptomatic end organ damage are appropriate
(2) Members with Stage 2 hypertension or with end organ damage (retinopathy nephropathy vascular or cardiac complications) compromises the members ability to safely perform essential job tasks 1 5 7 9 and 130 and the physician shall report the applicable job limitations to the fire department
A94201 Chronic hypertension can damage the eye (retinopathy) the kidneys (nephropathy) the vascular system (stroke transient ischemic attack or peripheral artery disease) or the heart (left ventricular hypertrophy and heart failure) These hypertension complications are known as end organ damage The cardiac and vascular complications are associated with an increased risk of sudden incapacitation and sudden cardiac death (Koren et al 1991) Fortunately with proper evaluation life style modification and treatment these complications can be avoided Life style modification includes weight reduction DASH eating plan reduction in dietary sodium an increase in aerobic physical activity and moderation in alcohol consumption [Chobanian 2003]
A94201 (1) Members with Stage I hypertension whose BP returns to either pre-hypertenion or normal with lifestyle modification andor treatment can return to an annual medical evaluation For members with long-standing Stage I hypertension whose BP has not been reduced additional evaluation for possible end organ damage should be considered This evaluation could include any or all of the following
a) a compete patient history for symptoms of heart failure (eg shortness of breath upon exertion) or transient ischemic attacks (TIAs)
b) dilated eye examination for retinopathy
c) blood creatinine measurement for nephropathy
d) tests for left ventricular hypertrophy Unfortunately use of the resting EKG to detect left ventricular hypertrophy is very insensitive (eg 5 sensitivity) The echocardiogram is the best test for diagnosing left ventricular hypertrophy
A 94201 (2) Due to the high risk of a sudden cardiovascular event members with Stage 2 hypertension should be restricted until their BP can be brought under control Once the BP is brought under control they should be followed in the same manner as a member with Stage I hypertension
D22 Cardiology
40
Hypertension
Gibbons RJ Balady GJ Bricker JT Chaitman BR Fletcher GF Froelicher VF Mark DB McCallister BD Mooss AN OrsquoReilly MG Winters WL Jr [2002] ACCAHA 2002 guideline update for exercise testing summary article a report of the ACCAHA Task Force on Practice Guidelines (Committee to Update the 1997 Exercise Testing guidelines) J Am Coll Cardiol 401531ndash 40
Chobanian AV Bakris GL Black HR Cushman WC Green LA Izzo JL Jr Jones DW Materson BJ Oparil S Wright JT Jr Roccella EJ the National High Blood Pressure Education Program Coordinating Committee [2003] The seventh report of the Joint National Committee [JNC-7] on Prevention Detection Evaluation and Treatment of High Blood Pressure JAMA 2892560ndash2571
Soteriades ES Kales SN Liarokapis D Christiani DC [2003] Prospective surveillance of hypertension in firefighters J Clin Hypertens 5315-320
Kales SN Tsismenakis AJ Zhang C Soteriades ES [2009] Blood pressure in fire fighters police officers and other emergency responders Am J Hypertens 2211-20
41
NFPA 1582‐ Draft Revisions for CVDHTN
EKG and stress tests
Reason for Revision
1) Change requirement for annual resting EKG to periodically to be more consistent with ACCAHA
recommendation (Schlant et al 1992)
2) Add language to clarify what constitutes a positive ST
3) Make criteria for conducting diagnostic ST in asymptomatic patients consistent with the
ACCAHA
Language in 2007 Edition with draft revisions in Red (Track changes)
776 Electrocardiograms (EKG)) and Stress Tests 7761 A resting EKG shall be performed as part of the baseline medical evaluation and shall be obtained periodically (every 1 to 5 years) annually thereafter
A7761 A baseline resting EKGs shall be conducted Follow-up resting EKGs should be conducted as clinically indicated but at a minimum of every 1 to 5 years The frequency of these follow-up resting EKGs should increase as a members age increases or with increasing number andor severity of coronary heart disease risk factors Members above the age of 40 should have annual resting EKGs (Schlant et al 1992)
7762 The fire department physician or other qualified medical evaluator shall compare EKGs obtained during yearly evaluations with baseline and subsequent EKGs
7763 Stress testing EKG with or without echocardiography or radionuclide scanning shall be performed as clinically indicated by history or symptoms
A7761 Baseline electrocardiography should be conducted (Periodic resting electrocardiograms have not been shown to be useful but can be reasonable as a members agefactors increase)
A7763 No firm guidelines for stress testingelectrocardiography in asymptomatic individuals have been developed Stress testingelectrocardiography as a screening tool is used as part of an evaluation of aerobic capacity during the annual occupational fitness evaluation Submaximal stress testingelectrocardiography testing to 85 percent is commonly used as part of this screening
Submaximal stress electrocardiography testing should not be used for diagnostic purposes Cardiology evaluation with maximal stress testingelectrocardiography together with imaging techniques (eg echocardiography technetium Tc99m sestamibi study andor coronary angiography) is necessary for diagnosticprognostic purposes for the following
42
(1) Fire fighters with positive or questionably positive changes on screening submaximal stress tests
(2) Fire fighters with new onset chest pain or other symptoms suggestive of coronary artery disease (CAD)
(3) Fire fighters with diabetes mellitus who
(a) are gt35 years old or
(b) have type I diabetes for more than 15 years or
(c) have type II diabetes for more than 10 years or
(d) have any other CHD risk factor (see below) or
(e) have the presence of microvascular disease (proliferative retinopathy)
(4) Fire fighters over the age of 45 (for men) and 55 (for women) with onetwo or more risk factors for CAD Risk factors for CAD include hypercholesterolemia (total cholesterol greater than 240 mgdL) hypertension (systolic gt140 mmHg or diastolic gt90 mmHg) smoking or family history of premature CAD (heart attack or sudden cardiac death in a first degree relative less than 60 years of age)
as defined below if stress electrocardiography with imaging is negative then repeat as clinically indicated or at least every 5 years
(5) Fire fighters with a Framingham Risk Score gt10 Risk calculator is available at [httphp2010nhlbihinnetatpiiicalculatorasp]
(6) Fire fighters identified in 9431
Negative stress tests should be repeated as clinically indicated or at least every 2 to 5 years
Interpreting stress tests as ldquopositiverdquo or ldquonegativerdquo is beyond the scope of this document However factors that should be taken into consideration should include the individualrsquos exercise capacity symptoms blood pressure response heart rate response EKG changes and the presence of arrhythmias (Gibbon et al 2002)
Risk factors for CAD include hypercholesterolemia (total cholesterol greater than 240 mgdL) hypertension (systolic greater than 140 andor diastolic greater than 90) smoking diabetes mellitus or family history of premature CAD (heart attack or sudden cardiac death in a first degree relative less than 60 years of age)
There are other non-invasive tests to screen for coronary artery disease One of the most promising appears to be coronary artery calcium (CAD) scoring by computed tomography In 2007 an expert committee published an update to their original guidance document The committeersquos consensus was that ldquoit may be reasonable to consider use of CAC measurement in such patients [between 10 and 20 10-year risk of estimated coronary event]helliprdquo The committee did not recommend CAC measurement in low risk patients [lt10 10-year risk of estimated coronary event] or in high risk patients [gt20 10-year risk of estimate coronary event] (Greenland et al 2007]
43
D22 Cardiology
Chobanian AV Bakris GL Black HR Cushman WC Green LA Izzo JL Jr Jones DW Materson BJ Oparil S Wright JT Jr Roccella EJ the National High Blood Pressure Education Program Coordinating Committee [2003] The seventh report of the Joint National Committee [JNC-7] on Prevention Detection Evaluation and Treatment of High Blood Pressure JAMA 2892560ndash2571
Gibbons RJ Balady GJ Bricker JT Chaitman BR Fletcher GF Froelicher VF Mark DB McCallister BD Mooss AN OrsquoReilly MG Winters WL Jr [2002] ACCAHA 2002 guideline update for exercise testing summary article a report of the ACCAHA Task Force on Practice Guidelines (Committee to Update the 1997 Exercise Testing guidelines) J Am Coll Cardiol 401531ndash 1540
Greenland et al [2007] ACCFAHA 2007 Clinical Expert Consensus Document on Coronary Artery Calcium Scoring By Computed Tomography in Global Cardiovascular Risk Assessment and in Evaluation of Patients With Chest Pain A Report of the American College of Cardiology Foundation Clinical Expert Consensus Task Force (ACCFAHA Writing Committee to Update the 2000 Expert Consensus Document on Electron Beam Computed Tomography) J Am Coll Cardiol 49378-402
Kales SN Tsismenakis AJ Zhang C Soteriades ES [2009] Blood pressure in fire fighters police officers and other emergency responders Am J Hypertens 2211-20
Schlant RC Adolph RJ DiMarco JP Dreifus LS Dunn MI Fisch C Garson A Jr Haywood LJ Levine HJ Murray JA Noble RJ Ronan JA Jr [1992] Guidelines for electrocardiography A report of the American College of CardiologyAmerican Heart Association Task Force on Assessment of Diagnostic and Therapeutic Cardiovascular Procedures (Committee on Electrocardiography) Circulation 85(3)1221-1228
Soteriades ES Kales SN Liarokapis D Christiani DC [2003] Prospective surveillance of hypertension in firefighters J Clin Hypertens 5315-320
Formatted Font Italic
Formatted Line spacing single
Formatted Font Italic
Formatted Font Italic
44
NFPA 1582‐ Draft Revisions for CVDHTN
EKG and stress tests
Reason for Revision
1) Change requirement for annual resting EKG to periodically to be more consistent with ACCAHA
recommendation (Schlant et al 1992)
2) Add language to clarify what constitutes a positive ST
3) Make criteria for conducting diagnostic ST in asymptomatic patients consistent with the
ACCAHA
Language in 2007 Edition with draft revisions in Red (Track changes)
776 Electrocardiograms (EKG) and Stress Tests 7761 A resting EKG shall be performed as part of the baseline medical evaluation and shall be obtained periodically (every 1 to 5 years) thereafter
A7761 A baseline resting EKGs shall be conducted Follow-up resting EKGs should be conducted as clinically indicated but at a minimum of every 1 to 5 years The frequency of these follow-up resting EKGs should increase as a members age increases or with increasing number andor severity of coronary heart disease risk factors Members above the age of 40 should have annual resting EKGs (Schlant et al 1992)
7762 The fire department physician or other qualified medical evaluator shall compare baseline and subsequent EKGs
7763 Stress testing with or without echocardiography or radionuclide scanning shall be performed as clinically indicated by history or symptoms
A7763 No firm guidelines for stress testing in asymptomatic individuals have been developed Stress testing as a screening tool is used as part of an evaluation of aerobic capacity during the annual occupational fitness evaluation Submaximal stress testing testing to 85 percent is commonly used as part of this screening
Submaximal stress testing should not be used for diagnostic purposes Cardiology evaluation with maximal stress testing together with imaging techniques (eg echocardiography technetium Tc99m sestamibi study) is necessary for diagnosticprognostic purposes for the following
(1) Fire fighters with positive or questionably positive changes on screening submaximal stress tests
(2) Fire fighters with new onset chest pain or other symptoms suggestive of coronary artery disease (CAD)
45
(3) Fire fighters with diabetes mellitus who
(a) are gt35 years old or
(b) have type I diabetes for more than 15 years or
(c) have type II diabetes for more than 10 years or
(d) have any other CHD risk factor (see below) or
(e) have the presence of microvascular disease (proliferative retinopathy)
(4) Fire fighters over the age of 45 (for men) and 55 (for women) with one or more risk factors for CAD Risk factors for CAD include hypercholesterolemia (total cholesterol greater than 240 mgdL) hypertension (systolic gt140 mmHg or diastolic gt90 mmHg) smoking or family history of premature CAD (heart attack or sudden cardiac death in a first degree relative less than 60 years of age)
(5) Fire fighters with a Framingham Risk Score gt10 Risk calculator is available at [httphp2010nhlbihinnetatpiiicalculatorasp]
(6) Fire fighters identified in 9431
Negative stress tests should be repeated as clinically indicated or at least every 2 to 5 years
Interpreting stress tests as ldquopositiverdquo or ldquonegativerdquo is beyond the scope of this document However factors that should be taken into consideration should include the individualrsquos exercise capacity symptoms blood pressure response heart rate response EKG changes and the presence of arrhythmias (Gibbon et al 2002)
There are other non-invasive tests to screen for coronary artery disease One of the most promising appears to be coronary artery calcium (CAD) scoring by computed tomography In 2007 an expert committee published an update to their original guidance document The committeersquos consensus was that ldquoit may be reasonable to consider use of CAC measurement in such patients [between 10 and 20 10-year risk of estimated coronary event]helliprdquo The committee did not recommend CAC measurement in low risk patients [lt10 10-year risk of estimated coronary event] or in high risk patients [gt20 10-year risk of estimate coronary event] (Greenland et al 2007]
D22 Cardiology
Resting EKG and Stress Tests
46
Chobanian AV Bakris GL Black HR Cushman WC Green LA Izzo JL Jr Jones DW Materson BJ Oparil S Wright JT Jr Roccella EJ the National High Blood Pressure Education Program Coordinating Committee [2003] The seventh report of the Joint National Committee [JNC-7] on Prevention Detection Evaluation and Treatment of High Blood Pressure JAMA 2892560ndash2571
Gibbons RJ Balady GJ Bricker JT Chaitman BR Fletcher GF Froelicher VF Mark DB McCallister BD Mooss AN OrsquoReilly MG Winters WL Jr [2002] ACCAHA 2002 guideline update for exercise testing summary article a report of the ACCAHA Task Force on Practice Guidelines (Committee to Update the 1997 Exercise Testing guidelines) J Am Coll Cardiol 401531ndash 1540
Greenland et al [2007] ACCFAHA 2007 Clinical Expert Consensus Document on Coronary Artery Calcium Scoring By Computed Tomography in Global Cardiovascular Risk Assessment and in Evaluation of Patients With Chest Pain A Report of the American College of Cardiology Foundation Clinical Expert Consensus Task Force (ACCFAHA Writing Committee to Update the 2000 Expert Consensus Document on Electron Beam Computed Tomography) J Am Coll Cardiol 49378-402
Kales SN Tsismenakis AJ Zhang C Soteriades ES [2009] Blood pressure in fire fighters police officers and other emergency responders Am J Hypertens 2211-20
Schlant RC Adolph RJ DiMarco JP Dreifus LS Dunn MI Fisch C Garson A Jr Haywood LJ Levine HJ Murray JA Noble RJ Ronan JA Jr [1992] Guidelines for electrocardiography A report of the American College of CardiologyAmerican Heart Association Task Force on Assessment of Diagnostic and Therapeutic Cardiovascular Procedures (Committee on Electrocardiography) Circulation 85(3)1221-1228
Soteriades ES Kales SN Liarokapis D Christiani DC [2003] Prospective surveillance of hypertension in firefighters J Clin Hypertens 5315-320
47
ATTACHMENT F
48
1
Current 1582 (2007) language in reference to pregnancy 43 (4) Report to the fire department physician any medical condition that could interfere with the ability of the individual to safely perform essential job tasks such as illness or injury use of prescription or nonprescription drugs and pregnancy 6112 Category B medical conditions shall include the following (1) Pregnancy for its duration A7792 (e) If HIV prophylaxis is to be given the following tests should be done i CBC ii Glucose renal and hepatic chemical function iii Pregnancy test for females B121 Pregnancy and Reproduction Federal regulations as well as many court decisions including the US Supreme Courtrsquos decision in International Union et al v Johnson Controls Inc [499 US 187 111 S Ct 1196 (1991)] have interpreted the requirements of Title VII with respect to pregnancy and reproduction The AHJ should seek the advice of counsel in resolving specific questions concerning these requirements as well as other requirements that can be imposed by state or local laws C211 (4) Review health status with the individual being evaluated Contraindications for evaluations shall be reviewed addressing any changes in the individualrsquos health status since their last medical evaluation that would warrant deferring the evaluation including (g) Pregnancy Recommendations to language enhancement
A female employee who is assigned to regular fire line duty shall report a pregnancy immediately to their respective Supervisor and the fire department physician The employee will then be given the option of a non-hazardous alternative duty position for the duration of her pregnancy (can we say this or is it even appropriate) Any pregnant employee wishing to remain on regular line duty shall be informed of the possible risks and consequences to herself and her fetus that are associated with continued line fire fighting duty Among those risk factors are exposure to teratogens known to have negative effects on the developing fetus such as smoke diesel fumes hazardous chemicals and extreme heat
49
Page 2
appendix It is recommended that the pregnant employee complete a release of liability form signed by herself and her health care provider utilizing NFPArsquos 13 critical tasks as a reference This will inform the health care provider of specific job-related tasks that will need to be performed in order to continue regular line duty These tasks are basic physical standards that any entry level firefighter would have to be able to complete competently The employeersquos health condition will be kept confidential by the department in accordance with HIPAA standards Employees are allowed to remain on active regular duty until they are no longer able to perform their duties in a reasonable manner andor their protective gear no longer fits correctly It is the responsibility of the health care provider to evaluate the pregnant employee If at any time the health care provider feels the pregnant employee can no longer perform the job related tasks this should be reported to the employer by the employee immediately
50
ATTACHMENT G
51
From GLENN BENARICKTo Sawyer SteveSubject RE RE 7743Date Monday August 30 2010 21633 PM
Yes thats my understanding
Glenn P Benarick 211 Winged Elm CircleAiken SC 29803803-644-7093gbenarprodigynet
--- On Mon 83010 Sawyer Steve ltssawyerNFPAorggt wrote
From Sawyer Steve ltssawyerNFPAorggtSubject RE RE 7743To GLENN BENARICK ltgbenarprodigynetgtDate Monday August 30 2010 212 PM
So it should be ldquoorrdquo instead of ldquoandrdquo for now
Steven F Sawyer
Senior Fire Service Specialist
Executive Secretary IFMAFire Service Section
NFPA
1 Batterymarch Park
Quincy MA 02169
6179847423
Fax 6179847056
ssawyernfpaorg
From GLENN BENARICK [mailtogbenarprodigynet] Sent Monday August 30 2010 1202 PMTo Sawyer SteveSubject Fw RE 7743
52
Steve a couple of our docs agree with April Boyer
Glenn P Benarick 211 Winged Elm Circle
Aiken SC 29803
803-644-7093
gbenarprodigynet
--- On Mon 83010 David Prezant ltprezandfdnynycgovgt wrote
From David Prezant ltprezandfdnynycgovgtSubject RE 7743To Thomas R (CDCNIOSHDSHEFS) Hales lttrh1cdcgovgt GLENNBENARICK ltgbenarprodigynetgtCc Sandy Bogucki ltsandyboguckiyaleedugtDate Monday August 30 2010 1004 AM
agree
we should change this to NHANES III rather than Knudson we should alsomodify this to allow not only for predicted cutoffs but all for use of thelower limit of normal cutoff This is important to prevent false-classificationof spirometry as abnormal in older groups and in taller grps The latter ofparticular import to firefighter occupational health surveillance
thanks
David Prezant MDChief Medical Officer Office of Medical AffairsCo-Director WTC Medical Monitoring amp Treatment ProgramsNew York City Fire Department9 Metrotech Center - Rm 4W-1Brooklyn NY 11201Phone 718-999-2696Fax 718-999-0665
Life is full of twists and turns
53
This email may contain confidential information If you are the unintendedrecipient of this email please send it back and delete from your directory
gtgtgt Hales Thomas R (CDCNIOSHDSHEFS) lttrh1cdcgovgt 8302010955 AM gtgtgt
Glen
This seems like a very reasonable comment and illustrates the importance of having clinicians providefeedback on the std Im not familiar with the software program of the various spirometers (NHANES IIIvs KnudsonATS vs both) Given the large role both Dave Prezant and Sandy Bogucki had for thepulmonary section let me forward to them for clarification
Tom
From GLENN BENARICK [mailtogbenarprodigynet] Sent Sunday August 29 2010 456 PMTo Hales Thomas R (CDCNIOSHDSHEFS)Subject FW 7743
Tom is April Boyer correct
Glenn P Benarick 211 Winged Elm Circle
Aiken SC 29803
803-644-7093
gbenarprodigynet
--- On Thu 82610 Sawyer Steve ltssawyerNFPAorggt wrote
From Sawyer Steve ltssawyerNFPAorggtSubject FW 7743To GLENN BENARICK ltgbenarprodigynetgtDate Thursday August 26 2010 925 PM
FYI Do you have any answer She is write
Steven
54
Steven F Sawyer
Senior Fire Service Specialist
Executive Secretary IFMAFire Service Section
NFPA
1 Batterymarch Park
Quincy MA 02169
6179847423
Fax 6179847056
ssawyernfpaorg
From April Boyer [mailtoaboyerbicclinicorg] Sent Thursday August 26 2010 232 PMTo Sawyer SteveCc RobinMWebbmilstateorusSubject 7743
Steven
The spirometry tests cannot be corrected according to both references as the NFPA states because thereferences are contradictory The first part of 7743 states to follow the ATS guidelines and use theKnudsen (we at Basin Immediate Care use the Nhanes III) The second part states to follow the ACOEMguidelines and use the Nhanes III in the occupational setting if available with your unit (which is availableon ours) 7743 does not use the word OR regarding both requirements it uses the word AND whenreferring to the first and second parts thence making 7743 contradictory I realize the NFPA 1582 hasnot been updated since 2007 unless I have just not received an updated version
Our question to you is which part of 7743 do you want us to follow the first or the second part Anyfacility that has an updated computerized spirometry system (as we do) will not be able to follow bothrequired parts for obvious reasons We can either follow the first part of 7743 and use an oldercorrected version of the Knudson by going into our system and changing out of the Nhanes III conversionOR we can follow the second part of 7743 and use the newer corrected version of Nhanes III which ourunit offers too
If you have any questions you may contact me at anytime and I also have many references in regards toboth parts of 7743 if you would like to see them
55
Thank you~
April
Confidentiality NoticeThis message may contain information that isconfidential or privileged
If you are not the intended recipientPlease advise the sender immediately and delete this message
56
ATTACHMENT H
57
NFPA 1582 771(7) Proposed revisions
Why
Preliminary results of two prospective randomized trials on the PSA test were published in 2009 These studies resulted in medical organizations that previously providing guidance to modify their recommendations
Current language
771 Blood Tests Blood tests shall be performed annually and shall include the following
(7) Prostate specific antigen (PSA) after age 40 for positive family history if African American or if otherwise clinically indicated after age 50 for all other male member
Suggested Revision
771 Blood Tests Blood tests shall be performed annually and shall include the following
(7) Prostate specific antigen (PSA) after age 40 for positive family history if African American or if otherwise clinically indicated after age 50 for all other male member
772 Prostate-Specific Antigen (PSA) test At age 50 fire fighters shall have an opportunity to make an informed decision with either the Fire Department physician or their health care provider concerning the PSA test For fire fighters at increased risk of prostate cancer (African-Americans or those with a first degree relative diagnosed with prostate cancer before age 65) shall have the opportunity for this informed decision at age 40
A772 The PSA as a screening test for prostate cancer in asymptomatic men is controversial controversial for two reasons First there is no consensus that PSA screening actually saves lives For example the PSA test may detect small cancers that would never become life threatening Second it is unclear that the benefits of PSA screening outweigh the risks of follow-up diagnostic tests and cancer treatments For example the prostate biopsy used to diagnose prostate cancer may cause bleeding and infection And prostate cancer treatments such as surgery and radiation therapy may cause incontinence (inability to control urine flow) erectile dysfunction (erections inadequate for intercourse) and other complications For these reasons it is important that the benefits and risks of prostate diagnostic procedures and treatment be taken into account when considering the PSA screening test These considerations can be taken account during discussions with the fire department physician or onersquos health care provider
D211 Cancer Screening
Smith R A C J Mettlin K J Davis and H Eyre 2000 ldquoAmerican Cancer Society guidelines for the early detection of cancerrdquo CA J Clin 50(1)34ndash49
Added references
58
Carroll P Albertsen PC Greene K et al [2010] Prostate-specific antigen best practice statement 2009 update Am Urological Assoc Available at httpwwwauanetorgcontentguidelines-and-quality-careclinical-guidelinesmain-reportspsa09pdf Date accessed September 2010
Ferrini R Woolf SH [2009] Screening for prostate cancer in American men American College of Preventive Medicine Practice Policy Statement Available at httpwwwacpmorgprostatehtm Date accessed September 2010
National Cancer Institute [2009] Prostate-specific antigen test National Cancer Institute Fact Sheet Available at httpwwwcancergovcancertopicsfactsheetDetectionPSA Date accessed September 2010
Wolf AMD Wender RC Etzioni RB et al [2010] American Cancer Society guideline for the early detection of prostate cancer Update 2010 Available at httpcaonlineamcancersocorgcgicontentfullcaac20066v1 Date accessed September 2010
59
Typos A6921(2) 7th line down test should be plural 94201 Paragraph 2 target organ damage is used though end organ damage was defined earlier and in the appendix for that paragraph
A94201 Para A (1) d Id suggest deleting the phrases in brackets Im not sure either are predictably true or politically wise
a) tests for left ventricular hypertrophy Unfortunately use of the EKG to detect left ventricular hypertrophy is very insensitive (eg 5 sensitivity) The echocardiogram is the best test for diagnosing left ventricular hypertrophy but [it is relatively expensive and not readily available in small rural communities ] conducting echocardiograms on asymptomatic fire fighters with Stage 1 hypertension should be reserved only for those with long-standing hypertension
In addition
7761 A resting EKG shall be performed as part of the baseline medical evaluation and shall be obtained periodically thereafter
Changing from annually to periodically is noted has the language in the wellness-fitness initiative been changed as well Our previous decision was that we would support the W-F language since there was no compelling evidence to either support or refute it
Thanks
Sandy
32
NFPA 1582‐ HTN Draft 1
Reason for Revision
1) New classification of BP by the Joint National Commission [Chobanian et al 2002]
2) A high prevalence of FF have either HTN (~20) and Pre‐HTN (~20) [Soteriades et al 2003]
3) Among FF studies have shown a strong association between HTN and a number of adverse
cardiovascular events [Kales et al 2009]
4) A large percentage of on‐duty FF fatalities were found to have left ventricular hypertrophy a
complication of HTN at autopsy
Language in 2007 Edition with draft revisions in Red (Track changes)
611 The medical evaluation of a candidate shall include a medical history examination and any laboratory tests required to detect physical or medical condition(s) that could adversely affect hisher ability to safely perform the essential job tasks outlined in 511 A611 The medical history should include the candidates known health problems such as major illnesses surgeries medication use and allergies Symptom review is also important for detecting early signs of illness A medical history should also include a personal health history a family health history a health habit history an immunization history and a reproductive history
An occupational history should also be obtained to collect information about the persons past occupational and environmental exposures
(a) BP should be measured according to the Joint National Commission (JNC) -7 recommendations BP should be measured with a properly calibrated and validated instrument Patients should be seated quietly for at least 5 minutes in a chair with feet on the floor and arm supported at heart level An appropriate-sized cuff (cuff bladder encircling at least 80 of the arm) should be used to ensure accuracy At least 2 measurements should be made Systolic BP is the point at which the first of 2 or more sounds is heard (phase 1) and diastolic BP is the point before the disappearance of sounds (phase 5) [Chobanian et al 2003]
(2) Head eyes ears nose and throat (HEENT)
Formatted Font (Default) Times New RomanFont color Black
33
692 Vascular System 6921 Category A medical conditions shall include the following
(1) Uncontrolled or poorly controlled hypertension
(2) Hypertension with evidence of end organ damage
or not controlled by approved medications
A6921(1) Uncontrolled or poorly controlled hHypertension increases the risk of a sudden cardiac event This sudden cardiac event would cause sudden incapacitation which that is uncontrolled poorly controlled or requires medication likely to interferes with the safe performance of essential job tasks Uncontrolled or poorly controlled hypertension can be defined as the presence of end organ damage (see below) or stage 2 hypertension (BP systolic gt160 mmHg or BP diastolic gt100 mmHg) is an illness that can lead to functional impairment and potential for sudden incapacitation Individuals with pre- stage 1 or stage 2 hypertension should be referred to their primary care physician for evaluation lifestyle modification and treatment [QUESTION FOR GROUP _- WHAT ABOUT HAVING CANDIDATE RETURN IN ONE MONTH UNDER TREATMENT WITH NORMAL BP]
A6921(2)
Chronic hypertension can damage the eye (retinopathy) the kidneys (nephropathy) the vascular system (stroke transient ischemic attack or peripheral artery disease) or the heart (left ventricular hypertrophy and heart failure) These hypertension complications are known as end organ damage The cardiac and vascular complications are associated with an increased risk of sudden incapacitation and sudden cardiac death (Koren et al 1991) Unfortunately the cardiac complications are frequently asymptomatic and valid screening tests are not fast and are not inexpensive Therefore determining who to screen for cardiac complications (such as echocardiogram for LVH or a measurement of left ventricular ejection fraction for heart failure) should be based on the severity and the duration of HTN
76 Physical Examination The annual physical examination shall include each of the following components
(a) BP shall be measured according to the Joint National Commission (JNC)-7 recommendations
A76(1)(a) BP should be measured with a properly calibrated and validated instrument Patients should be seated quietly for at least 5 minutes in a chair with feet on the floor and arm supported at heart level An appropriate-sized cuff (cuff bladder encircling at least 80 of the arm) should be used to ensure accuracy At least 2 measurements should be made Systolic BP is the point at which the first of 2 or more sounds is heard (phase 1) and diastolic BP is the point before the disappearance of sounds (phase 5) [Chobanian et al 2003]
(2) Head eyes ears nose and throat (HEENT)
34
9420 Uncontrolled Hypertension 94201 Physician Evaluation Severe uncontrolled hypertension [defined as systolic pressure greater than 180 mm Hg diastolic pressure greater than 100 mm Hg or mean systolic blood
pressure ( systolic + diastolic) greater than 120 mm Hg] or malignant hypertension (defined as hypertension with the presence of target organ damage) compromises the members ability to safely perform essential job tasks 1 5 7 9 and 13 and the physician shall report the applicable job limitations to the fire department
Members with Pre-hypertention (systolic 120-139 mmHg or diastolic 80-89 mmHg) Stage 1 hypertension (systolic 140-159 mmHg or diastolic 90-99 mmHg) or Stage 2 hypertension (systolic ge160 mmHg or diastolic ge100 mmHg) should be referred to their primary care physician for evaluation lifestyle modification and treatment
(1) Members with Stage I hypertension should be followed-up not only by their primary care physician but also by the FD physician every 3 to 6 months to ensure their blood pressure is under control and to determine whether screening tests for asymptomatic end organ damage are appropriate
(2) Members with Stage 2 hypertension or with end organ damage (retinopathy nephropathy vascular or cardiac complications) compromises the members ability to safely perform essential job tasks 1 5 7 9 and 130 and the physician shall report the applicable job limitations to the fire department
A94201 Severe uncontrolled hypertension is a significant risk factor for the development of coronary artery disease congestive heart failure and stroke Blood pressure increases as a normal response to exercise This response is further exaggerated by the emotional and physical stress of performing these critical tasks while operating in personal protective clothing at extremes of temperature This normal elevation of blood pressure under these response conditions can lead to life-threatening hypertensive emergencies if a members daily blood pressure is already elevated to high levels In addition hypertension is a progressive illness that when uncontrolled ultimately and inevitably leads to target organ damage Target organs that are sensitive to the effects of elevated blood pressure are the central nervous system vision heart major blood vessels and kidneys
Chronic hypertension can damage the eye (retinopathy) the kidneys (nephropathy) the vascular system (stroke transient ischemic attack or peripheral artery disease) or the heart (left ventricular hypertrophy and heart failure) These hypertension complications are known as end organ damage The cardiac and vascular complications are associated with an increased risk of sudden incapacitation and sudden cardiac death (Koren et al 1991) Fortunately with proper evaluation life style modification and treatment these complications can be avoided Life style modification includes weight reduction DASH eating plan reduction in dietary sodium an increase in aerobic physical activity and moderation in alcohol consumption [Chobanian 2003]
Formatted Font (Default) Times New Roman12 pt Font color Black
Formatted Font (Default) Times New Roman12 pt Font color Black
35
A94201 (1) Members with Stage I hypertension whose BP returns to either pre-hypertenion or normal with lifestyle modification andor treatment can return to an annual medical evaluation For members with long-standing Stage I hypertension whose BP has not been reduced additional evaluation for possible end organ damage should be considered This evaluation could include any or all of the following
a) a compete patient history for symptoms of heart failure (eg shortness of breath upon exertion) or transient ischemic attacks (TIAs)
b) dilated eye examination for retinopathy
c) blood creatinine measurement for nephropathy
d) tests for left ventricular hypertrophy Unfortunately use of the resting EKG to detect left ventricular hypertrophy is very insensitive (eg 5 sensitivity) The echocardiogram is the best test for diagnosing left ventricular hypertrophy
A 94201 (2) Due to the high risk of a sudden cardiovascular event members with Stage 2 hypertension should be restricted until their BP can be brought under control Once the BP is brought under control they should be followed in the same manner as a member with Stage I hypertension
Formatted Font (Default) Times New Roman12 pt
36
D22 Cardiology Gibbons R J GJ Balady J W Beasley et al 1997 ACCAHA guidelines for exercise testing a report of American College of CardiologyAmerican Heart Association Task Force on Practice Guidelines (Committee on Exercise Testing) J Am Coll Cardiol 30260ndash311
Gibbons RJ Balady GJ Bricker JT Chaitman BR Fletcher GF Froelicher VF Mark DB McCallister BD Mooss AN OrsquoReilly MG Winters WL Jr [2002] ACCAHA 2002 guideline update for exercise testing summary article a report of the ACCAHA Task Force on Practice Guidelines (Committee to Update the 1997 Exercise Testing guidelines) J Am Coll Cardiol 401531ndash 40
Chobanian AV Bakris GL Black HR Cushman WC Green LA Izzo JL Jr Jones DW Materson BJ Oparil S Wright JT Jr Roccella EJ the National High Blood Pressure Education Program Coordinating Committee [2003] The seventh report of the Joint National Committee [JNC-7] on Prevention Detection Evaluation and Treatment of High Blood Pressure JAMA 2892560ndash2571
Soteriades ES Kales SN Liarokapis D Christiani DC [2003] Prospective surveillance of hypertension in firefighters J Clin Hypertens 5315-320
Kales SN Tsismenakis AJ Zhang C Soteriades ES [2009] Blood pressure in fire fighters police officers and other emergency responders Am J Hypertens 2211-20
37
NFPA 1582‐ HTN Draft 1
Reason for Revision
1) New classification of BP by the Joint National Commission [Chobanian et al 2002]
2) A high prevalence of FF have either HTN (~20) and Pre‐HTN (~20) [Soteriades et al 2003]
3) Among FF studies have shown a strong association between HTN and a number of adverse
cardiovascular events [Kales et al 2009]
4) A large percentage of on‐duty FF fatalities were found to have left ventricular hypertrophy a
complication of HTN at autopsy
Language in 2007 Edition with draft revisions in Red (Track changes)
611 The medical evaluation of a candidate shall include a medical history examination and any laboratory tests required to detect physical or medical condition(s) that could adversely affect hisher ability to safely perform the essential job tasks outlined in 511 A611 The medical history should include the candidates known health problems such as major illnesses surgeries medication use and allergies Symptom review is also important for detecting early signs of illness A medical history should also include a personal health history a family health history a health habit history an immunization history and a reproductive history
An occupational history should also be obtained to collect information about the persons past occupational and environmental exposures
(a) BP should be measured according to the Joint National Commission (JNC) -7 recommendations BP should be measured with a properly calibrated and validated instrument Patients should be seated quietly for at least 5 minutes in a chair with feet on the floor and arm supported at heart level An appropriate-sized cuff (cuff bladder encircling at least 80 of the arm) should be used to ensure accuracy At least 2 measurements should be made Systolic BP is the point at which the first of 2 or more sounds is heard (phase 1) and diastolic BP is the point before the disappearance of sounds (phase 5) [Chobanian et al 2003]
(2) Head eyes ears nose and throat
38
692 Vascular System 6921 Category A medical conditions shall include the following
(1) Uncontrolled or poorly controlled hypertension
(2) Hypertension with evidence of end organ damage
A6921(1) Uncontrolled or poorly controlled hypertension increases the risk of a sudden cardiac event This sudden cardiac event would cause sudden incapacitation which interferes with the safe performance of essential job tasks Uncontrolled or poorly controlled hypertension can be defined as the presence of end organ damage (see below) or stage 2 hypertension (BP systolic gt160 mmHg or BP diastolic gt100 mmHg) Individuals with pre- stage 1 or stage 2 hypertension should be referred to their primary care physician for evaluation lifestyle modification and treatment [QUESTION FOR GROUP _- WHAT ABOUT HAVING CANDIDATE RETURN IN ONE MONTH UNDER TREATMENT WITH NORMAL BP]
A6921(2)Chronic hypertension can damage the eye (retinopathy) the kidneys (nephropathy) the vascular system (stroke transient ischemic attack or peripheral artery disease) or the heart (left ventricular hypertrophy and heart failure) These hypertension complications are known as end organ damage The cardiac and vascular complications are associated with an increased risk of sudden incapacitation and sudden cardiac death (Koren et al 1991) Unfortunately the cardiac complications are frequently asymptomatic and valid screening tests are not fast and are not inexpensive Therefore determining who to screen for cardiac complications (such as echocardiogram for LVH or a measurement of left ventricular ejection fraction for heart failure) should be based on the severity and the duration of HTN
76 Physical Examination The annual physical examination shall include each of the following components
(a) BP shall be measured according to the Joint National Commission (JNC)-7 recommendations
A76(1)(a) BP should be measured with a properly calibrated and validated instrument Patients should be seated quietly for at least 5 minutes in a chair with feet on the floor and arm supported at heart level An appropriate-sized cuff (cuff bladder encircling at least 80 of the arm) should be used to ensure accuracy At least 2 measurements should be made Systolic BP is the point at which the first of 2 or more sounds is heard (phase 1) and diastolic BP is the point before the disappearance of sounds (phase 5) [Chobanian et al 2003]
(2) Head eyes ears nose and throat9420 Hypertension 94201 Physician Evaluation Members with Pre-hypertention (systolic 120-139 mmHg or diastolic 80-89 mmHg) Stage 1 hypertension (systolic 140-159 mmHg or diastolic 90-99 mmHg) or Stage 2 hypertension (systolic ge160 mmHg or diastolic ge100 mmHg) should be referred to their primary care physician for evaluation lifestyle modification and treatment
39
(1) Members with Stage I hypertension should be followed-up not only by their primary care physician but also by the FD physician every 3 to 6 months to ensure their blood pressure is under control and to determine whether screening tests for asymptomatic end organ damage are appropriate
(2) Members with Stage 2 hypertension or with end organ damage (retinopathy nephropathy vascular or cardiac complications) compromises the members ability to safely perform essential job tasks 1 5 7 9 and 130 and the physician shall report the applicable job limitations to the fire department
A94201 Chronic hypertension can damage the eye (retinopathy) the kidneys (nephropathy) the vascular system (stroke transient ischemic attack or peripheral artery disease) or the heart (left ventricular hypertrophy and heart failure) These hypertension complications are known as end organ damage The cardiac and vascular complications are associated with an increased risk of sudden incapacitation and sudden cardiac death (Koren et al 1991) Fortunately with proper evaluation life style modification and treatment these complications can be avoided Life style modification includes weight reduction DASH eating plan reduction in dietary sodium an increase in aerobic physical activity and moderation in alcohol consumption [Chobanian 2003]
A94201 (1) Members with Stage I hypertension whose BP returns to either pre-hypertenion or normal with lifestyle modification andor treatment can return to an annual medical evaluation For members with long-standing Stage I hypertension whose BP has not been reduced additional evaluation for possible end organ damage should be considered This evaluation could include any or all of the following
a) a compete patient history for symptoms of heart failure (eg shortness of breath upon exertion) or transient ischemic attacks (TIAs)
b) dilated eye examination for retinopathy
c) blood creatinine measurement for nephropathy
d) tests for left ventricular hypertrophy Unfortunately use of the resting EKG to detect left ventricular hypertrophy is very insensitive (eg 5 sensitivity) The echocardiogram is the best test for diagnosing left ventricular hypertrophy
A 94201 (2) Due to the high risk of a sudden cardiovascular event members with Stage 2 hypertension should be restricted until their BP can be brought under control Once the BP is brought under control they should be followed in the same manner as a member with Stage I hypertension
D22 Cardiology
40
Hypertension
Gibbons RJ Balady GJ Bricker JT Chaitman BR Fletcher GF Froelicher VF Mark DB McCallister BD Mooss AN OrsquoReilly MG Winters WL Jr [2002] ACCAHA 2002 guideline update for exercise testing summary article a report of the ACCAHA Task Force on Practice Guidelines (Committee to Update the 1997 Exercise Testing guidelines) J Am Coll Cardiol 401531ndash 40
Chobanian AV Bakris GL Black HR Cushman WC Green LA Izzo JL Jr Jones DW Materson BJ Oparil S Wright JT Jr Roccella EJ the National High Blood Pressure Education Program Coordinating Committee [2003] The seventh report of the Joint National Committee [JNC-7] on Prevention Detection Evaluation and Treatment of High Blood Pressure JAMA 2892560ndash2571
Soteriades ES Kales SN Liarokapis D Christiani DC [2003] Prospective surveillance of hypertension in firefighters J Clin Hypertens 5315-320
Kales SN Tsismenakis AJ Zhang C Soteriades ES [2009] Blood pressure in fire fighters police officers and other emergency responders Am J Hypertens 2211-20
41
NFPA 1582‐ Draft Revisions for CVDHTN
EKG and stress tests
Reason for Revision
1) Change requirement for annual resting EKG to periodically to be more consistent with ACCAHA
recommendation (Schlant et al 1992)
2) Add language to clarify what constitutes a positive ST
3) Make criteria for conducting diagnostic ST in asymptomatic patients consistent with the
ACCAHA
Language in 2007 Edition with draft revisions in Red (Track changes)
776 Electrocardiograms (EKG)) and Stress Tests 7761 A resting EKG shall be performed as part of the baseline medical evaluation and shall be obtained periodically (every 1 to 5 years) annually thereafter
A7761 A baseline resting EKGs shall be conducted Follow-up resting EKGs should be conducted as clinically indicated but at a minimum of every 1 to 5 years The frequency of these follow-up resting EKGs should increase as a members age increases or with increasing number andor severity of coronary heart disease risk factors Members above the age of 40 should have annual resting EKGs (Schlant et al 1992)
7762 The fire department physician or other qualified medical evaluator shall compare EKGs obtained during yearly evaluations with baseline and subsequent EKGs
7763 Stress testing EKG with or without echocardiography or radionuclide scanning shall be performed as clinically indicated by history or symptoms
A7761 Baseline electrocardiography should be conducted (Periodic resting electrocardiograms have not been shown to be useful but can be reasonable as a members agefactors increase)
A7763 No firm guidelines for stress testingelectrocardiography in asymptomatic individuals have been developed Stress testingelectrocardiography as a screening tool is used as part of an evaluation of aerobic capacity during the annual occupational fitness evaluation Submaximal stress testingelectrocardiography testing to 85 percent is commonly used as part of this screening
Submaximal stress electrocardiography testing should not be used for diagnostic purposes Cardiology evaluation with maximal stress testingelectrocardiography together with imaging techniques (eg echocardiography technetium Tc99m sestamibi study andor coronary angiography) is necessary for diagnosticprognostic purposes for the following
42
(1) Fire fighters with positive or questionably positive changes on screening submaximal stress tests
(2) Fire fighters with new onset chest pain or other symptoms suggestive of coronary artery disease (CAD)
(3) Fire fighters with diabetes mellitus who
(a) are gt35 years old or
(b) have type I diabetes for more than 15 years or
(c) have type II diabetes for more than 10 years or
(d) have any other CHD risk factor (see below) or
(e) have the presence of microvascular disease (proliferative retinopathy)
(4) Fire fighters over the age of 45 (for men) and 55 (for women) with onetwo or more risk factors for CAD Risk factors for CAD include hypercholesterolemia (total cholesterol greater than 240 mgdL) hypertension (systolic gt140 mmHg or diastolic gt90 mmHg) smoking or family history of premature CAD (heart attack or sudden cardiac death in a first degree relative less than 60 years of age)
as defined below if stress electrocardiography with imaging is negative then repeat as clinically indicated or at least every 5 years
(5) Fire fighters with a Framingham Risk Score gt10 Risk calculator is available at [httphp2010nhlbihinnetatpiiicalculatorasp]
(6) Fire fighters identified in 9431
Negative stress tests should be repeated as clinically indicated or at least every 2 to 5 years
Interpreting stress tests as ldquopositiverdquo or ldquonegativerdquo is beyond the scope of this document However factors that should be taken into consideration should include the individualrsquos exercise capacity symptoms blood pressure response heart rate response EKG changes and the presence of arrhythmias (Gibbon et al 2002)
Risk factors for CAD include hypercholesterolemia (total cholesterol greater than 240 mgdL) hypertension (systolic greater than 140 andor diastolic greater than 90) smoking diabetes mellitus or family history of premature CAD (heart attack or sudden cardiac death in a first degree relative less than 60 years of age)
There are other non-invasive tests to screen for coronary artery disease One of the most promising appears to be coronary artery calcium (CAD) scoring by computed tomography In 2007 an expert committee published an update to their original guidance document The committeersquos consensus was that ldquoit may be reasonable to consider use of CAC measurement in such patients [between 10 and 20 10-year risk of estimated coronary event]helliprdquo The committee did not recommend CAC measurement in low risk patients [lt10 10-year risk of estimated coronary event] or in high risk patients [gt20 10-year risk of estimate coronary event] (Greenland et al 2007]
43
D22 Cardiology
Chobanian AV Bakris GL Black HR Cushman WC Green LA Izzo JL Jr Jones DW Materson BJ Oparil S Wright JT Jr Roccella EJ the National High Blood Pressure Education Program Coordinating Committee [2003] The seventh report of the Joint National Committee [JNC-7] on Prevention Detection Evaluation and Treatment of High Blood Pressure JAMA 2892560ndash2571
Gibbons RJ Balady GJ Bricker JT Chaitman BR Fletcher GF Froelicher VF Mark DB McCallister BD Mooss AN OrsquoReilly MG Winters WL Jr [2002] ACCAHA 2002 guideline update for exercise testing summary article a report of the ACCAHA Task Force on Practice Guidelines (Committee to Update the 1997 Exercise Testing guidelines) J Am Coll Cardiol 401531ndash 1540
Greenland et al [2007] ACCFAHA 2007 Clinical Expert Consensus Document on Coronary Artery Calcium Scoring By Computed Tomography in Global Cardiovascular Risk Assessment and in Evaluation of Patients With Chest Pain A Report of the American College of Cardiology Foundation Clinical Expert Consensus Task Force (ACCFAHA Writing Committee to Update the 2000 Expert Consensus Document on Electron Beam Computed Tomography) J Am Coll Cardiol 49378-402
Kales SN Tsismenakis AJ Zhang C Soteriades ES [2009] Blood pressure in fire fighters police officers and other emergency responders Am J Hypertens 2211-20
Schlant RC Adolph RJ DiMarco JP Dreifus LS Dunn MI Fisch C Garson A Jr Haywood LJ Levine HJ Murray JA Noble RJ Ronan JA Jr [1992] Guidelines for electrocardiography A report of the American College of CardiologyAmerican Heart Association Task Force on Assessment of Diagnostic and Therapeutic Cardiovascular Procedures (Committee on Electrocardiography) Circulation 85(3)1221-1228
Soteriades ES Kales SN Liarokapis D Christiani DC [2003] Prospective surveillance of hypertension in firefighters J Clin Hypertens 5315-320
Formatted Font Italic
Formatted Line spacing single
Formatted Font Italic
Formatted Font Italic
44
NFPA 1582‐ Draft Revisions for CVDHTN
EKG and stress tests
Reason for Revision
1) Change requirement for annual resting EKG to periodically to be more consistent with ACCAHA
recommendation (Schlant et al 1992)
2) Add language to clarify what constitutes a positive ST
3) Make criteria for conducting diagnostic ST in asymptomatic patients consistent with the
ACCAHA
Language in 2007 Edition with draft revisions in Red (Track changes)
776 Electrocardiograms (EKG) and Stress Tests 7761 A resting EKG shall be performed as part of the baseline medical evaluation and shall be obtained periodically (every 1 to 5 years) thereafter
A7761 A baseline resting EKGs shall be conducted Follow-up resting EKGs should be conducted as clinically indicated but at a minimum of every 1 to 5 years The frequency of these follow-up resting EKGs should increase as a members age increases or with increasing number andor severity of coronary heart disease risk factors Members above the age of 40 should have annual resting EKGs (Schlant et al 1992)
7762 The fire department physician or other qualified medical evaluator shall compare baseline and subsequent EKGs
7763 Stress testing with or without echocardiography or radionuclide scanning shall be performed as clinically indicated by history or symptoms
A7763 No firm guidelines for stress testing in asymptomatic individuals have been developed Stress testing as a screening tool is used as part of an evaluation of aerobic capacity during the annual occupational fitness evaluation Submaximal stress testing testing to 85 percent is commonly used as part of this screening
Submaximal stress testing should not be used for diagnostic purposes Cardiology evaluation with maximal stress testing together with imaging techniques (eg echocardiography technetium Tc99m sestamibi study) is necessary for diagnosticprognostic purposes for the following
(1) Fire fighters with positive or questionably positive changes on screening submaximal stress tests
(2) Fire fighters with new onset chest pain or other symptoms suggestive of coronary artery disease (CAD)
45
(3) Fire fighters with diabetes mellitus who
(a) are gt35 years old or
(b) have type I diabetes for more than 15 years or
(c) have type II diabetes for more than 10 years or
(d) have any other CHD risk factor (see below) or
(e) have the presence of microvascular disease (proliferative retinopathy)
(4) Fire fighters over the age of 45 (for men) and 55 (for women) with one or more risk factors for CAD Risk factors for CAD include hypercholesterolemia (total cholesterol greater than 240 mgdL) hypertension (systolic gt140 mmHg or diastolic gt90 mmHg) smoking or family history of premature CAD (heart attack or sudden cardiac death in a first degree relative less than 60 years of age)
(5) Fire fighters with a Framingham Risk Score gt10 Risk calculator is available at [httphp2010nhlbihinnetatpiiicalculatorasp]
(6) Fire fighters identified in 9431
Negative stress tests should be repeated as clinically indicated or at least every 2 to 5 years
Interpreting stress tests as ldquopositiverdquo or ldquonegativerdquo is beyond the scope of this document However factors that should be taken into consideration should include the individualrsquos exercise capacity symptoms blood pressure response heart rate response EKG changes and the presence of arrhythmias (Gibbon et al 2002)
There are other non-invasive tests to screen for coronary artery disease One of the most promising appears to be coronary artery calcium (CAD) scoring by computed tomography In 2007 an expert committee published an update to their original guidance document The committeersquos consensus was that ldquoit may be reasonable to consider use of CAC measurement in such patients [between 10 and 20 10-year risk of estimated coronary event]helliprdquo The committee did not recommend CAC measurement in low risk patients [lt10 10-year risk of estimated coronary event] or in high risk patients [gt20 10-year risk of estimate coronary event] (Greenland et al 2007]
D22 Cardiology
Resting EKG and Stress Tests
46
Chobanian AV Bakris GL Black HR Cushman WC Green LA Izzo JL Jr Jones DW Materson BJ Oparil S Wright JT Jr Roccella EJ the National High Blood Pressure Education Program Coordinating Committee [2003] The seventh report of the Joint National Committee [JNC-7] on Prevention Detection Evaluation and Treatment of High Blood Pressure JAMA 2892560ndash2571
Gibbons RJ Balady GJ Bricker JT Chaitman BR Fletcher GF Froelicher VF Mark DB McCallister BD Mooss AN OrsquoReilly MG Winters WL Jr [2002] ACCAHA 2002 guideline update for exercise testing summary article a report of the ACCAHA Task Force on Practice Guidelines (Committee to Update the 1997 Exercise Testing guidelines) J Am Coll Cardiol 401531ndash 1540
Greenland et al [2007] ACCFAHA 2007 Clinical Expert Consensus Document on Coronary Artery Calcium Scoring By Computed Tomography in Global Cardiovascular Risk Assessment and in Evaluation of Patients With Chest Pain A Report of the American College of Cardiology Foundation Clinical Expert Consensus Task Force (ACCFAHA Writing Committee to Update the 2000 Expert Consensus Document on Electron Beam Computed Tomography) J Am Coll Cardiol 49378-402
Kales SN Tsismenakis AJ Zhang C Soteriades ES [2009] Blood pressure in fire fighters police officers and other emergency responders Am J Hypertens 2211-20
Schlant RC Adolph RJ DiMarco JP Dreifus LS Dunn MI Fisch C Garson A Jr Haywood LJ Levine HJ Murray JA Noble RJ Ronan JA Jr [1992] Guidelines for electrocardiography A report of the American College of CardiologyAmerican Heart Association Task Force on Assessment of Diagnostic and Therapeutic Cardiovascular Procedures (Committee on Electrocardiography) Circulation 85(3)1221-1228
Soteriades ES Kales SN Liarokapis D Christiani DC [2003] Prospective surveillance of hypertension in firefighters J Clin Hypertens 5315-320
47
ATTACHMENT F
48
1
Current 1582 (2007) language in reference to pregnancy 43 (4) Report to the fire department physician any medical condition that could interfere with the ability of the individual to safely perform essential job tasks such as illness or injury use of prescription or nonprescription drugs and pregnancy 6112 Category B medical conditions shall include the following (1) Pregnancy for its duration A7792 (e) If HIV prophylaxis is to be given the following tests should be done i CBC ii Glucose renal and hepatic chemical function iii Pregnancy test for females B121 Pregnancy and Reproduction Federal regulations as well as many court decisions including the US Supreme Courtrsquos decision in International Union et al v Johnson Controls Inc [499 US 187 111 S Ct 1196 (1991)] have interpreted the requirements of Title VII with respect to pregnancy and reproduction The AHJ should seek the advice of counsel in resolving specific questions concerning these requirements as well as other requirements that can be imposed by state or local laws C211 (4) Review health status with the individual being evaluated Contraindications for evaluations shall be reviewed addressing any changes in the individualrsquos health status since their last medical evaluation that would warrant deferring the evaluation including (g) Pregnancy Recommendations to language enhancement
A female employee who is assigned to regular fire line duty shall report a pregnancy immediately to their respective Supervisor and the fire department physician The employee will then be given the option of a non-hazardous alternative duty position for the duration of her pregnancy (can we say this or is it even appropriate) Any pregnant employee wishing to remain on regular line duty shall be informed of the possible risks and consequences to herself and her fetus that are associated with continued line fire fighting duty Among those risk factors are exposure to teratogens known to have negative effects on the developing fetus such as smoke diesel fumes hazardous chemicals and extreme heat
49
Page 2
appendix It is recommended that the pregnant employee complete a release of liability form signed by herself and her health care provider utilizing NFPArsquos 13 critical tasks as a reference This will inform the health care provider of specific job-related tasks that will need to be performed in order to continue regular line duty These tasks are basic physical standards that any entry level firefighter would have to be able to complete competently The employeersquos health condition will be kept confidential by the department in accordance with HIPAA standards Employees are allowed to remain on active regular duty until they are no longer able to perform their duties in a reasonable manner andor their protective gear no longer fits correctly It is the responsibility of the health care provider to evaluate the pregnant employee If at any time the health care provider feels the pregnant employee can no longer perform the job related tasks this should be reported to the employer by the employee immediately
50
ATTACHMENT G
51
From GLENN BENARICKTo Sawyer SteveSubject RE RE 7743Date Monday August 30 2010 21633 PM
Yes thats my understanding
Glenn P Benarick 211 Winged Elm CircleAiken SC 29803803-644-7093gbenarprodigynet
--- On Mon 83010 Sawyer Steve ltssawyerNFPAorggt wrote
From Sawyer Steve ltssawyerNFPAorggtSubject RE RE 7743To GLENN BENARICK ltgbenarprodigynetgtDate Monday August 30 2010 212 PM
So it should be ldquoorrdquo instead of ldquoandrdquo for now
Steven F Sawyer
Senior Fire Service Specialist
Executive Secretary IFMAFire Service Section
NFPA
1 Batterymarch Park
Quincy MA 02169
6179847423
Fax 6179847056
ssawyernfpaorg
From GLENN BENARICK [mailtogbenarprodigynet] Sent Monday August 30 2010 1202 PMTo Sawyer SteveSubject Fw RE 7743
52
Steve a couple of our docs agree with April Boyer
Glenn P Benarick 211 Winged Elm Circle
Aiken SC 29803
803-644-7093
gbenarprodigynet
--- On Mon 83010 David Prezant ltprezandfdnynycgovgt wrote
From David Prezant ltprezandfdnynycgovgtSubject RE 7743To Thomas R (CDCNIOSHDSHEFS) Hales lttrh1cdcgovgt GLENNBENARICK ltgbenarprodigynetgtCc Sandy Bogucki ltsandyboguckiyaleedugtDate Monday August 30 2010 1004 AM
agree
we should change this to NHANES III rather than Knudson we should alsomodify this to allow not only for predicted cutoffs but all for use of thelower limit of normal cutoff This is important to prevent false-classificationof spirometry as abnormal in older groups and in taller grps The latter ofparticular import to firefighter occupational health surveillance
thanks
David Prezant MDChief Medical Officer Office of Medical AffairsCo-Director WTC Medical Monitoring amp Treatment ProgramsNew York City Fire Department9 Metrotech Center - Rm 4W-1Brooklyn NY 11201Phone 718-999-2696Fax 718-999-0665
Life is full of twists and turns
53
This email may contain confidential information If you are the unintendedrecipient of this email please send it back and delete from your directory
gtgtgt Hales Thomas R (CDCNIOSHDSHEFS) lttrh1cdcgovgt 8302010955 AM gtgtgt
Glen
This seems like a very reasonable comment and illustrates the importance of having clinicians providefeedback on the std Im not familiar with the software program of the various spirometers (NHANES IIIvs KnudsonATS vs both) Given the large role both Dave Prezant and Sandy Bogucki had for thepulmonary section let me forward to them for clarification
Tom
From GLENN BENARICK [mailtogbenarprodigynet] Sent Sunday August 29 2010 456 PMTo Hales Thomas R (CDCNIOSHDSHEFS)Subject FW 7743
Tom is April Boyer correct
Glenn P Benarick 211 Winged Elm Circle
Aiken SC 29803
803-644-7093
gbenarprodigynet
--- On Thu 82610 Sawyer Steve ltssawyerNFPAorggt wrote
From Sawyer Steve ltssawyerNFPAorggtSubject FW 7743To GLENN BENARICK ltgbenarprodigynetgtDate Thursday August 26 2010 925 PM
FYI Do you have any answer She is write
Steven
54
Steven F Sawyer
Senior Fire Service Specialist
Executive Secretary IFMAFire Service Section
NFPA
1 Batterymarch Park
Quincy MA 02169
6179847423
Fax 6179847056
ssawyernfpaorg
From April Boyer [mailtoaboyerbicclinicorg] Sent Thursday August 26 2010 232 PMTo Sawyer SteveCc RobinMWebbmilstateorusSubject 7743
Steven
The spirometry tests cannot be corrected according to both references as the NFPA states because thereferences are contradictory The first part of 7743 states to follow the ATS guidelines and use theKnudsen (we at Basin Immediate Care use the Nhanes III) The second part states to follow the ACOEMguidelines and use the Nhanes III in the occupational setting if available with your unit (which is availableon ours) 7743 does not use the word OR regarding both requirements it uses the word AND whenreferring to the first and second parts thence making 7743 contradictory I realize the NFPA 1582 hasnot been updated since 2007 unless I have just not received an updated version
Our question to you is which part of 7743 do you want us to follow the first or the second part Anyfacility that has an updated computerized spirometry system (as we do) will not be able to follow bothrequired parts for obvious reasons We can either follow the first part of 7743 and use an oldercorrected version of the Knudson by going into our system and changing out of the Nhanes III conversionOR we can follow the second part of 7743 and use the newer corrected version of Nhanes III which ourunit offers too
If you have any questions you may contact me at anytime and I also have many references in regards toboth parts of 7743 if you would like to see them
55
Thank you~
April
Confidentiality NoticeThis message may contain information that isconfidential or privileged
If you are not the intended recipientPlease advise the sender immediately and delete this message
56
ATTACHMENT H
57
NFPA 1582 771(7) Proposed revisions
Why
Preliminary results of two prospective randomized trials on the PSA test were published in 2009 These studies resulted in medical organizations that previously providing guidance to modify their recommendations
Current language
771 Blood Tests Blood tests shall be performed annually and shall include the following
(7) Prostate specific antigen (PSA) after age 40 for positive family history if African American or if otherwise clinically indicated after age 50 for all other male member
Suggested Revision
771 Blood Tests Blood tests shall be performed annually and shall include the following
(7) Prostate specific antigen (PSA) after age 40 for positive family history if African American or if otherwise clinically indicated after age 50 for all other male member
772 Prostate-Specific Antigen (PSA) test At age 50 fire fighters shall have an opportunity to make an informed decision with either the Fire Department physician or their health care provider concerning the PSA test For fire fighters at increased risk of prostate cancer (African-Americans or those with a first degree relative diagnosed with prostate cancer before age 65) shall have the opportunity for this informed decision at age 40
A772 The PSA as a screening test for prostate cancer in asymptomatic men is controversial controversial for two reasons First there is no consensus that PSA screening actually saves lives For example the PSA test may detect small cancers that would never become life threatening Second it is unclear that the benefits of PSA screening outweigh the risks of follow-up diagnostic tests and cancer treatments For example the prostate biopsy used to diagnose prostate cancer may cause bleeding and infection And prostate cancer treatments such as surgery and radiation therapy may cause incontinence (inability to control urine flow) erectile dysfunction (erections inadequate for intercourse) and other complications For these reasons it is important that the benefits and risks of prostate diagnostic procedures and treatment be taken into account when considering the PSA screening test These considerations can be taken account during discussions with the fire department physician or onersquos health care provider
D211 Cancer Screening
Smith R A C J Mettlin K J Davis and H Eyre 2000 ldquoAmerican Cancer Society guidelines for the early detection of cancerrdquo CA J Clin 50(1)34ndash49
Added references
58
Carroll P Albertsen PC Greene K et al [2010] Prostate-specific antigen best practice statement 2009 update Am Urological Assoc Available at httpwwwauanetorgcontentguidelines-and-quality-careclinical-guidelinesmain-reportspsa09pdf Date accessed September 2010
Ferrini R Woolf SH [2009] Screening for prostate cancer in American men American College of Preventive Medicine Practice Policy Statement Available at httpwwwacpmorgprostatehtm Date accessed September 2010
National Cancer Institute [2009] Prostate-specific antigen test National Cancer Institute Fact Sheet Available at httpwwwcancergovcancertopicsfactsheetDetectionPSA Date accessed September 2010
Wolf AMD Wender RC Etzioni RB et al [2010] American Cancer Society guideline for the early detection of prostate cancer Update 2010 Available at httpcaonlineamcancersocorgcgicontentfullcaac20066v1 Date accessed September 2010
59
NFPA 1582‐ HTN Draft 1
Reason for Revision
1) New classification of BP by the Joint National Commission [Chobanian et al 2002]
2) A high prevalence of FF have either HTN (~20) and Pre‐HTN (~20) [Soteriades et al 2003]
3) Among FF studies have shown a strong association between HTN and a number of adverse
cardiovascular events [Kales et al 2009]
4) A large percentage of on‐duty FF fatalities were found to have left ventricular hypertrophy a
complication of HTN at autopsy
Language in 2007 Edition with draft revisions in Red (Track changes)
611 The medical evaluation of a candidate shall include a medical history examination and any laboratory tests required to detect physical or medical condition(s) that could adversely affect hisher ability to safely perform the essential job tasks outlined in 511 A611 The medical history should include the candidates known health problems such as major illnesses surgeries medication use and allergies Symptom review is also important for detecting early signs of illness A medical history should also include a personal health history a family health history a health habit history an immunization history and a reproductive history
An occupational history should also be obtained to collect information about the persons past occupational and environmental exposures
(a) BP should be measured according to the Joint National Commission (JNC) -7 recommendations BP should be measured with a properly calibrated and validated instrument Patients should be seated quietly for at least 5 minutes in a chair with feet on the floor and arm supported at heart level An appropriate-sized cuff (cuff bladder encircling at least 80 of the arm) should be used to ensure accuracy At least 2 measurements should be made Systolic BP is the point at which the first of 2 or more sounds is heard (phase 1) and diastolic BP is the point before the disappearance of sounds (phase 5) [Chobanian et al 2003]
(2) Head eyes ears nose and throat (HEENT)
Formatted Font (Default) Times New RomanFont color Black
33
692 Vascular System 6921 Category A medical conditions shall include the following
(1) Uncontrolled or poorly controlled hypertension
(2) Hypertension with evidence of end organ damage
or not controlled by approved medications
A6921(1) Uncontrolled or poorly controlled hHypertension increases the risk of a sudden cardiac event This sudden cardiac event would cause sudden incapacitation which that is uncontrolled poorly controlled or requires medication likely to interferes with the safe performance of essential job tasks Uncontrolled or poorly controlled hypertension can be defined as the presence of end organ damage (see below) or stage 2 hypertension (BP systolic gt160 mmHg or BP diastolic gt100 mmHg) is an illness that can lead to functional impairment and potential for sudden incapacitation Individuals with pre- stage 1 or stage 2 hypertension should be referred to their primary care physician for evaluation lifestyle modification and treatment [QUESTION FOR GROUP _- WHAT ABOUT HAVING CANDIDATE RETURN IN ONE MONTH UNDER TREATMENT WITH NORMAL BP]
A6921(2)
Chronic hypertension can damage the eye (retinopathy) the kidneys (nephropathy) the vascular system (stroke transient ischemic attack or peripheral artery disease) or the heart (left ventricular hypertrophy and heart failure) These hypertension complications are known as end organ damage The cardiac and vascular complications are associated with an increased risk of sudden incapacitation and sudden cardiac death (Koren et al 1991) Unfortunately the cardiac complications are frequently asymptomatic and valid screening tests are not fast and are not inexpensive Therefore determining who to screen for cardiac complications (such as echocardiogram for LVH or a measurement of left ventricular ejection fraction for heart failure) should be based on the severity and the duration of HTN
76 Physical Examination The annual physical examination shall include each of the following components
(a) BP shall be measured according to the Joint National Commission (JNC)-7 recommendations
A76(1)(a) BP should be measured with a properly calibrated and validated instrument Patients should be seated quietly for at least 5 minutes in a chair with feet on the floor and arm supported at heart level An appropriate-sized cuff (cuff bladder encircling at least 80 of the arm) should be used to ensure accuracy At least 2 measurements should be made Systolic BP is the point at which the first of 2 or more sounds is heard (phase 1) and diastolic BP is the point before the disappearance of sounds (phase 5) [Chobanian et al 2003]
(2) Head eyes ears nose and throat (HEENT)
34
9420 Uncontrolled Hypertension 94201 Physician Evaluation Severe uncontrolled hypertension [defined as systolic pressure greater than 180 mm Hg diastolic pressure greater than 100 mm Hg or mean systolic blood
pressure ( systolic + diastolic) greater than 120 mm Hg] or malignant hypertension (defined as hypertension with the presence of target organ damage) compromises the members ability to safely perform essential job tasks 1 5 7 9 and 13 and the physician shall report the applicable job limitations to the fire department
Members with Pre-hypertention (systolic 120-139 mmHg or diastolic 80-89 mmHg) Stage 1 hypertension (systolic 140-159 mmHg or diastolic 90-99 mmHg) or Stage 2 hypertension (systolic ge160 mmHg or diastolic ge100 mmHg) should be referred to their primary care physician for evaluation lifestyle modification and treatment
(1) Members with Stage I hypertension should be followed-up not only by their primary care physician but also by the FD physician every 3 to 6 months to ensure their blood pressure is under control and to determine whether screening tests for asymptomatic end organ damage are appropriate
(2) Members with Stage 2 hypertension or with end organ damage (retinopathy nephropathy vascular or cardiac complications) compromises the members ability to safely perform essential job tasks 1 5 7 9 and 130 and the physician shall report the applicable job limitations to the fire department
A94201 Severe uncontrolled hypertension is a significant risk factor for the development of coronary artery disease congestive heart failure and stroke Blood pressure increases as a normal response to exercise This response is further exaggerated by the emotional and physical stress of performing these critical tasks while operating in personal protective clothing at extremes of temperature This normal elevation of blood pressure under these response conditions can lead to life-threatening hypertensive emergencies if a members daily blood pressure is already elevated to high levels In addition hypertension is a progressive illness that when uncontrolled ultimately and inevitably leads to target organ damage Target organs that are sensitive to the effects of elevated blood pressure are the central nervous system vision heart major blood vessels and kidneys
Chronic hypertension can damage the eye (retinopathy) the kidneys (nephropathy) the vascular system (stroke transient ischemic attack or peripheral artery disease) or the heart (left ventricular hypertrophy and heart failure) These hypertension complications are known as end organ damage The cardiac and vascular complications are associated with an increased risk of sudden incapacitation and sudden cardiac death (Koren et al 1991) Fortunately with proper evaluation life style modification and treatment these complications can be avoided Life style modification includes weight reduction DASH eating plan reduction in dietary sodium an increase in aerobic physical activity and moderation in alcohol consumption [Chobanian 2003]
Formatted Font (Default) Times New Roman12 pt Font color Black
Formatted Font (Default) Times New Roman12 pt Font color Black
35
A94201 (1) Members with Stage I hypertension whose BP returns to either pre-hypertenion or normal with lifestyle modification andor treatment can return to an annual medical evaluation For members with long-standing Stage I hypertension whose BP has not been reduced additional evaluation for possible end organ damage should be considered This evaluation could include any or all of the following
a) a compete patient history for symptoms of heart failure (eg shortness of breath upon exertion) or transient ischemic attacks (TIAs)
b) dilated eye examination for retinopathy
c) blood creatinine measurement for nephropathy
d) tests for left ventricular hypertrophy Unfortunately use of the resting EKG to detect left ventricular hypertrophy is very insensitive (eg 5 sensitivity) The echocardiogram is the best test for diagnosing left ventricular hypertrophy
A 94201 (2) Due to the high risk of a sudden cardiovascular event members with Stage 2 hypertension should be restricted until their BP can be brought under control Once the BP is brought under control they should be followed in the same manner as a member with Stage I hypertension
Formatted Font (Default) Times New Roman12 pt
36
D22 Cardiology Gibbons R J GJ Balady J W Beasley et al 1997 ACCAHA guidelines for exercise testing a report of American College of CardiologyAmerican Heart Association Task Force on Practice Guidelines (Committee on Exercise Testing) J Am Coll Cardiol 30260ndash311
Gibbons RJ Balady GJ Bricker JT Chaitman BR Fletcher GF Froelicher VF Mark DB McCallister BD Mooss AN OrsquoReilly MG Winters WL Jr [2002] ACCAHA 2002 guideline update for exercise testing summary article a report of the ACCAHA Task Force on Practice Guidelines (Committee to Update the 1997 Exercise Testing guidelines) J Am Coll Cardiol 401531ndash 40
Chobanian AV Bakris GL Black HR Cushman WC Green LA Izzo JL Jr Jones DW Materson BJ Oparil S Wright JT Jr Roccella EJ the National High Blood Pressure Education Program Coordinating Committee [2003] The seventh report of the Joint National Committee [JNC-7] on Prevention Detection Evaluation and Treatment of High Blood Pressure JAMA 2892560ndash2571
Soteriades ES Kales SN Liarokapis D Christiani DC [2003] Prospective surveillance of hypertension in firefighters J Clin Hypertens 5315-320
Kales SN Tsismenakis AJ Zhang C Soteriades ES [2009] Blood pressure in fire fighters police officers and other emergency responders Am J Hypertens 2211-20
37
NFPA 1582‐ HTN Draft 1
Reason for Revision
1) New classification of BP by the Joint National Commission [Chobanian et al 2002]
2) A high prevalence of FF have either HTN (~20) and Pre‐HTN (~20) [Soteriades et al 2003]
3) Among FF studies have shown a strong association between HTN and a number of adverse
cardiovascular events [Kales et al 2009]
4) A large percentage of on‐duty FF fatalities were found to have left ventricular hypertrophy a
complication of HTN at autopsy
Language in 2007 Edition with draft revisions in Red (Track changes)
611 The medical evaluation of a candidate shall include a medical history examination and any laboratory tests required to detect physical or medical condition(s) that could adversely affect hisher ability to safely perform the essential job tasks outlined in 511 A611 The medical history should include the candidates known health problems such as major illnesses surgeries medication use and allergies Symptom review is also important for detecting early signs of illness A medical history should also include a personal health history a family health history a health habit history an immunization history and a reproductive history
An occupational history should also be obtained to collect information about the persons past occupational and environmental exposures
(a) BP should be measured according to the Joint National Commission (JNC) -7 recommendations BP should be measured with a properly calibrated and validated instrument Patients should be seated quietly for at least 5 minutes in a chair with feet on the floor and arm supported at heart level An appropriate-sized cuff (cuff bladder encircling at least 80 of the arm) should be used to ensure accuracy At least 2 measurements should be made Systolic BP is the point at which the first of 2 or more sounds is heard (phase 1) and diastolic BP is the point before the disappearance of sounds (phase 5) [Chobanian et al 2003]
(2) Head eyes ears nose and throat
38
692 Vascular System 6921 Category A medical conditions shall include the following
(1) Uncontrolled or poorly controlled hypertension
(2) Hypertension with evidence of end organ damage
A6921(1) Uncontrolled or poorly controlled hypertension increases the risk of a sudden cardiac event This sudden cardiac event would cause sudden incapacitation which interferes with the safe performance of essential job tasks Uncontrolled or poorly controlled hypertension can be defined as the presence of end organ damage (see below) or stage 2 hypertension (BP systolic gt160 mmHg or BP diastolic gt100 mmHg) Individuals with pre- stage 1 or stage 2 hypertension should be referred to their primary care physician for evaluation lifestyle modification and treatment [QUESTION FOR GROUP _- WHAT ABOUT HAVING CANDIDATE RETURN IN ONE MONTH UNDER TREATMENT WITH NORMAL BP]
A6921(2)Chronic hypertension can damage the eye (retinopathy) the kidneys (nephropathy) the vascular system (stroke transient ischemic attack or peripheral artery disease) or the heart (left ventricular hypertrophy and heart failure) These hypertension complications are known as end organ damage The cardiac and vascular complications are associated with an increased risk of sudden incapacitation and sudden cardiac death (Koren et al 1991) Unfortunately the cardiac complications are frequently asymptomatic and valid screening tests are not fast and are not inexpensive Therefore determining who to screen for cardiac complications (such as echocardiogram for LVH or a measurement of left ventricular ejection fraction for heart failure) should be based on the severity and the duration of HTN
76 Physical Examination The annual physical examination shall include each of the following components
(a) BP shall be measured according to the Joint National Commission (JNC)-7 recommendations
A76(1)(a) BP should be measured with a properly calibrated and validated instrument Patients should be seated quietly for at least 5 minutes in a chair with feet on the floor and arm supported at heart level An appropriate-sized cuff (cuff bladder encircling at least 80 of the arm) should be used to ensure accuracy At least 2 measurements should be made Systolic BP is the point at which the first of 2 or more sounds is heard (phase 1) and diastolic BP is the point before the disappearance of sounds (phase 5) [Chobanian et al 2003]
(2) Head eyes ears nose and throat9420 Hypertension 94201 Physician Evaluation Members with Pre-hypertention (systolic 120-139 mmHg or diastolic 80-89 mmHg) Stage 1 hypertension (systolic 140-159 mmHg or diastolic 90-99 mmHg) or Stage 2 hypertension (systolic ge160 mmHg or diastolic ge100 mmHg) should be referred to their primary care physician for evaluation lifestyle modification and treatment
39
(1) Members with Stage I hypertension should be followed-up not only by their primary care physician but also by the FD physician every 3 to 6 months to ensure their blood pressure is under control and to determine whether screening tests for asymptomatic end organ damage are appropriate
(2) Members with Stage 2 hypertension or with end organ damage (retinopathy nephropathy vascular or cardiac complications) compromises the members ability to safely perform essential job tasks 1 5 7 9 and 130 and the physician shall report the applicable job limitations to the fire department
A94201 Chronic hypertension can damage the eye (retinopathy) the kidneys (nephropathy) the vascular system (stroke transient ischemic attack or peripheral artery disease) or the heart (left ventricular hypertrophy and heart failure) These hypertension complications are known as end organ damage The cardiac and vascular complications are associated with an increased risk of sudden incapacitation and sudden cardiac death (Koren et al 1991) Fortunately with proper evaluation life style modification and treatment these complications can be avoided Life style modification includes weight reduction DASH eating plan reduction in dietary sodium an increase in aerobic physical activity and moderation in alcohol consumption [Chobanian 2003]
A94201 (1) Members with Stage I hypertension whose BP returns to either pre-hypertenion or normal with lifestyle modification andor treatment can return to an annual medical evaluation For members with long-standing Stage I hypertension whose BP has not been reduced additional evaluation for possible end organ damage should be considered This evaluation could include any or all of the following
a) a compete patient history for symptoms of heart failure (eg shortness of breath upon exertion) or transient ischemic attacks (TIAs)
b) dilated eye examination for retinopathy
c) blood creatinine measurement for nephropathy
d) tests for left ventricular hypertrophy Unfortunately use of the resting EKG to detect left ventricular hypertrophy is very insensitive (eg 5 sensitivity) The echocardiogram is the best test for diagnosing left ventricular hypertrophy
A 94201 (2) Due to the high risk of a sudden cardiovascular event members with Stage 2 hypertension should be restricted until their BP can be brought under control Once the BP is brought under control they should be followed in the same manner as a member with Stage I hypertension
D22 Cardiology
40
Hypertension
Gibbons RJ Balady GJ Bricker JT Chaitman BR Fletcher GF Froelicher VF Mark DB McCallister BD Mooss AN OrsquoReilly MG Winters WL Jr [2002] ACCAHA 2002 guideline update for exercise testing summary article a report of the ACCAHA Task Force on Practice Guidelines (Committee to Update the 1997 Exercise Testing guidelines) J Am Coll Cardiol 401531ndash 40
Chobanian AV Bakris GL Black HR Cushman WC Green LA Izzo JL Jr Jones DW Materson BJ Oparil S Wright JT Jr Roccella EJ the National High Blood Pressure Education Program Coordinating Committee [2003] The seventh report of the Joint National Committee [JNC-7] on Prevention Detection Evaluation and Treatment of High Blood Pressure JAMA 2892560ndash2571
Soteriades ES Kales SN Liarokapis D Christiani DC [2003] Prospective surveillance of hypertension in firefighters J Clin Hypertens 5315-320
Kales SN Tsismenakis AJ Zhang C Soteriades ES [2009] Blood pressure in fire fighters police officers and other emergency responders Am J Hypertens 2211-20
41
NFPA 1582‐ Draft Revisions for CVDHTN
EKG and stress tests
Reason for Revision
1) Change requirement for annual resting EKG to periodically to be more consistent with ACCAHA
recommendation (Schlant et al 1992)
2) Add language to clarify what constitutes a positive ST
3) Make criteria for conducting diagnostic ST in asymptomatic patients consistent with the
ACCAHA
Language in 2007 Edition with draft revisions in Red (Track changes)
776 Electrocardiograms (EKG)) and Stress Tests 7761 A resting EKG shall be performed as part of the baseline medical evaluation and shall be obtained periodically (every 1 to 5 years) annually thereafter
A7761 A baseline resting EKGs shall be conducted Follow-up resting EKGs should be conducted as clinically indicated but at a minimum of every 1 to 5 years The frequency of these follow-up resting EKGs should increase as a members age increases or with increasing number andor severity of coronary heart disease risk factors Members above the age of 40 should have annual resting EKGs (Schlant et al 1992)
7762 The fire department physician or other qualified medical evaluator shall compare EKGs obtained during yearly evaluations with baseline and subsequent EKGs
7763 Stress testing EKG with or without echocardiography or radionuclide scanning shall be performed as clinically indicated by history or symptoms
A7761 Baseline electrocardiography should be conducted (Periodic resting electrocardiograms have not been shown to be useful but can be reasonable as a members agefactors increase)
A7763 No firm guidelines for stress testingelectrocardiography in asymptomatic individuals have been developed Stress testingelectrocardiography as a screening tool is used as part of an evaluation of aerobic capacity during the annual occupational fitness evaluation Submaximal stress testingelectrocardiography testing to 85 percent is commonly used as part of this screening
Submaximal stress electrocardiography testing should not be used for diagnostic purposes Cardiology evaluation with maximal stress testingelectrocardiography together with imaging techniques (eg echocardiography technetium Tc99m sestamibi study andor coronary angiography) is necessary for diagnosticprognostic purposes for the following
42
(1) Fire fighters with positive or questionably positive changes on screening submaximal stress tests
(2) Fire fighters with new onset chest pain or other symptoms suggestive of coronary artery disease (CAD)
(3) Fire fighters with diabetes mellitus who
(a) are gt35 years old or
(b) have type I diabetes for more than 15 years or
(c) have type II diabetes for more than 10 years or
(d) have any other CHD risk factor (see below) or
(e) have the presence of microvascular disease (proliferative retinopathy)
(4) Fire fighters over the age of 45 (for men) and 55 (for women) with onetwo or more risk factors for CAD Risk factors for CAD include hypercholesterolemia (total cholesterol greater than 240 mgdL) hypertension (systolic gt140 mmHg or diastolic gt90 mmHg) smoking or family history of premature CAD (heart attack or sudden cardiac death in a first degree relative less than 60 years of age)
as defined below if stress electrocardiography with imaging is negative then repeat as clinically indicated or at least every 5 years
(5) Fire fighters with a Framingham Risk Score gt10 Risk calculator is available at [httphp2010nhlbihinnetatpiiicalculatorasp]
(6) Fire fighters identified in 9431
Negative stress tests should be repeated as clinically indicated or at least every 2 to 5 years
Interpreting stress tests as ldquopositiverdquo or ldquonegativerdquo is beyond the scope of this document However factors that should be taken into consideration should include the individualrsquos exercise capacity symptoms blood pressure response heart rate response EKG changes and the presence of arrhythmias (Gibbon et al 2002)
Risk factors for CAD include hypercholesterolemia (total cholesterol greater than 240 mgdL) hypertension (systolic greater than 140 andor diastolic greater than 90) smoking diabetes mellitus or family history of premature CAD (heart attack or sudden cardiac death in a first degree relative less than 60 years of age)
There are other non-invasive tests to screen for coronary artery disease One of the most promising appears to be coronary artery calcium (CAD) scoring by computed tomography In 2007 an expert committee published an update to their original guidance document The committeersquos consensus was that ldquoit may be reasonable to consider use of CAC measurement in such patients [between 10 and 20 10-year risk of estimated coronary event]helliprdquo The committee did not recommend CAC measurement in low risk patients [lt10 10-year risk of estimated coronary event] or in high risk patients [gt20 10-year risk of estimate coronary event] (Greenland et al 2007]
43
D22 Cardiology
Chobanian AV Bakris GL Black HR Cushman WC Green LA Izzo JL Jr Jones DW Materson BJ Oparil S Wright JT Jr Roccella EJ the National High Blood Pressure Education Program Coordinating Committee [2003] The seventh report of the Joint National Committee [JNC-7] on Prevention Detection Evaluation and Treatment of High Blood Pressure JAMA 2892560ndash2571
Gibbons RJ Balady GJ Bricker JT Chaitman BR Fletcher GF Froelicher VF Mark DB McCallister BD Mooss AN OrsquoReilly MG Winters WL Jr [2002] ACCAHA 2002 guideline update for exercise testing summary article a report of the ACCAHA Task Force on Practice Guidelines (Committee to Update the 1997 Exercise Testing guidelines) J Am Coll Cardiol 401531ndash 1540
Greenland et al [2007] ACCFAHA 2007 Clinical Expert Consensus Document on Coronary Artery Calcium Scoring By Computed Tomography in Global Cardiovascular Risk Assessment and in Evaluation of Patients With Chest Pain A Report of the American College of Cardiology Foundation Clinical Expert Consensus Task Force (ACCFAHA Writing Committee to Update the 2000 Expert Consensus Document on Electron Beam Computed Tomography) J Am Coll Cardiol 49378-402
Kales SN Tsismenakis AJ Zhang C Soteriades ES [2009] Blood pressure in fire fighters police officers and other emergency responders Am J Hypertens 2211-20
Schlant RC Adolph RJ DiMarco JP Dreifus LS Dunn MI Fisch C Garson A Jr Haywood LJ Levine HJ Murray JA Noble RJ Ronan JA Jr [1992] Guidelines for electrocardiography A report of the American College of CardiologyAmerican Heart Association Task Force on Assessment of Diagnostic and Therapeutic Cardiovascular Procedures (Committee on Electrocardiography) Circulation 85(3)1221-1228
Soteriades ES Kales SN Liarokapis D Christiani DC [2003] Prospective surveillance of hypertension in firefighters J Clin Hypertens 5315-320
Formatted Font Italic
Formatted Line spacing single
Formatted Font Italic
Formatted Font Italic
44
NFPA 1582‐ Draft Revisions for CVDHTN
EKG and stress tests
Reason for Revision
1) Change requirement for annual resting EKG to periodically to be more consistent with ACCAHA
recommendation (Schlant et al 1992)
2) Add language to clarify what constitutes a positive ST
3) Make criteria for conducting diagnostic ST in asymptomatic patients consistent with the
ACCAHA
Language in 2007 Edition with draft revisions in Red (Track changes)
776 Electrocardiograms (EKG) and Stress Tests 7761 A resting EKG shall be performed as part of the baseline medical evaluation and shall be obtained periodically (every 1 to 5 years) thereafter
A7761 A baseline resting EKGs shall be conducted Follow-up resting EKGs should be conducted as clinically indicated but at a minimum of every 1 to 5 years The frequency of these follow-up resting EKGs should increase as a members age increases or with increasing number andor severity of coronary heart disease risk factors Members above the age of 40 should have annual resting EKGs (Schlant et al 1992)
7762 The fire department physician or other qualified medical evaluator shall compare baseline and subsequent EKGs
7763 Stress testing with or without echocardiography or radionuclide scanning shall be performed as clinically indicated by history or symptoms
A7763 No firm guidelines for stress testing in asymptomatic individuals have been developed Stress testing as a screening tool is used as part of an evaluation of aerobic capacity during the annual occupational fitness evaluation Submaximal stress testing testing to 85 percent is commonly used as part of this screening
Submaximal stress testing should not be used for diagnostic purposes Cardiology evaluation with maximal stress testing together with imaging techniques (eg echocardiography technetium Tc99m sestamibi study) is necessary for diagnosticprognostic purposes for the following
(1) Fire fighters with positive or questionably positive changes on screening submaximal stress tests
(2) Fire fighters with new onset chest pain or other symptoms suggestive of coronary artery disease (CAD)
45
(3) Fire fighters with diabetes mellitus who
(a) are gt35 years old or
(b) have type I diabetes for more than 15 years or
(c) have type II diabetes for more than 10 years or
(d) have any other CHD risk factor (see below) or
(e) have the presence of microvascular disease (proliferative retinopathy)
(4) Fire fighters over the age of 45 (for men) and 55 (for women) with one or more risk factors for CAD Risk factors for CAD include hypercholesterolemia (total cholesterol greater than 240 mgdL) hypertension (systolic gt140 mmHg or diastolic gt90 mmHg) smoking or family history of premature CAD (heart attack or sudden cardiac death in a first degree relative less than 60 years of age)
(5) Fire fighters with a Framingham Risk Score gt10 Risk calculator is available at [httphp2010nhlbihinnetatpiiicalculatorasp]
(6) Fire fighters identified in 9431
Negative stress tests should be repeated as clinically indicated or at least every 2 to 5 years
Interpreting stress tests as ldquopositiverdquo or ldquonegativerdquo is beyond the scope of this document However factors that should be taken into consideration should include the individualrsquos exercise capacity symptoms blood pressure response heart rate response EKG changes and the presence of arrhythmias (Gibbon et al 2002)
There are other non-invasive tests to screen for coronary artery disease One of the most promising appears to be coronary artery calcium (CAD) scoring by computed tomography In 2007 an expert committee published an update to their original guidance document The committeersquos consensus was that ldquoit may be reasonable to consider use of CAC measurement in such patients [between 10 and 20 10-year risk of estimated coronary event]helliprdquo The committee did not recommend CAC measurement in low risk patients [lt10 10-year risk of estimated coronary event] or in high risk patients [gt20 10-year risk of estimate coronary event] (Greenland et al 2007]
D22 Cardiology
Resting EKG and Stress Tests
46
Chobanian AV Bakris GL Black HR Cushman WC Green LA Izzo JL Jr Jones DW Materson BJ Oparil S Wright JT Jr Roccella EJ the National High Blood Pressure Education Program Coordinating Committee [2003] The seventh report of the Joint National Committee [JNC-7] on Prevention Detection Evaluation and Treatment of High Blood Pressure JAMA 2892560ndash2571
Gibbons RJ Balady GJ Bricker JT Chaitman BR Fletcher GF Froelicher VF Mark DB McCallister BD Mooss AN OrsquoReilly MG Winters WL Jr [2002] ACCAHA 2002 guideline update for exercise testing summary article a report of the ACCAHA Task Force on Practice Guidelines (Committee to Update the 1997 Exercise Testing guidelines) J Am Coll Cardiol 401531ndash 1540
Greenland et al [2007] ACCFAHA 2007 Clinical Expert Consensus Document on Coronary Artery Calcium Scoring By Computed Tomography in Global Cardiovascular Risk Assessment and in Evaluation of Patients With Chest Pain A Report of the American College of Cardiology Foundation Clinical Expert Consensus Task Force (ACCFAHA Writing Committee to Update the 2000 Expert Consensus Document on Electron Beam Computed Tomography) J Am Coll Cardiol 49378-402
Kales SN Tsismenakis AJ Zhang C Soteriades ES [2009] Blood pressure in fire fighters police officers and other emergency responders Am J Hypertens 2211-20
Schlant RC Adolph RJ DiMarco JP Dreifus LS Dunn MI Fisch C Garson A Jr Haywood LJ Levine HJ Murray JA Noble RJ Ronan JA Jr [1992] Guidelines for electrocardiography A report of the American College of CardiologyAmerican Heart Association Task Force on Assessment of Diagnostic and Therapeutic Cardiovascular Procedures (Committee on Electrocardiography) Circulation 85(3)1221-1228
Soteriades ES Kales SN Liarokapis D Christiani DC [2003] Prospective surveillance of hypertension in firefighters J Clin Hypertens 5315-320
47
ATTACHMENT F
48
1
Current 1582 (2007) language in reference to pregnancy 43 (4) Report to the fire department physician any medical condition that could interfere with the ability of the individual to safely perform essential job tasks such as illness or injury use of prescription or nonprescription drugs and pregnancy 6112 Category B medical conditions shall include the following (1) Pregnancy for its duration A7792 (e) If HIV prophylaxis is to be given the following tests should be done i CBC ii Glucose renal and hepatic chemical function iii Pregnancy test for females B121 Pregnancy and Reproduction Federal regulations as well as many court decisions including the US Supreme Courtrsquos decision in International Union et al v Johnson Controls Inc [499 US 187 111 S Ct 1196 (1991)] have interpreted the requirements of Title VII with respect to pregnancy and reproduction The AHJ should seek the advice of counsel in resolving specific questions concerning these requirements as well as other requirements that can be imposed by state or local laws C211 (4) Review health status with the individual being evaluated Contraindications for evaluations shall be reviewed addressing any changes in the individualrsquos health status since their last medical evaluation that would warrant deferring the evaluation including (g) Pregnancy Recommendations to language enhancement
A female employee who is assigned to regular fire line duty shall report a pregnancy immediately to their respective Supervisor and the fire department physician The employee will then be given the option of a non-hazardous alternative duty position for the duration of her pregnancy (can we say this or is it even appropriate) Any pregnant employee wishing to remain on regular line duty shall be informed of the possible risks and consequences to herself and her fetus that are associated with continued line fire fighting duty Among those risk factors are exposure to teratogens known to have negative effects on the developing fetus such as smoke diesel fumes hazardous chemicals and extreme heat
49
Page 2
appendix It is recommended that the pregnant employee complete a release of liability form signed by herself and her health care provider utilizing NFPArsquos 13 critical tasks as a reference This will inform the health care provider of specific job-related tasks that will need to be performed in order to continue regular line duty These tasks are basic physical standards that any entry level firefighter would have to be able to complete competently The employeersquos health condition will be kept confidential by the department in accordance with HIPAA standards Employees are allowed to remain on active regular duty until they are no longer able to perform their duties in a reasonable manner andor their protective gear no longer fits correctly It is the responsibility of the health care provider to evaluate the pregnant employee If at any time the health care provider feels the pregnant employee can no longer perform the job related tasks this should be reported to the employer by the employee immediately
50
ATTACHMENT G
51
From GLENN BENARICKTo Sawyer SteveSubject RE RE 7743Date Monday August 30 2010 21633 PM
Yes thats my understanding
Glenn P Benarick 211 Winged Elm CircleAiken SC 29803803-644-7093gbenarprodigynet
--- On Mon 83010 Sawyer Steve ltssawyerNFPAorggt wrote
From Sawyer Steve ltssawyerNFPAorggtSubject RE RE 7743To GLENN BENARICK ltgbenarprodigynetgtDate Monday August 30 2010 212 PM
So it should be ldquoorrdquo instead of ldquoandrdquo for now
Steven F Sawyer
Senior Fire Service Specialist
Executive Secretary IFMAFire Service Section
NFPA
1 Batterymarch Park
Quincy MA 02169
6179847423
Fax 6179847056
ssawyernfpaorg
From GLENN BENARICK [mailtogbenarprodigynet] Sent Monday August 30 2010 1202 PMTo Sawyer SteveSubject Fw RE 7743
52
Steve a couple of our docs agree with April Boyer
Glenn P Benarick 211 Winged Elm Circle
Aiken SC 29803
803-644-7093
gbenarprodigynet
--- On Mon 83010 David Prezant ltprezandfdnynycgovgt wrote
From David Prezant ltprezandfdnynycgovgtSubject RE 7743To Thomas R (CDCNIOSHDSHEFS) Hales lttrh1cdcgovgt GLENNBENARICK ltgbenarprodigynetgtCc Sandy Bogucki ltsandyboguckiyaleedugtDate Monday August 30 2010 1004 AM
agree
we should change this to NHANES III rather than Knudson we should alsomodify this to allow not only for predicted cutoffs but all for use of thelower limit of normal cutoff This is important to prevent false-classificationof spirometry as abnormal in older groups and in taller grps The latter ofparticular import to firefighter occupational health surveillance
thanks
David Prezant MDChief Medical Officer Office of Medical AffairsCo-Director WTC Medical Monitoring amp Treatment ProgramsNew York City Fire Department9 Metrotech Center - Rm 4W-1Brooklyn NY 11201Phone 718-999-2696Fax 718-999-0665
Life is full of twists and turns
53
This email may contain confidential information If you are the unintendedrecipient of this email please send it back and delete from your directory
gtgtgt Hales Thomas R (CDCNIOSHDSHEFS) lttrh1cdcgovgt 8302010955 AM gtgtgt
Glen
This seems like a very reasonable comment and illustrates the importance of having clinicians providefeedback on the std Im not familiar with the software program of the various spirometers (NHANES IIIvs KnudsonATS vs both) Given the large role both Dave Prezant and Sandy Bogucki had for thepulmonary section let me forward to them for clarification
Tom
From GLENN BENARICK [mailtogbenarprodigynet] Sent Sunday August 29 2010 456 PMTo Hales Thomas R (CDCNIOSHDSHEFS)Subject FW 7743
Tom is April Boyer correct
Glenn P Benarick 211 Winged Elm Circle
Aiken SC 29803
803-644-7093
gbenarprodigynet
--- On Thu 82610 Sawyer Steve ltssawyerNFPAorggt wrote
From Sawyer Steve ltssawyerNFPAorggtSubject FW 7743To GLENN BENARICK ltgbenarprodigynetgtDate Thursday August 26 2010 925 PM
FYI Do you have any answer She is write
Steven
54
Steven F Sawyer
Senior Fire Service Specialist
Executive Secretary IFMAFire Service Section
NFPA
1 Batterymarch Park
Quincy MA 02169
6179847423
Fax 6179847056
ssawyernfpaorg
From April Boyer [mailtoaboyerbicclinicorg] Sent Thursday August 26 2010 232 PMTo Sawyer SteveCc RobinMWebbmilstateorusSubject 7743
Steven
The spirometry tests cannot be corrected according to both references as the NFPA states because thereferences are contradictory The first part of 7743 states to follow the ATS guidelines and use theKnudsen (we at Basin Immediate Care use the Nhanes III) The second part states to follow the ACOEMguidelines and use the Nhanes III in the occupational setting if available with your unit (which is availableon ours) 7743 does not use the word OR regarding both requirements it uses the word AND whenreferring to the first and second parts thence making 7743 contradictory I realize the NFPA 1582 hasnot been updated since 2007 unless I have just not received an updated version
Our question to you is which part of 7743 do you want us to follow the first or the second part Anyfacility that has an updated computerized spirometry system (as we do) will not be able to follow bothrequired parts for obvious reasons We can either follow the first part of 7743 and use an oldercorrected version of the Knudson by going into our system and changing out of the Nhanes III conversionOR we can follow the second part of 7743 and use the newer corrected version of Nhanes III which ourunit offers too
If you have any questions you may contact me at anytime and I also have many references in regards toboth parts of 7743 if you would like to see them
55
Thank you~
April
Confidentiality NoticeThis message may contain information that isconfidential or privileged
If you are not the intended recipientPlease advise the sender immediately and delete this message
56
ATTACHMENT H
57
NFPA 1582 771(7) Proposed revisions
Why
Preliminary results of two prospective randomized trials on the PSA test were published in 2009 These studies resulted in medical organizations that previously providing guidance to modify their recommendations
Current language
771 Blood Tests Blood tests shall be performed annually and shall include the following
(7) Prostate specific antigen (PSA) after age 40 for positive family history if African American or if otherwise clinically indicated after age 50 for all other male member
Suggested Revision
771 Blood Tests Blood tests shall be performed annually and shall include the following
(7) Prostate specific antigen (PSA) after age 40 for positive family history if African American or if otherwise clinically indicated after age 50 for all other male member
772 Prostate-Specific Antigen (PSA) test At age 50 fire fighters shall have an opportunity to make an informed decision with either the Fire Department physician or their health care provider concerning the PSA test For fire fighters at increased risk of prostate cancer (African-Americans or those with a first degree relative diagnosed with prostate cancer before age 65) shall have the opportunity for this informed decision at age 40
A772 The PSA as a screening test for prostate cancer in asymptomatic men is controversial controversial for two reasons First there is no consensus that PSA screening actually saves lives For example the PSA test may detect small cancers that would never become life threatening Second it is unclear that the benefits of PSA screening outweigh the risks of follow-up diagnostic tests and cancer treatments For example the prostate biopsy used to diagnose prostate cancer may cause bleeding and infection And prostate cancer treatments such as surgery and radiation therapy may cause incontinence (inability to control urine flow) erectile dysfunction (erections inadequate for intercourse) and other complications For these reasons it is important that the benefits and risks of prostate diagnostic procedures and treatment be taken into account when considering the PSA screening test These considerations can be taken account during discussions with the fire department physician or onersquos health care provider
D211 Cancer Screening
Smith R A C J Mettlin K J Davis and H Eyre 2000 ldquoAmerican Cancer Society guidelines for the early detection of cancerrdquo CA J Clin 50(1)34ndash49
Added references
58
Carroll P Albertsen PC Greene K et al [2010] Prostate-specific antigen best practice statement 2009 update Am Urological Assoc Available at httpwwwauanetorgcontentguidelines-and-quality-careclinical-guidelinesmain-reportspsa09pdf Date accessed September 2010
Ferrini R Woolf SH [2009] Screening for prostate cancer in American men American College of Preventive Medicine Practice Policy Statement Available at httpwwwacpmorgprostatehtm Date accessed September 2010
National Cancer Institute [2009] Prostate-specific antigen test National Cancer Institute Fact Sheet Available at httpwwwcancergovcancertopicsfactsheetDetectionPSA Date accessed September 2010
Wolf AMD Wender RC Etzioni RB et al [2010] American Cancer Society guideline for the early detection of prostate cancer Update 2010 Available at httpcaonlineamcancersocorgcgicontentfullcaac20066v1 Date accessed September 2010
59
692 Vascular System 6921 Category A medical conditions shall include the following
(1) Uncontrolled or poorly controlled hypertension
(2) Hypertension with evidence of end organ damage
or not controlled by approved medications
A6921(1) Uncontrolled or poorly controlled hHypertension increases the risk of a sudden cardiac event This sudden cardiac event would cause sudden incapacitation which that is uncontrolled poorly controlled or requires medication likely to interferes with the safe performance of essential job tasks Uncontrolled or poorly controlled hypertension can be defined as the presence of end organ damage (see below) or stage 2 hypertension (BP systolic gt160 mmHg or BP diastolic gt100 mmHg) is an illness that can lead to functional impairment and potential for sudden incapacitation Individuals with pre- stage 1 or stage 2 hypertension should be referred to their primary care physician for evaluation lifestyle modification and treatment [QUESTION FOR GROUP _- WHAT ABOUT HAVING CANDIDATE RETURN IN ONE MONTH UNDER TREATMENT WITH NORMAL BP]
A6921(2)
Chronic hypertension can damage the eye (retinopathy) the kidneys (nephropathy) the vascular system (stroke transient ischemic attack or peripheral artery disease) or the heart (left ventricular hypertrophy and heart failure) These hypertension complications are known as end organ damage The cardiac and vascular complications are associated with an increased risk of sudden incapacitation and sudden cardiac death (Koren et al 1991) Unfortunately the cardiac complications are frequently asymptomatic and valid screening tests are not fast and are not inexpensive Therefore determining who to screen for cardiac complications (such as echocardiogram for LVH or a measurement of left ventricular ejection fraction for heart failure) should be based on the severity and the duration of HTN
76 Physical Examination The annual physical examination shall include each of the following components
(a) BP shall be measured according to the Joint National Commission (JNC)-7 recommendations
A76(1)(a) BP should be measured with a properly calibrated and validated instrument Patients should be seated quietly for at least 5 minutes in a chair with feet on the floor and arm supported at heart level An appropriate-sized cuff (cuff bladder encircling at least 80 of the arm) should be used to ensure accuracy At least 2 measurements should be made Systolic BP is the point at which the first of 2 or more sounds is heard (phase 1) and diastolic BP is the point before the disappearance of sounds (phase 5) [Chobanian et al 2003]
(2) Head eyes ears nose and throat (HEENT)
34
9420 Uncontrolled Hypertension 94201 Physician Evaluation Severe uncontrolled hypertension [defined as systolic pressure greater than 180 mm Hg diastolic pressure greater than 100 mm Hg or mean systolic blood
pressure ( systolic + diastolic) greater than 120 mm Hg] or malignant hypertension (defined as hypertension with the presence of target organ damage) compromises the members ability to safely perform essential job tasks 1 5 7 9 and 13 and the physician shall report the applicable job limitations to the fire department
Members with Pre-hypertention (systolic 120-139 mmHg or diastolic 80-89 mmHg) Stage 1 hypertension (systolic 140-159 mmHg or diastolic 90-99 mmHg) or Stage 2 hypertension (systolic ge160 mmHg or diastolic ge100 mmHg) should be referred to their primary care physician for evaluation lifestyle modification and treatment
(1) Members with Stage I hypertension should be followed-up not only by their primary care physician but also by the FD physician every 3 to 6 months to ensure their blood pressure is under control and to determine whether screening tests for asymptomatic end organ damage are appropriate
(2) Members with Stage 2 hypertension or with end organ damage (retinopathy nephropathy vascular or cardiac complications) compromises the members ability to safely perform essential job tasks 1 5 7 9 and 130 and the physician shall report the applicable job limitations to the fire department
A94201 Severe uncontrolled hypertension is a significant risk factor for the development of coronary artery disease congestive heart failure and stroke Blood pressure increases as a normal response to exercise This response is further exaggerated by the emotional and physical stress of performing these critical tasks while operating in personal protective clothing at extremes of temperature This normal elevation of blood pressure under these response conditions can lead to life-threatening hypertensive emergencies if a members daily blood pressure is already elevated to high levels In addition hypertension is a progressive illness that when uncontrolled ultimately and inevitably leads to target organ damage Target organs that are sensitive to the effects of elevated blood pressure are the central nervous system vision heart major blood vessels and kidneys
Chronic hypertension can damage the eye (retinopathy) the kidneys (nephropathy) the vascular system (stroke transient ischemic attack or peripheral artery disease) or the heart (left ventricular hypertrophy and heart failure) These hypertension complications are known as end organ damage The cardiac and vascular complications are associated with an increased risk of sudden incapacitation and sudden cardiac death (Koren et al 1991) Fortunately with proper evaluation life style modification and treatment these complications can be avoided Life style modification includes weight reduction DASH eating plan reduction in dietary sodium an increase in aerobic physical activity and moderation in alcohol consumption [Chobanian 2003]
Formatted Font (Default) Times New Roman12 pt Font color Black
Formatted Font (Default) Times New Roman12 pt Font color Black
35
A94201 (1) Members with Stage I hypertension whose BP returns to either pre-hypertenion or normal with lifestyle modification andor treatment can return to an annual medical evaluation For members with long-standing Stage I hypertension whose BP has not been reduced additional evaluation for possible end organ damage should be considered This evaluation could include any or all of the following
a) a compete patient history for symptoms of heart failure (eg shortness of breath upon exertion) or transient ischemic attacks (TIAs)
b) dilated eye examination for retinopathy
c) blood creatinine measurement for nephropathy
d) tests for left ventricular hypertrophy Unfortunately use of the resting EKG to detect left ventricular hypertrophy is very insensitive (eg 5 sensitivity) The echocardiogram is the best test for diagnosing left ventricular hypertrophy
A 94201 (2) Due to the high risk of a sudden cardiovascular event members with Stage 2 hypertension should be restricted until their BP can be brought under control Once the BP is brought under control they should be followed in the same manner as a member with Stage I hypertension
Formatted Font (Default) Times New Roman12 pt
36
D22 Cardiology Gibbons R J GJ Balady J W Beasley et al 1997 ACCAHA guidelines for exercise testing a report of American College of CardiologyAmerican Heart Association Task Force on Practice Guidelines (Committee on Exercise Testing) J Am Coll Cardiol 30260ndash311
Gibbons RJ Balady GJ Bricker JT Chaitman BR Fletcher GF Froelicher VF Mark DB McCallister BD Mooss AN OrsquoReilly MG Winters WL Jr [2002] ACCAHA 2002 guideline update for exercise testing summary article a report of the ACCAHA Task Force on Practice Guidelines (Committee to Update the 1997 Exercise Testing guidelines) J Am Coll Cardiol 401531ndash 40
Chobanian AV Bakris GL Black HR Cushman WC Green LA Izzo JL Jr Jones DW Materson BJ Oparil S Wright JT Jr Roccella EJ the National High Blood Pressure Education Program Coordinating Committee [2003] The seventh report of the Joint National Committee [JNC-7] on Prevention Detection Evaluation and Treatment of High Blood Pressure JAMA 2892560ndash2571
Soteriades ES Kales SN Liarokapis D Christiani DC [2003] Prospective surveillance of hypertension in firefighters J Clin Hypertens 5315-320
Kales SN Tsismenakis AJ Zhang C Soteriades ES [2009] Blood pressure in fire fighters police officers and other emergency responders Am J Hypertens 2211-20
37
NFPA 1582‐ HTN Draft 1
Reason for Revision
1) New classification of BP by the Joint National Commission [Chobanian et al 2002]
2) A high prevalence of FF have either HTN (~20) and Pre‐HTN (~20) [Soteriades et al 2003]
3) Among FF studies have shown a strong association between HTN and a number of adverse
cardiovascular events [Kales et al 2009]
4) A large percentage of on‐duty FF fatalities were found to have left ventricular hypertrophy a
complication of HTN at autopsy
Language in 2007 Edition with draft revisions in Red (Track changes)
611 The medical evaluation of a candidate shall include a medical history examination and any laboratory tests required to detect physical or medical condition(s) that could adversely affect hisher ability to safely perform the essential job tasks outlined in 511 A611 The medical history should include the candidates known health problems such as major illnesses surgeries medication use and allergies Symptom review is also important for detecting early signs of illness A medical history should also include a personal health history a family health history a health habit history an immunization history and a reproductive history
An occupational history should also be obtained to collect information about the persons past occupational and environmental exposures
(a) BP should be measured according to the Joint National Commission (JNC) -7 recommendations BP should be measured with a properly calibrated and validated instrument Patients should be seated quietly for at least 5 minutes in a chair with feet on the floor and arm supported at heart level An appropriate-sized cuff (cuff bladder encircling at least 80 of the arm) should be used to ensure accuracy At least 2 measurements should be made Systolic BP is the point at which the first of 2 or more sounds is heard (phase 1) and diastolic BP is the point before the disappearance of sounds (phase 5) [Chobanian et al 2003]
(2) Head eyes ears nose and throat
38
692 Vascular System 6921 Category A medical conditions shall include the following
(1) Uncontrolled or poorly controlled hypertension
(2) Hypertension with evidence of end organ damage
A6921(1) Uncontrolled or poorly controlled hypertension increases the risk of a sudden cardiac event This sudden cardiac event would cause sudden incapacitation which interferes with the safe performance of essential job tasks Uncontrolled or poorly controlled hypertension can be defined as the presence of end organ damage (see below) or stage 2 hypertension (BP systolic gt160 mmHg or BP diastolic gt100 mmHg) Individuals with pre- stage 1 or stage 2 hypertension should be referred to their primary care physician for evaluation lifestyle modification and treatment [QUESTION FOR GROUP _- WHAT ABOUT HAVING CANDIDATE RETURN IN ONE MONTH UNDER TREATMENT WITH NORMAL BP]
A6921(2)Chronic hypertension can damage the eye (retinopathy) the kidneys (nephropathy) the vascular system (stroke transient ischemic attack or peripheral artery disease) or the heart (left ventricular hypertrophy and heart failure) These hypertension complications are known as end organ damage The cardiac and vascular complications are associated with an increased risk of sudden incapacitation and sudden cardiac death (Koren et al 1991) Unfortunately the cardiac complications are frequently asymptomatic and valid screening tests are not fast and are not inexpensive Therefore determining who to screen for cardiac complications (such as echocardiogram for LVH or a measurement of left ventricular ejection fraction for heart failure) should be based on the severity and the duration of HTN
76 Physical Examination The annual physical examination shall include each of the following components
(a) BP shall be measured according to the Joint National Commission (JNC)-7 recommendations
A76(1)(a) BP should be measured with a properly calibrated and validated instrument Patients should be seated quietly for at least 5 minutes in a chair with feet on the floor and arm supported at heart level An appropriate-sized cuff (cuff bladder encircling at least 80 of the arm) should be used to ensure accuracy At least 2 measurements should be made Systolic BP is the point at which the first of 2 or more sounds is heard (phase 1) and diastolic BP is the point before the disappearance of sounds (phase 5) [Chobanian et al 2003]
(2) Head eyes ears nose and throat9420 Hypertension 94201 Physician Evaluation Members with Pre-hypertention (systolic 120-139 mmHg or diastolic 80-89 mmHg) Stage 1 hypertension (systolic 140-159 mmHg or diastolic 90-99 mmHg) or Stage 2 hypertension (systolic ge160 mmHg or diastolic ge100 mmHg) should be referred to their primary care physician for evaluation lifestyle modification and treatment
39
(1) Members with Stage I hypertension should be followed-up not only by their primary care physician but also by the FD physician every 3 to 6 months to ensure their blood pressure is under control and to determine whether screening tests for asymptomatic end organ damage are appropriate
(2) Members with Stage 2 hypertension or with end organ damage (retinopathy nephropathy vascular or cardiac complications) compromises the members ability to safely perform essential job tasks 1 5 7 9 and 130 and the physician shall report the applicable job limitations to the fire department
A94201 Chronic hypertension can damage the eye (retinopathy) the kidneys (nephropathy) the vascular system (stroke transient ischemic attack or peripheral artery disease) or the heart (left ventricular hypertrophy and heart failure) These hypertension complications are known as end organ damage The cardiac and vascular complications are associated with an increased risk of sudden incapacitation and sudden cardiac death (Koren et al 1991) Fortunately with proper evaluation life style modification and treatment these complications can be avoided Life style modification includes weight reduction DASH eating plan reduction in dietary sodium an increase in aerobic physical activity and moderation in alcohol consumption [Chobanian 2003]
A94201 (1) Members with Stage I hypertension whose BP returns to either pre-hypertenion or normal with lifestyle modification andor treatment can return to an annual medical evaluation For members with long-standing Stage I hypertension whose BP has not been reduced additional evaluation for possible end organ damage should be considered This evaluation could include any or all of the following
a) a compete patient history for symptoms of heart failure (eg shortness of breath upon exertion) or transient ischemic attacks (TIAs)
b) dilated eye examination for retinopathy
c) blood creatinine measurement for nephropathy
d) tests for left ventricular hypertrophy Unfortunately use of the resting EKG to detect left ventricular hypertrophy is very insensitive (eg 5 sensitivity) The echocardiogram is the best test for diagnosing left ventricular hypertrophy
A 94201 (2) Due to the high risk of a sudden cardiovascular event members with Stage 2 hypertension should be restricted until their BP can be brought under control Once the BP is brought under control they should be followed in the same manner as a member with Stage I hypertension
D22 Cardiology
40
Hypertension
Gibbons RJ Balady GJ Bricker JT Chaitman BR Fletcher GF Froelicher VF Mark DB McCallister BD Mooss AN OrsquoReilly MG Winters WL Jr [2002] ACCAHA 2002 guideline update for exercise testing summary article a report of the ACCAHA Task Force on Practice Guidelines (Committee to Update the 1997 Exercise Testing guidelines) J Am Coll Cardiol 401531ndash 40
Chobanian AV Bakris GL Black HR Cushman WC Green LA Izzo JL Jr Jones DW Materson BJ Oparil S Wright JT Jr Roccella EJ the National High Blood Pressure Education Program Coordinating Committee [2003] The seventh report of the Joint National Committee [JNC-7] on Prevention Detection Evaluation and Treatment of High Blood Pressure JAMA 2892560ndash2571
Soteriades ES Kales SN Liarokapis D Christiani DC [2003] Prospective surveillance of hypertension in firefighters J Clin Hypertens 5315-320
Kales SN Tsismenakis AJ Zhang C Soteriades ES [2009] Blood pressure in fire fighters police officers and other emergency responders Am J Hypertens 2211-20
41
NFPA 1582‐ Draft Revisions for CVDHTN
EKG and stress tests
Reason for Revision
1) Change requirement for annual resting EKG to periodically to be more consistent with ACCAHA
recommendation (Schlant et al 1992)
2) Add language to clarify what constitutes a positive ST
3) Make criteria for conducting diagnostic ST in asymptomatic patients consistent with the
ACCAHA
Language in 2007 Edition with draft revisions in Red (Track changes)
776 Electrocardiograms (EKG)) and Stress Tests 7761 A resting EKG shall be performed as part of the baseline medical evaluation and shall be obtained periodically (every 1 to 5 years) annually thereafter
A7761 A baseline resting EKGs shall be conducted Follow-up resting EKGs should be conducted as clinically indicated but at a minimum of every 1 to 5 years The frequency of these follow-up resting EKGs should increase as a members age increases or with increasing number andor severity of coronary heart disease risk factors Members above the age of 40 should have annual resting EKGs (Schlant et al 1992)
7762 The fire department physician or other qualified medical evaluator shall compare EKGs obtained during yearly evaluations with baseline and subsequent EKGs
7763 Stress testing EKG with or without echocardiography or radionuclide scanning shall be performed as clinically indicated by history or symptoms
A7761 Baseline electrocardiography should be conducted (Periodic resting electrocardiograms have not been shown to be useful but can be reasonable as a members agefactors increase)
A7763 No firm guidelines for stress testingelectrocardiography in asymptomatic individuals have been developed Stress testingelectrocardiography as a screening tool is used as part of an evaluation of aerobic capacity during the annual occupational fitness evaluation Submaximal stress testingelectrocardiography testing to 85 percent is commonly used as part of this screening
Submaximal stress electrocardiography testing should not be used for diagnostic purposes Cardiology evaluation with maximal stress testingelectrocardiography together with imaging techniques (eg echocardiography technetium Tc99m sestamibi study andor coronary angiography) is necessary for diagnosticprognostic purposes for the following
42
(1) Fire fighters with positive or questionably positive changes on screening submaximal stress tests
(2) Fire fighters with new onset chest pain or other symptoms suggestive of coronary artery disease (CAD)
(3) Fire fighters with diabetes mellitus who
(a) are gt35 years old or
(b) have type I diabetes for more than 15 years or
(c) have type II diabetes for more than 10 years or
(d) have any other CHD risk factor (see below) or
(e) have the presence of microvascular disease (proliferative retinopathy)
(4) Fire fighters over the age of 45 (for men) and 55 (for women) with onetwo or more risk factors for CAD Risk factors for CAD include hypercholesterolemia (total cholesterol greater than 240 mgdL) hypertension (systolic gt140 mmHg or diastolic gt90 mmHg) smoking or family history of premature CAD (heart attack or sudden cardiac death in a first degree relative less than 60 years of age)
as defined below if stress electrocardiography with imaging is negative then repeat as clinically indicated or at least every 5 years
(5) Fire fighters with a Framingham Risk Score gt10 Risk calculator is available at [httphp2010nhlbihinnetatpiiicalculatorasp]
(6) Fire fighters identified in 9431
Negative stress tests should be repeated as clinically indicated or at least every 2 to 5 years
Interpreting stress tests as ldquopositiverdquo or ldquonegativerdquo is beyond the scope of this document However factors that should be taken into consideration should include the individualrsquos exercise capacity symptoms blood pressure response heart rate response EKG changes and the presence of arrhythmias (Gibbon et al 2002)
Risk factors for CAD include hypercholesterolemia (total cholesterol greater than 240 mgdL) hypertension (systolic greater than 140 andor diastolic greater than 90) smoking diabetes mellitus or family history of premature CAD (heart attack or sudden cardiac death in a first degree relative less than 60 years of age)
There are other non-invasive tests to screen for coronary artery disease One of the most promising appears to be coronary artery calcium (CAD) scoring by computed tomography In 2007 an expert committee published an update to their original guidance document The committeersquos consensus was that ldquoit may be reasonable to consider use of CAC measurement in such patients [between 10 and 20 10-year risk of estimated coronary event]helliprdquo The committee did not recommend CAC measurement in low risk patients [lt10 10-year risk of estimated coronary event] or in high risk patients [gt20 10-year risk of estimate coronary event] (Greenland et al 2007]
43
D22 Cardiology
Chobanian AV Bakris GL Black HR Cushman WC Green LA Izzo JL Jr Jones DW Materson BJ Oparil S Wright JT Jr Roccella EJ the National High Blood Pressure Education Program Coordinating Committee [2003] The seventh report of the Joint National Committee [JNC-7] on Prevention Detection Evaluation and Treatment of High Blood Pressure JAMA 2892560ndash2571
Gibbons RJ Balady GJ Bricker JT Chaitman BR Fletcher GF Froelicher VF Mark DB McCallister BD Mooss AN OrsquoReilly MG Winters WL Jr [2002] ACCAHA 2002 guideline update for exercise testing summary article a report of the ACCAHA Task Force on Practice Guidelines (Committee to Update the 1997 Exercise Testing guidelines) J Am Coll Cardiol 401531ndash 1540
Greenland et al [2007] ACCFAHA 2007 Clinical Expert Consensus Document on Coronary Artery Calcium Scoring By Computed Tomography in Global Cardiovascular Risk Assessment and in Evaluation of Patients With Chest Pain A Report of the American College of Cardiology Foundation Clinical Expert Consensus Task Force (ACCFAHA Writing Committee to Update the 2000 Expert Consensus Document on Electron Beam Computed Tomography) J Am Coll Cardiol 49378-402
Kales SN Tsismenakis AJ Zhang C Soteriades ES [2009] Blood pressure in fire fighters police officers and other emergency responders Am J Hypertens 2211-20
Schlant RC Adolph RJ DiMarco JP Dreifus LS Dunn MI Fisch C Garson A Jr Haywood LJ Levine HJ Murray JA Noble RJ Ronan JA Jr [1992] Guidelines for electrocardiography A report of the American College of CardiologyAmerican Heart Association Task Force on Assessment of Diagnostic and Therapeutic Cardiovascular Procedures (Committee on Electrocardiography) Circulation 85(3)1221-1228
Soteriades ES Kales SN Liarokapis D Christiani DC [2003] Prospective surveillance of hypertension in firefighters J Clin Hypertens 5315-320
Formatted Font Italic
Formatted Line spacing single
Formatted Font Italic
Formatted Font Italic
44
NFPA 1582‐ Draft Revisions for CVDHTN
EKG and stress tests
Reason for Revision
1) Change requirement for annual resting EKG to periodically to be more consistent with ACCAHA
recommendation (Schlant et al 1992)
2) Add language to clarify what constitutes a positive ST
3) Make criteria for conducting diagnostic ST in asymptomatic patients consistent with the
ACCAHA
Language in 2007 Edition with draft revisions in Red (Track changes)
776 Electrocardiograms (EKG) and Stress Tests 7761 A resting EKG shall be performed as part of the baseline medical evaluation and shall be obtained periodically (every 1 to 5 years) thereafter
A7761 A baseline resting EKGs shall be conducted Follow-up resting EKGs should be conducted as clinically indicated but at a minimum of every 1 to 5 years The frequency of these follow-up resting EKGs should increase as a members age increases or with increasing number andor severity of coronary heart disease risk factors Members above the age of 40 should have annual resting EKGs (Schlant et al 1992)
7762 The fire department physician or other qualified medical evaluator shall compare baseline and subsequent EKGs
7763 Stress testing with or without echocardiography or radionuclide scanning shall be performed as clinically indicated by history or symptoms
A7763 No firm guidelines for stress testing in asymptomatic individuals have been developed Stress testing as a screening tool is used as part of an evaluation of aerobic capacity during the annual occupational fitness evaluation Submaximal stress testing testing to 85 percent is commonly used as part of this screening
Submaximal stress testing should not be used for diagnostic purposes Cardiology evaluation with maximal stress testing together with imaging techniques (eg echocardiography technetium Tc99m sestamibi study) is necessary for diagnosticprognostic purposes for the following
(1) Fire fighters with positive or questionably positive changes on screening submaximal stress tests
(2) Fire fighters with new onset chest pain or other symptoms suggestive of coronary artery disease (CAD)
45
(3) Fire fighters with diabetes mellitus who
(a) are gt35 years old or
(b) have type I diabetes for more than 15 years or
(c) have type II diabetes for more than 10 years or
(d) have any other CHD risk factor (see below) or
(e) have the presence of microvascular disease (proliferative retinopathy)
(4) Fire fighters over the age of 45 (for men) and 55 (for women) with one or more risk factors for CAD Risk factors for CAD include hypercholesterolemia (total cholesterol greater than 240 mgdL) hypertension (systolic gt140 mmHg or diastolic gt90 mmHg) smoking or family history of premature CAD (heart attack or sudden cardiac death in a first degree relative less than 60 years of age)
(5) Fire fighters with a Framingham Risk Score gt10 Risk calculator is available at [httphp2010nhlbihinnetatpiiicalculatorasp]
(6) Fire fighters identified in 9431
Negative stress tests should be repeated as clinically indicated or at least every 2 to 5 years
Interpreting stress tests as ldquopositiverdquo or ldquonegativerdquo is beyond the scope of this document However factors that should be taken into consideration should include the individualrsquos exercise capacity symptoms blood pressure response heart rate response EKG changes and the presence of arrhythmias (Gibbon et al 2002)
There are other non-invasive tests to screen for coronary artery disease One of the most promising appears to be coronary artery calcium (CAD) scoring by computed tomography In 2007 an expert committee published an update to their original guidance document The committeersquos consensus was that ldquoit may be reasonable to consider use of CAC measurement in such patients [between 10 and 20 10-year risk of estimated coronary event]helliprdquo The committee did not recommend CAC measurement in low risk patients [lt10 10-year risk of estimated coronary event] or in high risk patients [gt20 10-year risk of estimate coronary event] (Greenland et al 2007]
D22 Cardiology
Resting EKG and Stress Tests
46
Chobanian AV Bakris GL Black HR Cushman WC Green LA Izzo JL Jr Jones DW Materson BJ Oparil S Wright JT Jr Roccella EJ the National High Blood Pressure Education Program Coordinating Committee [2003] The seventh report of the Joint National Committee [JNC-7] on Prevention Detection Evaluation and Treatment of High Blood Pressure JAMA 2892560ndash2571
Gibbons RJ Balady GJ Bricker JT Chaitman BR Fletcher GF Froelicher VF Mark DB McCallister BD Mooss AN OrsquoReilly MG Winters WL Jr [2002] ACCAHA 2002 guideline update for exercise testing summary article a report of the ACCAHA Task Force on Practice Guidelines (Committee to Update the 1997 Exercise Testing guidelines) J Am Coll Cardiol 401531ndash 1540
Greenland et al [2007] ACCFAHA 2007 Clinical Expert Consensus Document on Coronary Artery Calcium Scoring By Computed Tomography in Global Cardiovascular Risk Assessment and in Evaluation of Patients With Chest Pain A Report of the American College of Cardiology Foundation Clinical Expert Consensus Task Force (ACCFAHA Writing Committee to Update the 2000 Expert Consensus Document on Electron Beam Computed Tomography) J Am Coll Cardiol 49378-402
Kales SN Tsismenakis AJ Zhang C Soteriades ES [2009] Blood pressure in fire fighters police officers and other emergency responders Am J Hypertens 2211-20
Schlant RC Adolph RJ DiMarco JP Dreifus LS Dunn MI Fisch C Garson A Jr Haywood LJ Levine HJ Murray JA Noble RJ Ronan JA Jr [1992] Guidelines for electrocardiography A report of the American College of CardiologyAmerican Heart Association Task Force on Assessment of Diagnostic and Therapeutic Cardiovascular Procedures (Committee on Electrocardiography) Circulation 85(3)1221-1228
Soteriades ES Kales SN Liarokapis D Christiani DC [2003] Prospective surveillance of hypertension in firefighters J Clin Hypertens 5315-320
47
ATTACHMENT F
48
1
Current 1582 (2007) language in reference to pregnancy 43 (4) Report to the fire department physician any medical condition that could interfere with the ability of the individual to safely perform essential job tasks such as illness or injury use of prescription or nonprescription drugs and pregnancy 6112 Category B medical conditions shall include the following (1) Pregnancy for its duration A7792 (e) If HIV prophylaxis is to be given the following tests should be done i CBC ii Glucose renal and hepatic chemical function iii Pregnancy test for females B121 Pregnancy and Reproduction Federal regulations as well as many court decisions including the US Supreme Courtrsquos decision in International Union et al v Johnson Controls Inc [499 US 187 111 S Ct 1196 (1991)] have interpreted the requirements of Title VII with respect to pregnancy and reproduction The AHJ should seek the advice of counsel in resolving specific questions concerning these requirements as well as other requirements that can be imposed by state or local laws C211 (4) Review health status with the individual being evaluated Contraindications for evaluations shall be reviewed addressing any changes in the individualrsquos health status since their last medical evaluation that would warrant deferring the evaluation including (g) Pregnancy Recommendations to language enhancement
A female employee who is assigned to regular fire line duty shall report a pregnancy immediately to their respective Supervisor and the fire department physician The employee will then be given the option of a non-hazardous alternative duty position for the duration of her pregnancy (can we say this or is it even appropriate) Any pregnant employee wishing to remain on regular line duty shall be informed of the possible risks and consequences to herself and her fetus that are associated with continued line fire fighting duty Among those risk factors are exposure to teratogens known to have negative effects on the developing fetus such as smoke diesel fumes hazardous chemicals and extreme heat
49
Page 2
appendix It is recommended that the pregnant employee complete a release of liability form signed by herself and her health care provider utilizing NFPArsquos 13 critical tasks as a reference This will inform the health care provider of specific job-related tasks that will need to be performed in order to continue regular line duty These tasks are basic physical standards that any entry level firefighter would have to be able to complete competently The employeersquos health condition will be kept confidential by the department in accordance with HIPAA standards Employees are allowed to remain on active regular duty until they are no longer able to perform their duties in a reasonable manner andor their protective gear no longer fits correctly It is the responsibility of the health care provider to evaluate the pregnant employee If at any time the health care provider feels the pregnant employee can no longer perform the job related tasks this should be reported to the employer by the employee immediately
50
ATTACHMENT G
51
From GLENN BENARICKTo Sawyer SteveSubject RE RE 7743Date Monday August 30 2010 21633 PM
Yes thats my understanding
Glenn P Benarick 211 Winged Elm CircleAiken SC 29803803-644-7093gbenarprodigynet
--- On Mon 83010 Sawyer Steve ltssawyerNFPAorggt wrote
From Sawyer Steve ltssawyerNFPAorggtSubject RE RE 7743To GLENN BENARICK ltgbenarprodigynetgtDate Monday August 30 2010 212 PM
So it should be ldquoorrdquo instead of ldquoandrdquo for now
Steven F Sawyer
Senior Fire Service Specialist
Executive Secretary IFMAFire Service Section
NFPA
1 Batterymarch Park
Quincy MA 02169
6179847423
Fax 6179847056
ssawyernfpaorg
From GLENN BENARICK [mailtogbenarprodigynet] Sent Monday August 30 2010 1202 PMTo Sawyer SteveSubject Fw RE 7743
52
Steve a couple of our docs agree with April Boyer
Glenn P Benarick 211 Winged Elm Circle
Aiken SC 29803
803-644-7093
gbenarprodigynet
--- On Mon 83010 David Prezant ltprezandfdnynycgovgt wrote
From David Prezant ltprezandfdnynycgovgtSubject RE 7743To Thomas R (CDCNIOSHDSHEFS) Hales lttrh1cdcgovgt GLENNBENARICK ltgbenarprodigynetgtCc Sandy Bogucki ltsandyboguckiyaleedugtDate Monday August 30 2010 1004 AM
agree
we should change this to NHANES III rather than Knudson we should alsomodify this to allow not only for predicted cutoffs but all for use of thelower limit of normal cutoff This is important to prevent false-classificationof spirometry as abnormal in older groups and in taller grps The latter ofparticular import to firefighter occupational health surveillance
thanks
David Prezant MDChief Medical Officer Office of Medical AffairsCo-Director WTC Medical Monitoring amp Treatment ProgramsNew York City Fire Department9 Metrotech Center - Rm 4W-1Brooklyn NY 11201Phone 718-999-2696Fax 718-999-0665
Life is full of twists and turns
53
This email may contain confidential information If you are the unintendedrecipient of this email please send it back and delete from your directory
gtgtgt Hales Thomas R (CDCNIOSHDSHEFS) lttrh1cdcgovgt 8302010955 AM gtgtgt
Glen
This seems like a very reasonable comment and illustrates the importance of having clinicians providefeedback on the std Im not familiar with the software program of the various spirometers (NHANES IIIvs KnudsonATS vs both) Given the large role both Dave Prezant and Sandy Bogucki had for thepulmonary section let me forward to them for clarification
Tom
From GLENN BENARICK [mailtogbenarprodigynet] Sent Sunday August 29 2010 456 PMTo Hales Thomas R (CDCNIOSHDSHEFS)Subject FW 7743
Tom is April Boyer correct
Glenn P Benarick 211 Winged Elm Circle
Aiken SC 29803
803-644-7093
gbenarprodigynet
--- On Thu 82610 Sawyer Steve ltssawyerNFPAorggt wrote
From Sawyer Steve ltssawyerNFPAorggtSubject FW 7743To GLENN BENARICK ltgbenarprodigynetgtDate Thursday August 26 2010 925 PM
FYI Do you have any answer She is write
Steven
54
Steven F Sawyer
Senior Fire Service Specialist
Executive Secretary IFMAFire Service Section
NFPA
1 Batterymarch Park
Quincy MA 02169
6179847423
Fax 6179847056
ssawyernfpaorg
From April Boyer [mailtoaboyerbicclinicorg] Sent Thursday August 26 2010 232 PMTo Sawyer SteveCc RobinMWebbmilstateorusSubject 7743
Steven
The spirometry tests cannot be corrected according to both references as the NFPA states because thereferences are contradictory The first part of 7743 states to follow the ATS guidelines and use theKnudsen (we at Basin Immediate Care use the Nhanes III) The second part states to follow the ACOEMguidelines and use the Nhanes III in the occupational setting if available with your unit (which is availableon ours) 7743 does not use the word OR regarding both requirements it uses the word AND whenreferring to the first and second parts thence making 7743 contradictory I realize the NFPA 1582 hasnot been updated since 2007 unless I have just not received an updated version
Our question to you is which part of 7743 do you want us to follow the first or the second part Anyfacility that has an updated computerized spirometry system (as we do) will not be able to follow bothrequired parts for obvious reasons We can either follow the first part of 7743 and use an oldercorrected version of the Knudson by going into our system and changing out of the Nhanes III conversionOR we can follow the second part of 7743 and use the newer corrected version of Nhanes III which ourunit offers too
If you have any questions you may contact me at anytime and I also have many references in regards toboth parts of 7743 if you would like to see them
55
Thank you~
April
Confidentiality NoticeThis message may contain information that isconfidential or privileged
If you are not the intended recipientPlease advise the sender immediately and delete this message
56
ATTACHMENT H
57
NFPA 1582 771(7) Proposed revisions
Why
Preliminary results of two prospective randomized trials on the PSA test were published in 2009 These studies resulted in medical organizations that previously providing guidance to modify their recommendations
Current language
771 Blood Tests Blood tests shall be performed annually and shall include the following
(7) Prostate specific antigen (PSA) after age 40 for positive family history if African American or if otherwise clinically indicated after age 50 for all other male member
Suggested Revision
771 Blood Tests Blood tests shall be performed annually and shall include the following
(7) Prostate specific antigen (PSA) after age 40 for positive family history if African American or if otherwise clinically indicated after age 50 for all other male member
772 Prostate-Specific Antigen (PSA) test At age 50 fire fighters shall have an opportunity to make an informed decision with either the Fire Department physician or their health care provider concerning the PSA test For fire fighters at increased risk of prostate cancer (African-Americans or those with a first degree relative diagnosed with prostate cancer before age 65) shall have the opportunity for this informed decision at age 40
A772 The PSA as a screening test for prostate cancer in asymptomatic men is controversial controversial for two reasons First there is no consensus that PSA screening actually saves lives For example the PSA test may detect small cancers that would never become life threatening Second it is unclear that the benefits of PSA screening outweigh the risks of follow-up diagnostic tests and cancer treatments For example the prostate biopsy used to diagnose prostate cancer may cause bleeding and infection And prostate cancer treatments such as surgery and radiation therapy may cause incontinence (inability to control urine flow) erectile dysfunction (erections inadequate for intercourse) and other complications For these reasons it is important that the benefits and risks of prostate diagnostic procedures and treatment be taken into account when considering the PSA screening test These considerations can be taken account during discussions with the fire department physician or onersquos health care provider
D211 Cancer Screening
Smith R A C J Mettlin K J Davis and H Eyre 2000 ldquoAmerican Cancer Society guidelines for the early detection of cancerrdquo CA J Clin 50(1)34ndash49
Added references
58
Carroll P Albertsen PC Greene K et al [2010] Prostate-specific antigen best practice statement 2009 update Am Urological Assoc Available at httpwwwauanetorgcontentguidelines-and-quality-careclinical-guidelinesmain-reportspsa09pdf Date accessed September 2010
Ferrini R Woolf SH [2009] Screening for prostate cancer in American men American College of Preventive Medicine Practice Policy Statement Available at httpwwwacpmorgprostatehtm Date accessed September 2010
National Cancer Institute [2009] Prostate-specific antigen test National Cancer Institute Fact Sheet Available at httpwwwcancergovcancertopicsfactsheetDetectionPSA Date accessed September 2010
Wolf AMD Wender RC Etzioni RB et al [2010] American Cancer Society guideline for the early detection of prostate cancer Update 2010 Available at httpcaonlineamcancersocorgcgicontentfullcaac20066v1 Date accessed September 2010
59
9420 Uncontrolled Hypertension 94201 Physician Evaluation Severe uncontrolled hypertension [defined as systolic pressure greater than 180 mm Hg diastolic pressure greater than 100 mm Hg or mean systolic blood
pressure ( systolic + diastolic) greater than 120 mm Hg] or malignant hypertension (defined as hypertension with the presence of target organ damage) compromises the members ability to safely perform essential job tasks 1 5 7 9 and 13 and the physician shall report the applicable job limitations to the fire department
Members with Pre-hypertention (systolic 120-139 mmHg or diastolic 80-89 mmHg) Stage 1 hypertension (systolic 140-159 mmHg or diastolic 90-99 mmHg) or Stage 2 hypertension (systolic ge160 mmHg or diastolic ge100 mmHg) should be referred to their primary care physician for evaluation lifestyle modification and treatment
(1) Members with Stage I hypertension should be followed-up not only by their primary care physician but also by the FD physician every 3 to 6 months to ensure their blood pressure is under control and to determine whether screening tests for asymptomatic end organ damage are appropriate
(2) Members with Stage 2 hypertension or with end organ damage (retinopathy nephropathy vascular or cardiac complications) compromises the members ability to safely perform essential job tasks 1 5 7 9 and 130 and the physician shall report the applicable job limitations to the fire department
A94201 Severe uncontrolled hypertension is a significant risk factor for the development of coronary artery disease congestive heart failure and stroke Blood pressure increases as a normal response to exercise This response is further exaggerated by the emotional and physical stress of performing these critical tasks while operating in personal protective clothing at extremes of temperature This normal elevation of blood pressure under these response conditions can lead to life-threatening hypertensive emergencies if a members daily blood pressure is already elevated to high levels In addition hypertension is a progressive illness that when uncontrolled ultimately and inevitably leads to target organ damage Target organs that are sensitive to the effects of elevated blood pressure are the central nervous system vision heart major blood vessels and kidneys
Chronic hypertension can damage the eye (retinopathy) the kidneys (nephropathy) the vascular system (stroke transient ischemic attack or peripheral artery disease) or the heart (left ventricular hypertrophy and heart failure) These hypertension complications are known as end organ damage The cardiac and vascular complications are associated with an increased risk of sudden incapacitation and sudden cardiac death (Koren et al 1991) Fortunately with proper evaluation life style modification and treatment these complications can be avoided Life style modification includes weight reduction DASH eating plan reduction in dietary sodium an increase in aerobic physical activity and moderation in alcohol consumption [Chobanian 2003]
Formatted Font (Default) Times New Roman12 pt Font color Black
Formatted Font (Default) Times New Roman12 pt Font color Black
35
A94201 (1) Members with Stage I hypertension whose BP returns to either pre-hypertenion or normal with lifestyle modification andor treatment can return to an annual medical evaluation For members with long-standing Stage I hypertension whose BP has not been reduced additional evaluation for possible end organ damage should be considered This evaluation could include any or all of the following
a) a compete patient history for symptoms of heart failure (eg shortness of breath upon exertion) or transient ischemic attacks (TIAs)
b) dilated eye examination for retinopathy
c) blood creatinine measurement for nephropathy
d) tests for left ventricular hypertrophy Unfortunately use of the resting EKG to detect left ventricular hypertrophy is very insensitive (eg 5 sensitivity) The echocardiogram is the best test for diagnosing left ventricular hypertrophy
A 94201 (2) Due to the high risk of a sudden cardiovascular event members with Stage 2 hypertension should be restricted until their BP can be brought under control Once the BP is brought under control they should be followed in the same manner as a member with Stage I hypertension
Formatted Font (Default) Times New Roman12 pt
36
D22 Cardiology Gibbons R J GJ Balady J W Beasley et al 1997 ACCAHA guidelines for exercise testing a report of American College of CardiologyAmerican Heart Association Task Force on Practice Guidelines (Committee on Exercise Testing) J Am Coll Cardiol 30260ndash311
Gibbons RJ Balady GJ Bricker JT Chaitman BR Fletcher GF Froelicher VF Mark DB McCallister BD Mooss AN OrsquoReilly MG Winters WL Jr [2002] ACCAHA 2002 guideline update for exercise testing summary article a report of the ACCAHA Task Force on Practice Guidelines (Committee to Update the 1997 Exercise Testing guidelines) J Am Coll Cardiol 401531ndash 40
Chobanian AV Bakris GL Black HR Cushman WC Green LA Izzo JL Jr Jones DW Materson BJ Oparil S Wright JT Jr Roccella EJ the National High Blood Pressure Education Program Coordinating Committee [2003] The seventh report of the Joint National Committee [JNC-7] on Prevention Detection Evaluation and Treatment of High Blood Pressure JAMA 2892560ndash2571
Soteriades ES Kales SN Liarokapis D Christiani DC [2003] Prospective surveillance of hypertension in firefighters J Clin Hypertens 5315-320
Kales SN Tsismenakis AJ Zhang C Soteriades ES [2009] Blood pressure in fire fighters police officers and other emergency responders Am J Hypertens 2211-20
37
NFPA 1582‐ HTN Draft 1
Reason for Revision
1) New classification of BP by the Joint National Commission [Chobanian et al 2002]
2) A high prevalence of FF have either HTN (~20) and Pre‐HTN (~20) [Soteriades et al 2003]
3) Among FF studies have shown a strong association between HTN and a number of adverse
cardiovascular events [Kales et al 2009]
4) A large percentage of on‐duty FF fatalities were found to have left ventricular hypertrophy a
complication of HTN at autopsy
Language in 2007 Edition with draft revisions in Red (Track changes)
611 The medical evaluation of a candidate shall include a medical history examination and any laboratory tests required to detect physical or medical condition(s) that could adversely affect hisher ability to safely perform the essential job tasks outlined in 511 A611 The medical history should include the candidates known health problems such as major illnesses surgeries medication use and allergies Symptom review is also important for detecting early signs of illness A medical history should also include a personal health history a family health history a health habit history an immunization history and a reproductive history
An occupational history should also be obtained to collect information about the persons past occupational and environmental exposures
(a) BP should be measured according to the Joint National Commission (JNC) -7 recommendations BP should be measured with a properly calibrated and validated instrument Patients should be seated quietly for at least 5 minutes in a chair with feet on the floor and arm supported at heart level An appropriate-sized cuff (cuff bladder encircling at least 80 of the arm) should be used to ensure accuracy At least 2 measurements should be made Systolic BP is the point at which the first of 2 or more sounds is heard (phase 1) and diastolic BP is the point before the disappearance of sounds (phase 5) [Chobanian et al 2003]
(2) Head eyes ears nose and throat
38
692 Vascular System 6921 Category A medical conditions shall include the following
(1) Uncontrolled or poorly controlled hypertension
(2) Hypertension with evidence of end organ damage
A6921(1) Uncontrolled or poorly controlled hypertension increases the risk of a sudden cardiac event This sudden cardiac event would cause sudden incapacitation which interferes with the safe performance of essential job tasks Uncontrolled or poorly controlled hypertension can be defined as the presence of end organ damage (see below) or stage 2 hypertension (BP systolic gt160 mmHg or BP diastolic gt100 mmHg) Individuals with pre- stage 1 or stage 2 hypertension should be referred to their primary care physician for evaluation lifestyle modification and treatment [QUESTION FOR GROUP _- WHAT ABOUT HAVING CANDIDATE RETURN IN ONE MONTH UNDER TREATMENT WITH NORMAL BP]
A6921(2)Chronic hypertension can damage the eye (retinopathy) the kidneys (nephropathy) the vascular system (stroke transient ischemic attack or peripheral artery disease) or the heart (left ventricular hypertrophy and heart failure) These hypertension complications are known as end organ damage The cardiac and vascular complications are associated with an increased risk of sudden incapacitation and sudden cardiac death (Koren et al 1991) Unfortunately the cardiac complications are frequently asymptomatic and valid screening tests are not fast and are not inexpensive Therefore determining who to screen for cardiac complications (such as echocardiogram for LVH or a measurement of left ventricular ejection fraction for heart failure) should be based on the severity and the duration of HTN
76 Physical Examination The annual physical examination shall include each of the following components
(a) BP shall be measured according to the Joint National Commission (JNC)-7 recommendations
A76(1)(a) BP should be measured with a properly calibrated and validated instrument Patients should be seated quietly for at least 5 minutes in a chair with feet on the floor and arm supported at heart level An appropriate-sized cuff (cuff bladder encircling at least 80 of the arm) should be used to ensure accuracy At least 2 measurements should be made Systolic BP is the point at which the first of 2 or more sounds is heard (phase 1) and diastolic BP is the point before the disappearance of sounds (phase 5) [Chobanian et al 2003]
(2) Head eyes ears nose and throat9420 Hypertension 94201 Physician Evaluation Members with Pre-hypertention (systolic 120-139 mmHg or diastolic 80-89 mmHg) Stage 1 hypertension (systolic 140-159 mmHg or diastolic 90-99 mmHg) or Stage 2 hypertension (systolic ge160 mmHg or diastolic ge100 mmHg) should be referred to their primary care physician for evaluation lifestyle modification and treatment
39
(1) Members with Stage I hypertension should be followed-up not only by their primary care physician but also by the FD physician every 3 to 6 months to ensure their blood pressure is under control and to determine whether screening tests for asymptomatic end organ damage are appropriate
(2) Members with Stage 2 hypertension or with end organ damage (retinopathy nephropathy vascular or cardiac complications) compromises the members ability to safely perform essential job tasks 1 5 7 9 and 130 and the physician shall report the applicable job limitations to the fire department
A94201 Chronic hypertension can damage the eye (retinopathy) the kidneys (nephropathy) the vascular system (stroke transient ischemic attack or peripheral artery disease) or the heart (left ventricular hypertrophy and heart failure) These hypertension complications are known as end organ damage The cardiac and vascular complications are associated with an increased risk of sudden incapacitation and sudden cardiac death (Koren et al 1991) Fortunately with proper evaluation life style modification and treatment these complications can be avoided Life style modification includes weight reduction DASH eating plan reduction in dietary sodium an increase in aerobic physical activity and moderation in alcohol consumption [Chobanian 2003]
A94201 (1) Members with Stage I hypertension whose BP returns to either pre-hypertenion or normal with lifestyle modification andor treatment can return to an annual medical evaluation For members with long-standing Stage I hypertension whose BP has not been reduced additional evaluation for possible end organ damage should be considered This evaluation could include any or all of the following
a) a compete patient history for symptoms of heart failure (eg shortness of breath upon exertion) or transient ischemic attacks (TIAs)
b) dilated eye examination for retinopathy
c) blood creatinine measurement for nephropathy
d) tests for left ventricular hypertrophy Unfortunately use of the resting EKG to detect left ventricular hypertrophy is very insensitive (eg 5 sensitivity) The echocardiogram is the best test for diagnosing left ventricular hypertrophy
A 94201 (2) Due to the high risk of a sudden cardiovascular event members with Stage 2 hypertension should be restricted until their BP can be brought under control Once the BP is brought under control they should be followed in the same manner as a member with Stage I hypertension
D22 Cardiology
40
Hypertension
Gibbons RJ Balady GJ Bricker JT Chaitman BR Fletcher GF Froelicher VF Mark DB McCallister BD Mooss AN OrsquoReilly MG Winters WL Jr [2002] ACCAHA 2002 guideline update for exercise testing summary article a report of the ACCAHA Task Force on Practice Guidelines (Committee to Update the 1997 Exercise Testing guidelines) J Am Coll Cardiol 401531ndash 40
Chobanian AV Bakris GL Black HR Cushman WC Green LA Izzo JL Jr Jones DW Materson BJ Oparil S Wright JT Jr Roccella EJ the National High Blood Pressure Education Program Coordinating Committee [2003] The seventh report of the Joint National Committee [JNC-7] on Prevention Detection Evaluation and Treatment of High Blood Pressure JAMA 2892560ndash2571
Soteriades ES Kales SN Liarokapis D Christiani DC [2003] Prospective surveillance of hypertension in firefighters J Clin Hypertens 5315-320
Kales SN Tsismenakis AJ Zhang C Soteriades ES [2009] Blood pressure in fire fighters police officers and other emergency responders Am J Hypertens 2211-20
41
NFPA 1582‐ Draft Revisions for CVDHTN
EKG and stress tests
Reason for Revision
1) Change requirement for annual resting EKG to periodically to be more consistent with ACCAHA
recommendation (Schlant et al 1992)
2) Add language to clarify what constitutes a positive ST
3) Make criteria for conducting diagnostic ST in asymptomatic patients consistent with the
ACCAHA
Language in 2007 Edition with draft revisions in Red (Track changes)
776 Electrocardiograms (EKG)) and Stress Tests 7761 A resting EKG shall be performed as part of the baseline medical evaluation and shall be obtained periodically (every 1 to 5 years) annually thereafter
A7761 A baseline resting EKGs shall be conducted Follow-up resting EKGs should be conducted as clinically indicated but at a minimum of every 1 to 5 years The frequency of these follow-up resting EKGs should increase as a members age increases or with increasing number andor severity of coronary heart disease risk factors Members above the age of 40 should have annual resting EKGs (Schlant et al 1992)
7762 The fire department physician or other qualified medical evaluator shall compare EKGs obtained during yearly evaluations with baseline and subsequent EKGs
7763 Stress testing EKG with or without echocardiography or radionuclide scanning shall be performed as clinically indicated by history or symptoms
A7761 Baseline electrocardiography should be conducted (Periodic resting electrocardiograms have not been shown to be useful but can be reasonable as a members agefactors increase)
A7763 No firm guidelines for stress testingelectrocardiography in asymptomatic individuals have been developed Stress testingelectrocardiography as a screening tool is used as part of an evaluation of aerobic capacity during the annual occupational fitness evaluation Submaximal stress testingelectrocardiography testing to 85 percent is commonly used as part of this screening
Submaximal stress electrocardiography testing should not be used for diagnostic purposes Cardiology evaluation with maximal stress testingelectrocardiography together with imaging techniques (eg echocardiography technetium Tc99m sestamibi study andor coronary angiography) is necessary for diagnosticprognostic purposes for the following
42
(1) Fire fighters with positive or questionably positive changes on screening submaximal stress tests
(2) Fire fighters with new onset chest pain or other symptoms suggestive of coronary artery disease (CAD)
(3) Fire fighters with diabetes mellitus who
(a) are gt35 years old or
(b) have type I diabetes for more than 15 years or
(c) have type II diabetes for more than 10 years or
(d) have any other CHD risk factor (see below) or
(e) have the presence of microvascular disease (proliferative retinopathy)
(4) Fire fighters over the age of 45 (for men) and 55 (for women) with onetwo or more risk factors for CAD Risk factors for CAD include hypercholesterolemia (total cholesterol greater than 240 mgdL) hypertension (systolic gt140 mmHg or diastolic gt90 mmHg) smoking or family history of premature CAD (heart attack or sudden cardiac death in a first degree relative less than 60 years of age)
as defined below if stress electrocardiography with imaging is negative then repeat as clinically indicated or at least every 5 years
(5) Fire fighters with a Framingham Risk Score gt10 Risk calculator is available at [httphp2010nhlbihinnetatpiiicalculatorasp]
(6) Fire fighters identified in 9431
Negative stress tests should be repeated as clinically indicated or at least every 2 to 5 years
Interpreting stress tests as ldquopositiverdquo or ldquonegativerdquo is beyond the scope of this document However factors that should be taken into consideration should include the individualrsquos exercise capacity symptoms blood pressure response heart rate response EKG changes and the presence of arrhythmias (Gibbon et al 2002)
Risk factors for CAD include hypercholesterolemia (total cholesterol greater than 240 mgdL) hypertension (systolic greater than 140 andor diastolic greater than 90) smoking diabetes mellitus or family history of premature CAD (heart attack or sudden cardiac death in a first degree relative less than 60 years of age)
There are other non-invasive tests to screen for coronary artery disease One of the most promising appears to be coronary artery calcium (CAD) scoring by computed tomography In 2007 an expert committee published an update to their original guidance document The committeersquos consensus was that ldquoit may be reasonable to consider use of CAC measurement in such patients [between 10 and 20 10-year risk of estimated coronary event]helliprdquo The committee did not recommend CAC measurement in low risk patients [lt10 10-year risk of estimated coronary event] or in high risk patients [gt20 10-year risk of estimate coronary event] (Greenland et al 2007]
43
D22 Cardiology
Chobanian AV Bakris GL Black HR Cushman WC Green LA Izzo JL Jr Jones DW Materson BJ Oparil S Wright JT Jr Roccella EJ the National High Blood Pressure Education Program Coordinating Committee [2003] The seventh report of the Joint National Committee [JNC-7] on Prevention Detection Evaluation and Treatment of High Blood Pressure JAMA 2892560ndash2571
Gibbons RJ Balady GJ Bricker JT Chaitman BR Fletcher GF Froelicher VF Mark DB McCallister BD Mooss AN OrsquoReilly MG Winters WL Jr [2002] ACCAHA 2002 guideline update for exercise testing summary article a report of the ACCAHA Task Force on Practice Guidelines (Committee to Update the 1997 Exercise Testing guidelines) J Am Coll Cardiol 401531ndash 1540
Greenland et al [2007] ACCFAHA 2007 Clinical Expert Consensus Document on Coronary Artery Calcium Scoring By Computed Tomography in Global Cardiovascular Risk Assessment and in Evaluation of Patients With Chest Pain A Report of the American College of Cardiology Foundation Clinical Expert Consensus Task Force (ACCFAHA Writing Committee to Update the 2000 Expert Consensus Document on Electron Beam Computed Tomography) J Am Coll Cardiol 49378-402
Kales SN Tsismenakis AJ Zhang C Soteriades ES [2009] Blood pressure in fire fighters police officers and other emergency responders Am J Hypertens 2211-20
Schlant RC Adolph RJ DiMarco JP Dreifus LS Dunn MI Fisch C Garson A Jr Haywood LJ Levine HJ Murray JA Noble RJ Ronan JA Jr [1992] Guidelines for electrocardiography A report of the American College of CardiologyAmerican Heart Association Task Force on Assessment of Diagnostic and Therapeutic Cardiovascular Procedures (Committee on Electrocardiography) Circulation 85(3)1221-1228
Soteriades ES Kales SN Liarokapis D Christiani DC [2003] Prospective surveillance of hypertension in firefighters J Clin Hypertens 5315-320
Formatted Font Italic
Formatted Line spacing single
Formatted Font Italic
Formatted Font Italic
44
NFPA 1582‐ Draft Revisions for CVDHTN
EKG and stress tests
Reason for Revision
1) Change requirement for annual resting EKG to periodically to be more consistent with ACCAHA
recommendation (Schlant et al 1992)
2) Add language to clarify what constitutes a positive ST
3) Make criteria for conducting diagnostic ST in asymptomatic patients consistent with the
ACCAHA
Language in 2007 Edition with draft revisions in Red (Track changes)
776 Electrocardiograms (EKG) and Stress Tests 7761 A resting EKG shall be performed as part of the baseline medical evaluation and shall be obtained periodically (every 1 to 5 years) thereafter
A7761 A baseline resting EKGs shall be conducted Follow-up resting EKGs should be conducted as clinically indicated but at a minimum of every 1 to 5 years The frequency of these follow-up resting EKGs should increase as a members age increases or with increasing number andor severity of coronary heart disease risk factors Members above the age of 40 should have annual resting EKGs (Schlant et al 1992)
7762 The fire department physician or other qualified medical evaluator shall compare baseline and subsequent EKGs
7763 Stress testing with or without echocardiography or radionuclide scanning shall be performed as clinically indicated by history or symptoms
A7763 No firm guidelines for stress testing in asymptomatic individuals have been developed Stress testing as a screening tool is used as part of an evaluation of aerobic capacity during the annual occupational fitness evaluation Submaximal stress testing testing to 85 percent is commonly used as part of this screening
Submaximal stress testing should not be used for diagnostic purposes Cardiology evaluation with maximal stress testing together with imaging techniques (eg echocardiography technetium Tc99m sestamibi study) is necessary for diagnosticprognostic purposes for the following
(1) Fire fighters with positive or questionably positive changes on screening submaximal stress tests
(2) Fire fighters with new onset chest pain or other symptoms suggestive of coronary artery disease (CAD)
45
(3) Fire fighters with diabetes mellitus who
(a) are gt35 years old or
(b) have type I diabetes for more than 15 years or
(c) have type II diabetes for more than 10 years or
(d) have any other CHD risk factor (see below) or
(e) have the presence of microvascular disease (proliferative retinopathy)
(4) Fire fighters over the age of 45 (for men) and 55 (for women) with one or more risk factors for CAD Risk factors for CAD include hypercholesterolemia (total cholesterol greater than 240 mgdL) hypertension (systolic gt140 mmHg or diastolic gt90 mmHg) smoking or family history of premature CAD (heart attack or sudden cardiac death in a first degree relative less than 60 years of age)
(5) Fire fighters with a Framingham Risk Score gt10 Risk calculator is available at [httphp2010nhlbihinnetatpiiicalculatorasp]
(6) Fire fighters identified in 9431
Negative stress tests should be repeated as clinically indicated or at least every 2 to 5 years
Interpreting stress tests as ldquopositiverdquo or ldquonegativerdquo is beyond the scope of this document However factors that should be taken into consideration should include the individualrsquos exercise capacity symptoms blood pressure response heart rate response EKG changes and the presence of arrhythmias (Gibbon et al 2002)
There are other non-invasive tests to screen for coronary artery disease One of the most promising appears to be coronary artery calcium (CAD) scoring by computed tomography In 2007 an expert committee published an update to their original guidance document The committeersquos consensus was that ldquoit may be reasonable to consider use of CAC measurement in such patients [between 10 and 20 10-year risk of estimated coronary event]helliprdquo The committee did not recommend CAC measurement in low risk patients [lt10 10-year risk of estimated coronary event] or in high risk patients [gt20 10-year risk of estimate coronary event] (Greenland et al 2007]
D22 Cardiology
Resting EKG and Stress Tests
46
Chobanian AV Bakris GL Black HR Cushman WC Green LA Izzo JL Jr Jones DW Materson BJ Oparil S Wright JT Jr Roccella EJ the National High Blood Pressure Education Program Coordinating Committee [2003] The seventh report of the Joint National Committee [JNC-7] on Prevention Detection Evaluation and Treatment of High Blood Pressure JAMA 2892560ndash2571
Gibbons RJ Balady GJ Bricker JT Chaitman BR Fletcher GF Froelicher VF Mark DB McCallister BD Mooss AN OrsquoReilly MG Winters WL Jr [2002] ACCAHA 2002 guideline update for exercise testing summary article a report of the ACCAHA Task Force on Practice Guidelines (Committee to Update the 1997 Exercise Testing guidelines) J Am Coll Cardiol 401531ndash 1540
Greenland et al [2007] ACCFAHA 2007 Clinical Expert Consensus Document on Coronary Artery Calcium Scoring By Computed Tomography in Global Cardiovascular Risk Assessment and in Evaluation of Patients With Chest Pain A Report of the American College of Cardiology Foundation Clinical Expert Consensus Task Force (ACCFAHA Writing Committee to Update the 2000 Expert Consensus Document on Electron Beam Computed Tomography) J Am Coll Cardiol 49378-402
Kales SN Tsismenakis AJ Zhang C Soteriades ES [2009] Blood pressure in fire fighters police officers and other emergency responders Am J Hypertens 2211-20
Schlant RC Adolph RJ DiMarco JP Dreifus LS Dunn MI Fisch C Garson A Jr Haywood LJ Levine HJ Murray JA Noble RJ Ronan JA Jr [1992] Guidelines for electrocardiography A report of the American College of CardiologyAmerican Heart Association Task Force on Assessment of Diagnostic and Therapeutic Cardiovascular Procedures (Committee on Electrocardiography) Circulation 85(3)1221-1228
Soteriades ES Kales SN Liarokapis D Christiani DC [2003] Prospective surveillance of hypertension in firefighters J Clin Hypertens 5315-320
47
ATTACHMENT F
48
1
Current 1582 (2007) language in reference to pregnancy 43 (4) Report to the fire department physician any medical condition that could interfere with the ability of the individual to safely perform essential job tasks such as illness or injury use of prescription or nonprescription drugs and pregnancy 6112 Category B medical conditions shall include the following (1) Pregnancy for its duration A7792 (e) If HIV prophylaxis is to be given the following tests should be done i CBC ii Glucose renal and hepatic chemical function iii Pregnancy test for females B121 Pregnancy and Reproduction Federal regulations as well as many court decisions including the US Supreme Courtrsquos decision in International Union et al v Johnson Controls Inc [499 US 187 111 S Ct 1196 (1991)] have interpreted the requirements of Title VII with respect to pregnancy and reproduction The AHJ should seek the advice of counsel in resolving specific questions concerning these requirements as well as other requirements that can be imposed by state or local laws C211 (4) Review health status with the individual being evaluated Contraindications for evaluations shall be reviewed addressing any changes in the individualrsquos health status since their last medical evaluation that would warrant deferring the evaluation including (g) Pregnancy Recommendations to language enhancement
A female employee who is assigned to regular fire line duty shall report a pregnancy immediately to their respective Supervisor and the fire department physician The employee will then be given the option of a non-hazardous alternative duty position for the duration of her pregnancy (can we say this or is it even appropriate) Any pregnant employee wishing to remain on regular line duty shall be informed of the possible risks and consequences to herself and her fetus that are associated with continued line fire fighting duty Among those risk factors are exposure to teratogens known to have negative effects on the developing fetus such as smoke diesel fumes hazardous chemicals and extreme heat
49
Page 2
appendix It is recommended that the pregnant employee complete a release of liability form signed by herself and her health care provider utilizing NFPArsquos 13 critical tasks as a reference This will inform the health care provider of specific job-related tasks that will need to be performed in order to continue regular line duty These tasks are basic physical standards that any entry level firefighter would have to be able to complete competently The employeersquos health condition will be kept confidential by the department in accordance with HIPAA standards Employees are allowed to remain on active regular duty until they are no longer able to perform their duties in a reasonable manner andor their protective gear no longer fits correctly It is the responsibility of the health care provider to evaluate the pregnant employee If at any time the health care provider feels the pregnant employee can no longer perform the job related tasks this should be reported to the employer by the employee immediately
50
ATTACHMENT G
51
From GLENN BENARICKTo Sawyer SteveSubject RE RE 7743Date Monday August 30 2010 21633 PM
Yes thats my understanding
Glenn P Benarick 211 Winged Elm CircleAiken SC 29803803-644-7093gbenarprodigynet
--- On Mon 83010 Sawyer Steve ltssawyerNFPAorggt wrote
From Sawyer Steve ltssawyerNFPAorggtSubject RE RE 7743To GLENN BENARICK ltgbenarprodigynetgtDate Monday August 30 2010 212 PM
So it should be ldquoorrdquo instead of ldquoandrdquo for now
Steven F Sawyer
Senior Fire Service Specialist
Executive Secretary IFMAFire Service Section
NFPA
1 Batterymarch Park
Quincy MA 02169
6179847423
Fax 6179847056
ssawyernfpaorg
From GLENN BENARICK [mailtogbenarprodigynet] Sent Monday August 30 2010 1202 PMTo Sawyer SteveSubject Fw RE 7743
52
Steve a couple of our docs agree with April Boyer
Glenn P Benarick 211 Winged Elm Circle
Aiken SC 29803
803-644-7093
gbenarprodigynet
--- On Mon 83010 David Prezant ltprezandfdnynycgovgt wrote
From David Prezant ltprezandfdnynycgovgtSubject RE 7743To Thomas R (CDCNIOSHDSHEFS) Hales lttrh1cdcgovgt GLENNBENARICK ltgbenarprodigynetgtCc Sandy Bogucki ltsandyboguckiyaleedugtDate Monday August 30 2010 1004 AM
agree
we should change this to NHANES III rather than Knudson we should alsomodify this to allow not only for predicted cutoffs but all for use of thelower limit of normal cutoff This is important to prevent false-classificationof spirometry as abnormal in older groups and in taller grps The latter ofparticular import to firefighter occupational health surveillance
thanks
David Prezant MDChief Medical Officer Office of Medical AffairsCo-Director WTC Medical Monitoring amp Treatment ProgramsNew York City Fire Department9 Metrotech Center - Rm 4W-1Brooklyn NY 11201Phone 718-999-2696Fax 718-999-0665
Life is full of twists and turns
53
This email may contain confidential information If you are the unintendedrecipient of this email please send it back and delete from your directory
gtgtgt Hales Thomas R (CDCNIOSHDSHEFS) lttrh1cdcgovgt 8302010955 AM gtgtgt
Glen
This seems like a very reasonable comment and illustrates the importance of having clinicians providefeedback on the std Im not familiar with the software program of the various spirometers (NHANES IIIvs KnudsonATS vs both) Given the large role both Dave Prezant and Sandy Bogucki had for thepulmonary section let me forward to them for clarification
Tom
From GLENN BENARICK [mailtogbenarprodigynet] Sent Sunday August 29 2010 456 PMTo Hales Thomas R (CDCNIOSHDSHEFS)Subject FW 7743
Tom is April Boyer correct
Glenn P Benarick 211 Winged Elm Circle
Aiken SC 29803
803-644-7093
gbenarprodigynet
--- On Thu 82610 Sawyer Steve ltssawyerNFPAorggt wrote
From Sawyer Steve ltssawyerNFPAorggtSubject FW 7743To GLENN BENARICK ltgbenarprodigynetgtDate Thursday August 26 2010 925 PM
FYI Do you have any answer She is write
Steven
54
Steven F Sawyer
Senior Fire Service Specialist
Executive Secretary IFMAFire Service Section
NFPA
1 Batterymarch Park
Quincy MA 02169
6179847423
Fax 6179847056
ssawyernfpaorg
From April Boyer [mailtoaboyerbicclinicorg] Sent Thursday August 26 2010 232 PMTo Sawyer SteveCc RobinMWebbmilstateorusSubject 7743
Steven
The spirometry tests cannot be corrected according to both references as the NFPA states because thereferences are contradictory The first part of 7743 states to follow the ATS guidelines and use theKnudsen (we at Basin Immediate Care use the Nhanes III) The second part states to follow the ACOEMguidelines and use the Nhanes III in the occupational setting if available with your unit (which is availableon ours) 7743 does not use the word OR regarding both requirements it uses the word AND whenreferring to the first and second parts thence making 7743 contradictory I realize the NFPA 1582 hasnot been updated since 2007 unless I have just not received an updated version
Our question to you is which part of 7743 do you want us to follow the first or the second part Anyfacility that has an updated computerized spirometry system (as we do) will not be able to follow bothrequired parts for obvious reasons We can either follow the first part of 7743 and use an oldercorrected version of the Knudson by going into our system and changing out of the Nhanes III conversionOR we can follow the second part of 7743 and use the newer corrected version of Nhanes III which ourunit offers too
If you have any questions you may contact me at anytime and I also have many references in regards toboth parts of 7743 if you would like to see them
55
Thank you~
April
Confidentiality NoticeThis message may contain information that isconfidential or privileged
If you are not the intended recipientPlease advise the sender immediately and delete this message
56
ATTACHMENT H
57
NFPA 1582 771(7) Proposed revisions
Why
Preliminary results of two prospective randomized trials on the PSA test were published in 2009 These studies resulted in medical organizations that previously providing guidance to modify their recommendations
Current language
771 Blood Tests Blood tests shall be performed annually and shall include the following
(7) Prostate specific antigen (PSA) after age 40 for positive family history if African American or if otherwise clinically indicated after age 50 for all other male member
Suggested Revision
771 Blood Tests Blood tests shall be performed annually and shall include the following
(7) Prostate specific antigen (PSA) after age 40 for positive family history if African American or if otherwise clinically indicated after age 50 for all other male member
772 Prostate-Specific Antigen (PSA) test At age 50 fire fighters shall have an opportunity to make an informed decision with either the Fire Department physician or their health care provider concerning the PSA test For fire fighters at increased risk of prostate cancer (African-Americans or those with a first degree relative diagnosed with prostate cancer before age 65) shall have the opportunity for this informed decision at age 40
A772 The PSA as a screening test for prostate cancer in asymptomatic men is controversial controversial for two reasons First there is no consensus that PSA screening actually saves lives For example the PSA test may detect small cancers that would never become life threatening Second it is unclear that the benefits of PSA screening outweigh the risks of follow-up diagnostic tests and cancer treatments For example the prostate biopsy used to diagnose prostate cancer may cause bleeding and infection And prostate cancer treatments such as surgery and radiation therapy may cause incontinence (inability to control urine flow) erectile dysfunction (erections inadequate for intercourse) and other complications For these reasons it is important that the benefits and risks of prostate diagnostic procedures and treatment be taken into account when considering the PSA screening test These considerations can be taken account during discussions with the fire department physician or onersquos health care provider
D211 Cancer Screening
Smith R A C J Mettlin K J Davis and H Eyre 2000 ldquoAmerican Cancer Society guidelines for the early detection of cancerrdquo CA J Clin 50(1)34ndash49
Added references
58
Carroll P Albertsen PC Greene K et al [2010] Prostate-specific antigen best practice statement 2009 update Am Urological Assoc Available at httpwwwauanetorgcontentguidelines-and-quality-careclinical-guidelinesmain-reportspsa09pdf Date accessed September 2010
Ferrini R Woolf SH [2009] Screening for prostate cancer in American men American College of Preventive Medicine Practice Policy Statement Available at httpwwwacpmorgprostatehtm Date accessed September 2010
National Cancer Institute [2009] Prostate-specific antigen test National Cancer Institute Fact Sheet Available at httpwwwcancergovcancertopicsfactsheetDetectionPSA Date accessed September 2010
Wolf AMD Wender RC Etzioni RB et al [2010] American Cancer Society guideline for the early detection of prostate cancer Update 2010 Available at httpcaonlineamcancersocorgcgicontentfullcaac20066v1 Date accessed September 2010
59
A94201 (1) Members with Stage I hypertension whose BP returns to either pre-hypertenion or normal with lifestyle modification andor treatment can return to an annual medical evaluation For members with long-standing Stage I hypertension whose BP has not been reduced additional evaluation for possible end organ damage should be considered This evaluation could include any or all of the following
a) a compete patient history for symptoms of heart failure (eg shortness of breath upon exertion) or transient ischemic attacks (TIAs)
b) dilated eye examination for retinopathy
c) blood creatinine measurement for nephropathy
d) tests for left ventricular hypertrophy Unfortunately use of the resting EKG to detect left ventricular hypertrophy is very insensitive (eg 5 sensitivity) The echocardiogram is the best test for diagnosing left ventricular hypertrophy
A 94201 (2) Due to the high risk of a sudden cardiovascular event members with Stage 2 hypertension should be restricted until their BP can be brought under control Once the BP is brought under control they should be followed in the same manner as a member with Stage I hypertension
Formatted Font (Default) Times New Roman12 pt
36
D22 Cardiology Gibbons R J GJ Balady J W Beasley et al 1997 ACCAHA guidelines for exercise testing a report of American College of CardiologyAmerican Heart Association Task Force on Practice Guidelines (Committee on Exercise Testing) J Am Coll Cardiol 30260ndash311
Gibbons RJ Balady GJ Bricker JT Chaitman BR Fletcher GF Froelicher VF Mark DB McCallister BD Mooss AN OrsquoReilly MG Winters WL Jr [2002] ACCAHA 2002 guideline update for exercise testing summary article a report of the ACCAHA Task Force on Practice Guidelines (Committee to Update the 1997 Exercise Testing guidelines) J Am Coll Cardiol 401531ndash 40
Chobanian AV Bakris GL Black HR Cushman WC Green LA Izzo JL Jr Jones DW Materson BJ Oparil S Wright JT Jr Roccella EJ the National High Blood Pressure Education Program Coordinating Committee [2003] The seventh report of the Joint National Committee [JNC-7] on Prevention Detection Evaluation and Treatment of High Blood Pressure JAMA 2892560ndash2571
Soteriades ES Kales SN Liarokapis D Christiani DC [2003] Prospective surveillance of hypertension in firefighters J Clin Hypertens 5315-320
Kales SN Tsismenakis AJ Zhang C Soteriades ES [2009] Blood pressure in fire fighters police officers and other emergency responders Am J Hypertens 2211-20
37
NFPA 1582‐ HTN Draft 1
Reason for Revision
1) New classification of BP by the Joint National Commission [Chobanian et al 2002]
2) A high prevalence of FF have either HTN (~20) and Pre‐HTN (~20) [Soteriades et al 2003]
3) Among FF studies have shown a strong association between HTN and a number of adverse
cardiovascular events [Kales et al 2009]
4) A large percentage of on‐duty FF fatalities were found to have left ventricular hypertrophy a
complication of HTN at autopsy
Language in 2007 Edition with draft revisions in Red (Track changes)
611 The medical evaluation of a candidate shall include a medical history examination and any laboratory tests required to detect physical or medical condition(s) that could adversely affect hisher ability to safely perform the essential job tasks outlined in 511 A611 The medical history should include the candidates known health problems such as major illnesses surgeries medication use and allergies Symptom review is also important for detecting early signs of illness A medical history should also include a personal health history a family health history a health habit history an immunization history and a reproductive history
An occupational history should also be obtained to collect information about the persons past occupational and environmental exposures
(a) BP should be measured according to the Joint National Commission (JNC) -7 recommendations BP should be measured with a properly calibrated and validated instrument Patients should be seated quietly for at least 5 minutes in a chair with feet on the floor and arm supported at heart level An appropriate-sized cuff (cuff bladder encircling at least 80 of the arm) should be used to ensure accuracy At least 2 measurements should be made Systolic BP is the point at which the first of 2 or more sounds is heard (phase 1) and diastolic BP is the point before the disappearance of sounds (phase 5) [Chobanian et al 2003]
(2) Head eyes ears nose and throat
38
692 Vascular System 6921 Category A medical conditions shall include the following
(1) Uncontrolled or poorly controlled hypertension
(2) Hypertension with evidence of end organ damage
A6921(1) Uncontrolled or poorly controlled hypertension increases the risk of a sudden cardiac event This sudden cardiac event would cause sudden incapacitation which interferes with the safe performance of essential job tasks Uncontrolled or poorly controlled hypertension can be defined as the presence of end organ damage (see below) or stage 2 hypertension (BP systolic gt160 mmHg or BP diastolic gt100 mmHg) Individuals with pre- stage 1 or stage 2 hypertension should be referred to their primary care physician for evaluation lifestyle modification and treatment [QUESTION FOR GROUP _- WHAT ABOUT HAVING CANDIDATE RETURN IN ONE MONTH UNDER TREATMENT WITH NORMAL BP]
A6921(2)Chronic hypertension can damage the eye (retinopathy) the kidneys (nephropathy) the vascular system (stroke transient ischemic attack or peripheral artery disease) or the heart (left ventricular hypertrophy and heart failure) These hypertension complications are known as end organ damage The cardiac and vascular complications are associated with an increased risk of sudden incapacitation and sudden cardiac death (Koren et al 1991) Unfortunately the cardiac complications are frequently asymptomatic and valid screening tests are not fast and are not inexpensive Therefore determining who to screen for cardiac complications (such as echocardiogram for LVH or a measurement of left ventricular ejection fraction for heart failure) should be based on the severity and the duration of HTN
76 Physical Examination The annual physical examination shall include each of the following components
(a) BP shall be measured according to the Joint National Commission (JNC)-7 recommendations
A76(1)(a) BP should be measured with a properly calibrated and validated instrument Patients should be seated quietly for at least 5 minutes in a chair with feet on the floor and arm supported at heart level An appropriate-sized cuff (cuff bladder encircling at least 80 of the arm) should be used to ensure accuracy At least 2 measurements should be made Systolic BP is the point at which the first of 2 or more sounds is heard (phase 1) and diastolic BP is the point before the disappearance of sounds (phase 5) [Chobanian et al 2003]
(2) Head eyes ears nose and throat9420 Hypertension 94201 Physician Evaluation Members with Pre-hypertention (systolic 120-139 mmHg or diastolic 80-89 mmHg) Stage 1 hypertension (systolic 140-159 mmHg or diastolic 90-99 mmHg) or Stage 2 hypertension (systolic ge160 mmHg or diastolic ge100 mmHg) should be referred to their primary care physician for evaluation lifestyle modification and treatment
39
(1) Members with Stage I hypertension should be followed-up not only by their primary care physician but also by the FD physician every 3 to 6 months to ensure their blood pressure is under control and to determine whether screening tests for asymptomatic end organ damage are appropriate
(2) Members with Stage 2 hypertension or with end organ damage (retinopathy nephropathy vascular or cardiac complications) compromises the members ability to safely perform essential job tasks 1 5 7 9 and 130 and the physician shall report the applicable job limitations to the fire department
A94201 Chronic hypertension can damage the eye (retinopathy) the kidneys (nephropathy) the vascular system (stroke transient ischemic attack or peripheral artery disease) or the heart (left ventricular hypertrophy and heart failure) These hypertension complications are known as end organ damage The cardiac and vascular complications are associated with an increased risk of sudden incapacitation and sudden cardiac death (Koren et al 1991) Fortunately with proper evaluation life style modification and treatment these complications can be avoided Life style modification includes weight reduction DASH eating plan reduction in dietary sodium an increase in aerobic physical activity and moderation in alcohol consumption [Chobanian 2003]
A94201 (1) Members with Stage I hypertension whose BP returns to either pre-hypertenion or normal with lifestyle modification andor treatment can return to an annual medical evaluation For members with long-standing Stage I hypertension whose BP has not been reduced additional evaluation for possible end organ damage should be considered This evaluation could include any or all of the following
a) a compete patient history for symptoms of heart failure (eg shortness of breath upon exertion) or transient ischemic attacks (TIAs)
b) dilated eye examination for retinopathy
c) blood creatinine measurement for nephropathy
d) tests for left ventricular hypertrophy Unfortunately use of the resting EKG to detect left ventricular hypertrophy is very insensitive (eg 5 sensitivity) The echocardiogram is the best test for diagnosing left ventricular hypertrophy
A 94201 (2) Due to the high risk of a sudden cardiovascular event members with Stage 2 hypertension should be restricted until their BP can be brought under control Once the BP is brought under control they should be followed in the same manner as a member with Stage I hypertension
D22 Cardiology
40
Hypertension
Gibbons RJ Balady GJ Bricker JT Chaitman BR Fletcher GF Froelicher VF Mark DB McCallister BD Mooss AN OrsquoReilly MG Winters WL Jr [2002] ACCAHA 2002 guideline update for exercise testing summary article a report of the ACCAHA Task Force on Practice Guidelines (Committee to Update the 1997 Exercise Testing guidelines) J Am Coll Cardiol 401531ndash 40
Chobanian AV Bakris GL Black HR Cushman WC Green LA Izzo JL Jr Jones DW Materson BJ Oparil S Wright JT Jr Roccella EJ the National High Blood Pressure Education Program Coordinating Committee [2003] The seventh report of the Joint National Committee [JNC-7] on Prevention Detection Evaluation and Treatment of High Blood Pressure JAMA 2892560ndash2571
Soteriades ES Kales SN Liarokapis D Christiani DC [2003] Prospective surveillance of hypertension in firefighters J Clin Hypertens 5315-320
Kales SN Tsismenakis AJ Zhang C Soteriades ES [2009] Blood pressure in fire fighters police officers and other emergency responders Am J Hypertens 2211-20
41
NFPA 1582‐ Draft Revisions for CVDHTN
EKG and stress tests
Reason for Revision
1) Change requirement for annual resting EKG to periodically to be more consistent with ACCAHA
recommendation (Schlant et al 1992)
2) Add language to clarify what constitutes a positive ST
3) Make criteria for conducting diagnostic ST in asymptomatic patients consistent with the
ACCAHA
Language in 2007 Edition with draft revisions in Red (Track changes)
776 Electrocardiograms (EKG)) and Stress Tests 7761 A resting EKG shall be performed as part of the baseline medical evaluation and shall be obtained periodically (every 1 to 5 years) annually thereafter
A7761 A baseline resting EKGs shall be conducted Follow-up resting EKGs should be conducted as clinically indicated but at a minimum of every 1 to 5 years The frequency of these follow-up resting EKGs should increase as a members age increases or with increasing number andor severity of coronary heart disease risk factors Members above the age of 40 should have annual resting EKGs (Schlant et al 1992)
7762 The fire department physician or other qualified medical evaluator shall compare EKGs obtained during yearly evaluations with baseline and subsequent EKGs
7763 Stress testing EKG with or without echocardiography or radionuclide scanning shall be performed as clinically indicated by history or symptoms
A7761 Baseline electrocardiography should be conducted (Periodic resting electrocardiograms have not been shown to be useful but can be reasonable as a members agefactors increase)
A7763 No firm guidelines for stress testingelectrocardiography in asymptomatic individuals have been developed Stress testingelectrocardiography as a screening tool is used as part of an evaluation of aerobic capacity during the annual occupational fitness evaluation Submaximal stress testingelectrocardiography testing to 85 percent is commonly used as part of this screening
Submaximal stress electrocardiography testing should not be used for diagnostic purposes Cardiology evaluation with maximal stress testingelectrocardiography together with imaging techniques (eg echocardiography technetium Tc99m sestamibi study andor coronary angiography) is necessary for diagnosticprognostic purposes for the following
42
(1) Fire fighters with positive or questionably positive changes on screening submaximal stress tests
(2) Fire fighters with new onset chest pain or other symptoms suggestive of coronary artery disease (CAD)
(3) Fire fighters with diabetes mellitus who
(a) are gt35 years old or
(b) have type I diabetes for more than 15 years or
(c) have type II diabetes for more than 10 years or
(d) have any other CHD risk factor (see below) or
(e) have the presence of microvascular disease (proliferative retinopathy)
(4) Fire fighters over the age of 45 (for men) and 55 (for women) with onetwo or more risk factors for CAD Risk factors for CAD include hypercholesterolemia (total cholesterol greater than 240 mgdL) hypertension (systolic gt140 mmHg or diastolic gt90 mmHg) smoking or family history of premature CAD (heart attack or sudden cardiac death in a first degree relative less than 60 years of age)
as defined below if stress electrocardiography with imaging is negative then repeat as clinically indicated or at least every 5 years
(5) Fire fighters with a Framingham Risk Score gt10 Risk calculator is available at [httphp2010nhlbihinnetatpiiicalculatorasp]
(6) Fire fighters identified in 9431
Negative stress tests should be repeated as clinically indicated or at least every 2 to 5 years
Interpreting stress tests as ldquopositiverdquo or ldquonegativerdquo is beyond the scope of this document However factors that should be taken into consideration should include the individualrsquos exercise capacity symptoms blood pressure response heart rate response EKG changes and the presence of arrhythmias (Gibbon et al 2002)
Risk factors for CAD include hypercholesterolemia (total cholesterol greater than 240 mgdL) hypertension (systolic greater than 140 andor diastolic greater than 90) smoking diabetes mellitus or family history of premature CAD (heart attack or sudden cardiac death in a first degree relative less than 60 years of age)
There are other non-invasive tests to screen for coronary artery disease One of the most promising appears to be coronary artery calcium (CAD) scoring by computed tomography In 2007 an expert committee published an update to their original guidance document The committeersquos consensus was that ldquoit may be reasonable to consider use of CAC measurement in such patients [between 10 and 20 10-year risk of estimated coronary event]helliprdquo The committee did not recommend CAC measurement in low risk patients [lt10 10-year risk of estimated coronary event] or in high risk patients [gt20 10-year risk of estimate coronary event] (Greenland et al 2007]
43
D22 Cardiology
Chobanian AV Bakris GL Black HR Cushman WC Green LA Izzo JL Jr Jones DW Materson BJ Oparil S Wright JT Jr Roccella EJ the National High Blood Pressure Education Program Coordinating Committee [2003] The seventh report of the Joint National Committee [JNC-7] on Prevention Detection Evaluation and Treatment of High Blood Pressure JAMA 2892560ndash2571
Gibbons RJ Balady GJ Bricker JT Chaitman BR Fletcher GF Froelicher VF Mark DB McCallister BD Mooss AN OrsquoReilly MG Winters WL Jr [2002] ACCAHA 2002 guideline update for exercise testing summary article a report of the ACCAHA Task Force on Practice Guidelines (Committee to Update the 1997 Exercise Testing guidelines) J Am Coll Cardiol 401531ndash 1540
Greenland et al [2007] ACCFAHA 2007 Clinical Expert Consensus Document on Coronary Artery Calcium Scoring By Computed Tomography in Global Cardiovascular Risk Assessment and in Evaluation of Patients With Chest Pain A Report of the American College of Cardiology Foundation Clinical Expert Consensus Task Force (ACCFAHA Writing Committee to Update the 2000 Expert Consensus Document on Electron Beam Computed Tomography) J Am Coll Cardiol 49378-402
Kales SN Tsismenakis AJ Zhang C Soteriades ES [2009] Blood pressure in fire fighters police officers and other emergency responders Am J Hypertens 2211-20
Schlant RC Adolph RJ DiMarco JP Dreifus LS Dunn MI Fisch C Garson A Jr Haywood LJ Levine HJ Murray JA Noble RJ Ronan JA Jr [1992] Guidelines for electrocardiography A report of the American College of CardiologyAmerican Heart Association Task Force on Assessment of Diagnostic and Therapeutic Cardiovascular Procedures (Committee on Electrocardiography) Circulation 85(3)1221-1228
Soteriades ES Kales SN Liarokapis D Christiani DC [2003] Prospective surveillance of hypertension in firefighters J Clin Hypertens 5315-320
Formatted Font Italic
Formatted Line spacing single
Formatted Font Italic
Formatted Font Italic
44
NFPA 1582‐ Draft Revisions for CVDHTN
EKG and stress tests
Reason for Revision
1) Change requirement for annual resting EKG to periodically to be more consistent with ACCAHA
recommendation (Schlant et al 1992)
2) Add language to clarify what constitutes a positive ST
3) Make criteria for conducting diagnostic ST in asymptomatic patients consistent with the
ACCAHA
Language in 2007 Edition with draft revisions in Red (Track changes)
776 Electrocardiograms (EKG) and Stress Tests 7761 A resting EKG shall be performed as part of the baseline medical evaluation and shall be obtained periodically (every 1 to 5 years) thereafter
A7761 A baseline resting EKGs shall be conducted Follow-up resting EKGs should be conducted as clinically indicated but at a minimum of every 1 to 5 years The frequency of these follow-up resting EKGs should increase as a members age increases or with increasing number andor severity of coronary heart disease risk factors Members above the age of 40 should have annual resting EKGs (Schlant et al 1992)
7762 The fire department physician or other qualified medical evaluator shall compare baseline and subsequent EKGs
7763 Stress testing with or without echocardiography or radionuclide scanning shall be performed as clinically indicated by history or symptoms
A7763 No firm guidelines for stress testing in asymptomatic individuals have been developed Stress testing as a screening tool is used as part of an evaluation of aerobic capacity during the annual occupational fitness evaluation Submaximal stress testing testing to 85 percent is commonly used as part of this screening
Submaximal stress testing should not be used for diagnostic purposes Cardiology evaluation with maximal stress testing together with imaging techniques (eg echocardiography technetium Tc99m sestamibi study) is necessary for diagnosticprognostic purposes for the following
(1) Fire fighters with positive or questionably positive changes on screening submaximal stress tests
(2) Fire fighters with new onset chest pain or other symptoms suggestive of coronary artery disease (CAD)
45
(3) Fire fighters with diabetes mellitus who
(a) are gt35 years old or
(b) have type I diabetes for more than 15 years or
(c) have type II diabetes for more than 10 years or
(d) have any other CHD risk factor (see below) or
(e) have the presence of microvascular disease (proliferative retinopathy)
(4) Fire fighters over the age of 45 (for men) and 55 (for women) with one or more risk factors for CAD Risk factors for CAD include hypercholesterolemia (total cholesterol greater than 240 mgdL) hypertension (systolic gt140 mmHg or diastolic gt90 mmHg) smoking or family history of premature CAD (heart attack or sudden cardiac death in a first degree relative less than 60 years of age)
(5) Fire fighters with a Framingham Risk Score gt10 Risk calculator is available at [httphp2010nhlbihinnetatpiiicalculatorasp]
(6) Fire fighters identified in 9431
Negative stress tests should be repeated as clinically indicated or at least every 2 to 5 years
Interpreting stress tests as ldquopositiverdquo or ldquonegativerdquo is beyond the scope of this document However factors that should be taken into consideration should include the individualrsquos exercise capacity symptoms blood pressure response heart rate response EKG changes and the presence of arrhythmias (Gibbon et al 2002)
There are other non-invasive tests to screen for coronary artery disease One of the most promising appears to be coronary artery calcium (CAD) scoring by computed tomography In 2007 an expert committee published an update to their original guidance document The committeersquos consensus was that ldquoit may be reasonable to consider use of CAC measurement in such patients [between 10 and 20 10-year risk of estimated coronary event]helliprdquo The committee did not recommend CAC measurement in low risk patients [lt10 10-year risk of estimated coronary event] or in high risk patients [gt20 10-year risk of estimate coronary event] (Greenland et al 2007]
D22 Cardiology
Resting EKG and Stress Tests
46
Chobanian AV Bakris GL Black HR Cushman WC Green LA Izzo JL Jr Jones DW Materson BJ Oparil S Wright JT Jr Roccella EJ the National High Blood Pressure Education Program Coordinating Committee [2003] The seventh report of the Joint National Committee [JNC-7] on Prevention Detection Evaluation and Treatment of High Blood Pressure JAMA 2892560ndash2571
Gibbons RJ Balady GJ Bricker JT Chaitman BR Fletcher GF Froelicher VF Mark DB McCallister BD Mooss AN OrsquoReilly MG Winters WL Jr [2002] ACCAHA 2002 guideline update for exercise testing summary article a report of the ACCAHA Task Force on Practice Guidelines (Committee to Update the 1997 Exercise Testing guidelines) J Am Coll Cardiol 401531ndash 1540
Greenland et al [2007] ACCFAHA 2007 Clinical Expert Consensus Document on Coronary Artery Calcium Scoring By Computed Tomography in Global Cardiovascular Risk Assessment and in Evaluation of Patients With Chest Pain A Report of the American College of Cardiology Foundation Clinical Expert Consensus Task Force (ACCFAHA Writing Committee to Update the 2000 Expert Consensus Document on Electron Beam Computed Tomography) J Am Coll Cardiol 49378-402
Kales SN Tsismenakis AJ Zhang C Soteriades ES [2009] Blood pressure in fire fighters police officers and other emergency responders Am J Hypertens 2211-20
Schlant RC Adolph RJ DiMarco JP Dreifus LS Dunn MI Fisch C Garson A Jr Haywood LJ Levine HJ Murray JA Noble RJ Ronan JA Jr [1992] Guidelines for electrocardiography A report of the American College of CardiologyAmerican Heart Association Task Force on Assessment of Diagnostic and Therapeutic Cardiovascular Procedures (Committee on Electrocardiography) Circulation 85(3)1221-1228
Soteriades ES Kales SN Liarokapis D Christiani DC [2003] Prospective surveillance of hypertension in firefighters J Clin Hypertens 5315-320
47
ATTACHMENT F
48
1
Current 1582 (2007) language in reference to pregnancy 43 (4) Report to the fire department physician any medical condition that could interfere with the ability of the individual to safely perform essential job tasks such as illness or injury use of prescription or nonprescription drugs and pregnancy 6112 Category B medical conditions shall include the following (1) Pregnancy for its duration A7792 (e) If HIV prophylaxis is to be given the following tests should be done i CBC ii Glucose renal and hepatic chemical function iii Pregnancy test for females B121 Pregnancy and Reproduction Federal regulations as well as many court decisions including the US Supreme Courtrsquos decision in International Union et al v Johnson Controls Inc [499 US 187 111 S Ct 1196 (1991)] have interpreted the requirements of Title VII with respect to pregnancy and reproduction The AHJ should seek the advice of counsel in resolving specific questions concerning these requirements as well as other requirements that can be imposed by state or local laws C211 (4) Review health status with the individual being evaluated Contraindications for evaluations shall be reviewed addressing any changes in the individualrsquos health status since their last medical evaluation that would warrant deferring the evaluation including (g) Pregnancy Recommendations to language enhancement
A female employee who is assigned to regular fire line duty shall report a pregnancy immediately to their respective Supervisor and the fire department physician The employee will then be given the option of a non-hazardous alternative duty position for the duration of her pregnancy (can we say this or is it even appropriate) Any pregnant employee wishing to remain on regular line duty shall be informed of the possible risks and consequences to herself and her fetus that are associated with continued line fire fighting duty Among those risk factors are exposure to teratogens known to have negative effects on the developing fetus such as smoke diesel fumes hazardous chemicals and extreme heat
49
Page 2
appendix It is recommended that the pregnant employee complete a release of liability form signed by herself and her health care provider utilizing NFPArsquos 13 critical tasks as a reference This will inform the health care provider of specific job-related tasks that will need to be performed in order to continue regular line duty These tasks are basic physical standards that any entry level firefighter would have to be able to complete competently The employeersquos health condition will be kept confidential by the department in accordance with HIPAA standards Employees are allowed to remain on active regular duty until they are no longer able to perform their duties in a reasonable manner andor their protective gear no longer fits correctly It is the responsibility of the health care provider to evaluate the pregnant employee If at any time the health care provider feels the pregnant employee can no longer perform the job related tasks this should be reported to the employer by the employee immediately
50
ATTACHMENT G
51
From GLENN BENARICKTo Sawyer SteveSubject RE RE 7743Date Monday August 30 2010 21633 PM
Yes thats my understanding
Glenn P Benarick 211 Winged Elm CircleAiken SC 29803803-644-7093gbenarprodigynet
--- On Mon 83010 Sawyer Steve ltssawyerNFPAorggt wrote
From Sawyer Steve ltssawyerNFPAorggtSubject RE RE 7743To GLENN BENARICK ltgbenarprodigynetgtDate Monday August 30 2010 212 PM
So it should be ldquoorrdquo instead of ldquoandrdquo for now
Steven F Sawyer
Senior Fire Service Specialist
Executive Secretary IFMAFire Service Section
NFPA
1 Batterymarch Park
Quincy MA 02169
6179847423
Fax 6179847056
ssawyernfpaorg
From GLENN BENARICK [mailtogbenarprodigynet] Sent Monday August 30 2010 1202 PMTo Sawyer SteveSubject Fw RE 7743
52
Steve a couple of our docs agree with April Boyer
Glenn P Benarick 211 Winged Elm Circle
Aiken SC 29803
803-644-7093
gbenarprodigynet
--- On Mon 83010 David Prezant ltprezandfdnynycgovgt wrote
From David Prezant ltprezandfdnynycgovgtSubject RE 7743To Thomas R (CDCNIOSHDSHEFS) Hales lttrh1cdcgovgt GLENNBENARICK ltgbenarprodigynetgtCc Sandy Bogucki ltsandyboguckiyaleedugtDate Monday August 30 2010 1004 AM
agree
we should change this to NHANES III rather than Knudson we should alsomodify this to allow not only for predicted cutoffs but all for use of thelower limit of normal cutoff This is important to prevent false-classificationof spirometry as abnormal in older groups and in taller grps The latter ofparticular import to firefighter occupational health surveillance
thanks
David Prezant MDChief Medical Officer Office of Medical AffairsCo-Director WTC Medical Monitoring amp Treatment ProgramsNew York City Fire Department9 Metrotech Center - Rm 4W-1Brooklyn NY 11201Phone 718-999-2696Fax 718-999-0665
Life is full of twists and turns
53
This email may contain confidential information If you are the unintendedrecipient of this email please send it back and delete from your directory
gtgtgt Hales Thomas R (CDCNIOSHDSHEFS) lttrh1cdcgovgt 8302010955 AM gtgtgt
Glen
This seems like a very reasonable comment and illustrates the importance of having clinicians providefeedback on the std Im not familiar with the software program of the various spirometers (NHANES IIIvs KnudsonATS vs both) Given the large role both Dave Prezant and Sandy Bogucki had for thepulmonary section let me forward to them for clarification
Tom
From GLENN BENARICK [mailtogbenarprodigynet] Sent Sunday August 29 2010 456 PMTo Hales Thomas R (CDCNIOSHDSHEFS)Subject FW 7743
Tom is April Boyer correct
Glenn P Benarick 211 Winged Elm Circle
Aiken SC 29803
803-644-7093
gbenarprodigynet
--- On Thu 82610 Sawyer Steve ltssawyerNFPAorggt wrote
From Sawyer Steve ltssawyerNFPAorggtSubject FW 7743To GLENN BENARICK ltgbenarprodigynetgtDate Thursday August 26 2010 925 PM
FYI Do you have any answer She is write
Steven
54
Steven F Sawyer
Senior Fire Service Specialist
Executive Secretary IFMAFire Service Section
NFPA
1 Batterymarch Park
Quincy MA 02169
6179847423
Fax 6179847056
ssawyernfpaorg
From April Boyer [mailtoaboyerbicclinicorg] Sent Thursday August 26 2010 232 PMTo Sawyer SteveCc RobinMWebbmilstateorusSubject 7743
Steven
The spirometry tests cannot be corrected according to both references as the NFPA states because thereferences are contradictory The first part of 7743 states to follow the ATS guidelines and use theKnudsen (we at Basin Immediate Care use the Nhanes III) The second part states to follow the ACOEMguidelines and use the Nhanes III in the occupational setting if available with your unit (which is availableon ours) 7743 does not use the word OR regarding both requirements it uses the word AND whenreferring to the first and second parts thence making 7743 contradictory I realize the NFPA 1582 hasnot been updated since 2007 unless I have just not received an updated version
Our question to you is which part of 7743 do you want us to follow the first or the second part Anyfacility that has an updated computerized spirometry system (as we do) will not be able to follow bothrequired parts for obvious reasons We can either follow the first part of 7743 and use an oldercorrected version of the Knudson by going into our system and changing out of the Nhanes III conversionOR we can follow the second part of 7743 and use the newer corrected version of Nhanes III which ourunit offers too
If you have any questions you may contact me at anytime and I also have many references in regards toboth parts of 7743 if you would like to see them
55
Thank you~
April
Confidentiality NoticeThis message may contain information that isconfidential or privileged
If you are not the intended recipientPlease advise the sender immediately and delete this message
56
ATTACHMENT H
57
NFPA 1582 771(7) Proposed revisions
Why
Preliminary results of two prospective randomized trials on the PSA test were published in 2009 These studies resulted in medical organizations that previously providing guidance to modify their recommendations
Current language
771 Blood Tests Blood tests shall be performed annually and shall include the following
(7) Prostate specific antigen (PSA) after age 40 for positive family history if African American or if otherwise clinically indicated after age 50 for all other male member
Suggested Revision
771 Blood Tests Blood tests shall be performed annually and shall include the following
(7) Prostate specific antigen (PSA) after age 40 for positive family history if African American or if otherwise clinically indicated after age 50 for all other male member
772 Prostate-Specific Antigen (PSA) test At age 50 fire fighters shall have an opportunity to make an informed decision with either the Fire Department physician or their health care provider concerning the PSA test For fire fighters at increased risk of prostate cancer (African-Americans or those with a first degree relative diagnosed with prostate cancer before age 65) shall have the opportunity for this informed decision at age 40
A772 The PSA as a screening test for prostate cancer in asymptomatic men is controversial controversial for two reasons First there is no consensus that PSA screening actually saves lives For example the PSA test may detect small cancers that would never become life threatening Second it is unclear that the benefits of PSA screening outweigh the risks of follow-up diagnostic tests and cancer treatments For example the prostate biopsy used to diagnose prostate cancer may cause bleeding and infection And prostate cancer treatments such as surgery and radiation therapy may cause incontinence (inability to control urine flow) erectile dysfunction (erections inadequate for intercourse) and other complications For these reasons it is important that the benefits and risks of prostate diagnostic procedures and treatment be taken into account when considering the PSA screening test These considerations can be taken account during discussions with the fire department physician or onersquos health care provider
D211 Cancer Screening
Smith R A C J Mettlin K J Davis and H Eyre 2000 ldquoAmerican Cancer Society guidelines for the early detection of cancerrdquo CA J Clin 50(1)34ndash49
Added references
58
Carroll P Albertsen PC Greene K et al [2010] Prostate-specific antigen best practice statement 2009 update Am Urological Assoc Available at httpwwwauanetorgcontentguidelines-and-quality-careclinical-guidelinesmain-reportspsa09pdf Date accessed September 2010
Ferrini R Woolf SH [2009] Screening for prostate cancer in American men American College of Preventive Medicine Practice Policy Statement Available at httpwwwacpmorgprostatehtm Date accessed September 2010
National Cancer Institute [2009] Prostate-specific antigen test National Cancer Institute Fact Sheet Available at httpwwwcancergovcancertopicsfactsheetDetectionPSA Date accessed September 2010
Wolf AMD Wender RC Etzioni RB et al [2010] American Cancer Society guideline for the early detection of prostate cancer Update 2010 Available at httpcaonlineamcancersocorgcgicontentfullcaac20066v1 Date accessed September 2010
59
D22 Cardiology Gibbons R J GJ Balady J W Beasley et al 1997 ACCAHA guidelines for exercise testing a report of American College of CardiologyAmerican Heart Association Task Force on Practice Guidelines (Committee on Exercise Testing) J Am Coll Cardiol 30260ndash311
Gibbons RJ Balady GJ Bricker JT Chaitman BR Fletcher GF Froelicher VF Mark DB McCallister BD Mooss AN OrsquoReilly MG Winters WL Jr [2002] ACCAHA 2002 guideline update for exercise testing summary article a report of the ACCAHA Task Force on Practice Guidelines (Committee to Update the 1997 Exercise Testing guidelines) J Am Coll Cardiol 401531ndash 40
Chobanian AV Bakris GL Black HR Cushman WC Green LA Izzo JL Jr Jones DW Materson BJ Oparil S Wright JT Jr Roccella EJ the National High Blood Pressure Education Program Coordinating Committee [2003] The seventh report of the Joint National Committee [JNC-7] on Prevention Detection Evaluation and Treatment of High Blood Pressure JAMA 2892560ndash2571
Soteriades ES Kales SN Liarokapis D Christiani DC [2003] Prospective surveillance of hypertension in firefighters J Clin Hypertens 5315-320
Kales SN Tsismenakis AJ Zhang C Soteriades ES [2009] Blood pressure in fire fighters police officers and other emergency responders Am J Hypertens 2211-20
37
NFPA 1582‐ HTN Draft 1
Reason for Revision
1) New classification of BP by the Joint National Commission [Chobanian et al 2002]
2) A high prevalence of FF have either HTN (~20) and Pre‐HTN (~20) [Soteriades et al 2003]
3) Among FF studies have shown a strong association between HTN and a number of adverse
cardiovascular events [Kales et al 2009]
4) A large percentage of on‐duty FF fatalities were found to have left ventricular hypertrophy a
complication of HTN at autopsy
Language in 2007 Edition with draft revisions in Red (Track changes)
611 The medical evaluation of a candidate shall include a medical history examination and any laboratory tests required to detect physical or medical condition(s) that could adversely affect hisher ability to safely perform the essential job tasks outlined in 511 A611 The medical history should include the candidates known health problems such as major illnesses surgeries medication use and allergies Symptom review is also important for detecting early signs of illness A medical history should also include a personal health history a family health history a health habit history an immunization history and a reproductive history
An occupational history should also be obtained to collect information about the persons past occupational and environmental exposures
(a) BP should be measured according to the Joint National Commission (JNC) -7 recommendations BP should be measured with a properly calibrated and validated instrument Patients should be seated quietly for at least 5 minutes in a chair with feet on the floor and arm supported at heart level An appropriate-sized cuff (cuff bladder encircling at least 80 of the arm) should be used to ensure accuracy At least 2 measurements should be made Systolic BP is the point at which the first of 2 or more sounds is heard (phase 1) and diastolic BP is the point before the disappearance of sounds (phase 5) [Chobanian et al 2003]
(2) Head eyes ears nose and throat
38
692 Vascular System 6921 Category A medical conditions shall include the following
(1) Uncontrolled or poorly controlled hypertension
(2) Hypertension with evidence of end organ damage
A6921(1) Uncontrolled or poorly controlled hypertension increases the risk of a sudden cardiac event This sudden cardiac event would cause sudden incapacitation which interferes with the safe performance of essential job tasks Uncontrolled or poorly controlled hypertension can be defined as the presence of end organ damage (see below) or stage 2 hypertension (BP systolic gt160 mmHg or BP diastolic gt100 mmHg) Individuals with pre- stage 1 or stage 2 hypertension should be referred to their primary care physician for evaluation lifestyle modification and treatment [QUESTION FOR GROUP _- WHAT ABOUT HAVING CANDIDATE RETURN IN ONE MONTH UNDER TREATMENT WITH NORMAL BP]
A6921(2)Chronic hypertension can damage the eye (retinopathy) the kidneys (nephropathy) the vascular system (stroke transient ischemic attack or peripheral artery disease) or the heart (left ventricular hypertrophy and heart failure) These hypertension complications are known as end organ damage The cardiac and vascular complications are associated with an increased risk of sudden incapacitation and sudden cardiac death (Koren et al 1991) Unfortunately the cardiac complications are frequently asymptomatic and valid screening tests are not fast and are not inexpensive Therefore determining who to screen for cardiac complications (such as echocardiogram for LVH or a measurement of left ventricular ejection fraction for heart failure) should be based on the severity and the duration of HTN
76 Physical Examination The annual physical examination shall include each of the following components
(a) BP shall be measured according to the Joint National Commission (JNC)-7 recommendations
A76(1)(a) BP should be measured with a properly calibrated and validated instrument Patients should be seated quietly for at least 5 minutes in a chair with feet on the floor and arm supported at heart level An appropriate-sized cuff (cuff bladder encircling at least 80 of the arm) should be used to ensure accuracy At least 2 measurements should be made Systolic BP is the point at which the first of 2 or more sounds is heard (phase 1) and diastolic BP is the point before the disappearance of sounds (phase 5) [Chobanian et al 2003]
(2) Head eyes ears nose and throat9420 Hypertension 94201 Physician Evaluation Members with Pre-hypertention (systolic 120-139 mmHg or diastolic 80-89 mmHg) Stage 1 hypertension (systolic 140-159 mmHg or diastolic 90-99 mmHg) or Stage 2 hypertension (systolic ge160 mmHg or diastolic ge100 mmHg) should be referred to their primary care physician for evaluation lifestyle modification and treatment
39
(1) Members with Stage I hypertension should be followed-up not only by their primary care physician but also by the FD physician every 3 to 6 months to ensure their blood pressure is under control and to determine whether screening tests for asymptomatic end organ damage are appropriate
(2) Members with Stage 2 hypertension or with end organ damage (retinopathy nephropathy vascular or cardiac complications) compromises the members ability to safely perform essential job tasks 1 5 7 9 and 130 and the physician shall report the applicable job limitations to the fire department
A94201 Chronic hypertension can damage the eye (retinopathy) the kidneys (nephropathy) the vascular system (stroke transient ischemic attack or peripheral artery disease) or the heart (left ventricular hypertrophy and heart failure) These hypertension complications are known as end organ damage The cardiac and vascular complications are associated with an increased risk of sudden incapacitation and sudden cardiac death (Koren et al 1991) Fortunately with proper evaluation life style modification and treatment these complications can be avoided Life style modification includes weight reduction DASH eating plan reduction in dietary sodium an increase in aerobic physical activity and moderation in alcohol consumption [Chobanian 2003]
A94201 (1) Members with Stage I hypertension whose BP returns to either pre-hypertenion or normal with lifestyle modification andor treatment can return to an annual medical evaluation For members with long-standing Stage I hypertension whose BP has not been reduced additional evaluation for possible end organ damage should be considered This evaluation could include any or all of the following
a) a compete patient history for symptoms of heart failure (eg shortness of breath upon exertion) or transient ischemic attacks (TIAs)
b) dilated eye examination for retinopathy
c) blood creatinine measurement for nephropathy
d) tests for left ventricular hypertrophy Unfortunately use of the resting EKG to detect left ventricular hypertrophy is very insensitive (eg 5 sensitivity) The echocardiogram is the best test for diagnosing left ventricular hypertrophy
A 94201 (2) Due to the high risk of a sudden cardiovascular event members with Stage 2 hypertension should be restricted until their BP can be brought under control Once the BP is brought under control they should be followed in the same manner as a member with Stage I hypertension
D22 Cardiology
40
Hypertension
Gibbons RJ Balady GJ Bricker JT Chaitman BR Fletcher GF Froelicher VF Mark DB McCallister BD Mooss AN OrsquoReilly MG Winters WL Jr [2002] ACCAHA 2002 guideline update for exercise testing summary article a report of the ACCAHA Task Force on Practice Guidelines (Committee to Update the 1997 Exercise Testing guidelines) J Am Coll Cardiol 401531ndash 40
Chobanian AV Bakris GL Black HR Cushman WC Green LA Izzo JL Jr Jones DW Materson BJ Oparil S Wright JT Jr Roccella EJ the National High Blood Pressure Education Program Coordinating Committee [2003] The seventh report of the Joint National Committee [JNC-7] on Prevention Detection Evaluation and Treatment of High Blood Pressure JAMA 2892560ndash2571
Soteriades ES Kales SN Liarokapis D Christiani DC [2003] Prospective surveillance of hypertension in firefighters J Clin Hypertens 5315-320
Kales SN Tsismenakis AJ Zhang C Soteriades ES [2009] Blood pressure in fire fighters police officers and other emergency responders Am J Hypertens 2211-20
41
NFPA 1582‐ Draft Revisions for CVDHTN
EKG and stress tests
Reason for Revision
1) Change requirement for annual resting EKG to periodically to be more consistent with ACCAHA
recommendation (Schlant et al 1992)
2) Add language to clarify what constitutes a positive ST
3) Make criteria for conducting diagnostic ST in asymptomatic patients consistent with the
ACCAHA
Language in 2007 Edition with draft revisions in Red (Track changes)
776 Electrocardiograms (EKG)) and Stress Tests 7761 A resting EKG shall be performed as part of the baseline medical evaluation and shall be obtained periodically (every 1 to 5 years) annually thereafter
A7761 A baseline resting EKGs shall be conducted Follow-up resting EKGs should be conducted as clinically indicated but at a minimum of every 1 to 5 years The frequency of these follow-up resting EKGs should increase as a members age increases or with increasing number andor severity of coronary heart disease risk factors Members above the age of 40 should have annual resting EKGs (Schlant et al 1992)
7762 The fire department physician or other qualified medical evaluator shall compare EKGs obtained during yearly evaluations with baseline and subsequent EKGs
7763 Stress testing EKG with or without echocardiography or radionuclide scanning shall be performed as clinically indicated by history or symptoms
A7761 Baseline electrocardiography should be conducted (Periodic resting electrocardiograms have not been shown to be useful but can be reasonable as a members agefactors increase)
A7763 No firm guidelines for stress testingelectrocardiography in asymptomatic individuals have been developed Stress testingelectrocardiography as a screening tool is used as part of an evaluation of aerobic capacity during the annual occupational fitness evaluation Submaximal stress testingelectrocardiography testing to 85 percent is commonly used as part of this screening
Submaximal stress electrocardiography testing should not be used for diagnostic purposes Cardiology evaluation with maximal stress testingelectrocardiography together with imaging techniques (eg echocardiography technetium Tc99m sestamibi study andor coronary angiography) is necessary for diagnosticprognostic purposes for the following
42
(1) Fire fighters with positive or questionably positive changes on screening submaximal stress tests
(2) Fire fighters with new onset chest pain or other symptoms suggestive of coronary artery disease (CAD)
(3) Fire fighters with diabetes mellitus who
(a) are gt35 years old or
(b) have type I diabetes for more than 15 years or
(c) have type II diabetes for more than 10 years or
(d) have any other CHD risk factor (see below) or
(e) have the presence of microvascular disease (proliferative retinopathy)
(4) Fire fighters over the age of 45 (for men) and 55 (for women) with onetwo or more risk factors for CAD Risk factors for CAD include hypercholesterolemia (total cholesterol greater than 240 mgdL) hypertension (systolic gt140 mmHg or diastolic gt90 mmHg) smoking or family history of premature CAD (heart attack or sudden cardiac death in a first degree relative less than 60 years of age)
as defined below if stress electrocardiography with imaging is negative then repeat as clinically indicated or at least every 5 years
(5) Fire fighters with a Framingham Risk Score gt10 Risk calculator is available at [httphp2010nhlbihinnetatpiiicalculatorasp]
(6) Fire fighters identified in 9431
Negative stress tests should be repeated as clinically indicated or at least every 2 to 5 years
Interpreting stress tests as ldquopositiverdquo or ldquonegativerdquo is beyond the scope of this document However factors that should be taken into consideration should include the individualrsquos exercise capacity symptoms blood pressure response heart rate response EKG changes and the presence of arrhythmias (Gibbon et al 2002)
Risk factors for CAD include hypercholesterolemia (total cholesterol greater than 240 mgdL) hypertension (systolic greater than 140 andor diastolic greater than 90) smoking diabetes mellitus or family history of premature CAD (heart attack or sudden cardiac death in a first degree relative less than 60 years of age)
There are other non-invasive tests to screen for coronary artery disease One of the most promising appears to be coronary artery calcium (CAD) scoring by computed tomography In 2007 an expert committee published an update to their original guidance document The committeersquos consensus was that ldquoit may be reasonable to consider use of CAC measurement in such patients [between 10 and 20 10-year risk of estimated coronary event]helliprdquo The committee did not recommend CAC measurement in low risk patients [lt10 10-year risk of estimated coronary event] or in high risk patients [gt20 10-year risk of estimate coronary event] (Greenland et al 2007]
43
D22 Cardiology
Chobanian AV Bakris GL Black HR Cushman WC Green LA Izzo JL Jr Jones DW Materson BJ Oparil S Wright JT Jr Roccella EJ the National High Blood Pressure Education Program Coordinating Committee [2003] The seventh report of the Joint National Committee [JNC-7] on Prevention Detection Evaluation and Treatment of High Blood Pressure JAMA 2892560ndash2571
Gibbons RJ Balady GJ Bricker JT Chaitman BR Fletcher GF Froelicher VF Mark DB McCallister BD Mooss AN OrsquoReilly MG Winters WL Jr [2002] ACCAHA 2002 guideline update for exercise testing summary article a report of the ACCAHA Task Force on Practice Guidelines (Committee to Update the 1997 Exercise Testing guidelines) J Am Coll Cardiol 401531ndash 1540
Greenland et al [2007] ACCFAHA 2007 Clinical Expert Consensus Document on Coronary Artery Calcium Scoring By Computed Tomography in Global Cardiovascular Risk Assessment and in Evaluation of Patients With Chest Pain A Report of the American College of Cardiology Foundation Clinical Expert Consensus Task Force (ACCFAHA Writing Committee to Update the 2000 Expert Consensus Document on Electron Beam Computed Tomography) J Am Coll Cardiol 49378-402
Kales SN Tsismenakis AJ Zhang C Soteriades ES [2009] Blood pressure in fire fighters police officers and other emergency responders Am J Hypertens 2211-20
Schlant RC Adolph RJ DiMarco JP Dreifus LS Dunn MI Fisch C Garson A Jr Haywood LJ Levine HJ Murray JA Noble RJ Ronan JA Jr [1992] Guidelines for electrocardiography A report of the American College of CardiologyAmerican Heart Association Task Force on Assessment of Diagnostic and Therapeutic Cardiovascular Procedures (Committee on Electrocardiography) Circulation 85(3)1221-1228
Soteriades ES Kales SN Liarokapis D Christiani DC [2003] Prospective surveillance of hypertension in firefighters J Clin Hypertens 5315-320
Formatted Font Italic
Formatted Line spacing single
Formatted Font Italic
Formatted Font Italic
44
NFPA 1582‐ Draft Revisions for CVDHTN
EKG and stress tests
Reason for Revision
1) Change requirement for annual resting EKG to periodically to be more consistent with ACCAHA
recommendation (Schlant et al 1992)
2) Add language to clarify what constitutes a positive ST
3) Make criteria for conducting diagnostic ST in asymptomatic patients consistent with the
ACCAHA
Language in 2007 Edition with draft revisions in Red (Track changes)
776 Electrocardiograms (EKG) and Stress Tests 7761 A resting EKG shall be performed as part of the baseline medical evaluation and shall be obtained periodically (every 1 to 5 years) thereafter
A7761 A baseline resting EKGs shall be conducted Follow-up resting EKGs should be conducted as clinically indicated but at a minimum of every 1 to 5 years The frequency of these follow-up resting EKGs should increase as a members age increases or with increasing number andor severity of coronary heart disease risk factors Members above the age of 40 should have annual resting EKGs (Schlant et al 1992)
7762 The fire department physician or other qualified medical evaluator shall compare baseline and subsequent EKGs
7763 Stress testing with or without echocardiography or radionuclide scanning shall be performed as clinically indicated by history or symptoms
A7763 No firm guidelines for stress testing in asymptomatic individuals have been developed Stress testing as a screening tool is used as part of an evaluation of aerobic capacity during the annual occupational fitness evaluation Submaximal stress testing testing to 85 percent is commonly used as part of this screening
Submaximal stress testing should not be used for diagnostic purposes Cardiology evaluation with maximal stress testing together with imaging techniques (eg echocardiography technetium Tc99m sestamibi study) is necessary for diagnosticprognostic purposes for the following
(1) Fire fighters with positive or questionably positive changes on screening submaximal stress tests
(2) Fire fighters with new onset chest pain or other symptoms suggestive of coronary artery disease (CAD)
45
(3) Fire fighters with diabetes mellitus who
(a) are gt35 years old or
(b) have type I diabetes for more than 15 years or
(c) have type II diabetes for more than 10 years or
(d) have any other CHD risk factor (see below) or
(e) have the presence of microvascular disease (proliferative retinopathy)
(4) Fire fighters over the age of 45 (for men) and 55 (for women) with one or more risk factors for CAD Risk factors for CAD include hypercholesterolemia (total cholesterol greater than 240 mgdL) hypertension (systolic gt140 mmHg or diastolic gt90 mmHg) smoking or family history of premature CAD (heart attack or sudden cardiac death in a first degree relative less than 60 years of age)
(5) Fire fighters with a Framingham Risk Score gt10 Risk calculator is available at [httphp2010nhlbihinnetatpiiicalculatorasp]
(6) Fire fighters identified in 9431
Negative stress tests should be repeated as clinically indicated or at least every 2 to 5 years
Interpreting stress tests as ldquopositiverdquo or ldquonegativerdquo is beyond the scope of this document However factors that should be taken into consideration should include the individualrsquos exercise capacity symptoms blood pressure response heart rate response EKG changes and the presence of arrhythmias (Gibbon et al 2002)
There are other non-invasive tests to screen for coronary artery disease One of the most promising appears to be coronary artery calcium (CAD) scoring by computed tomography In 2007 an expert committee published an update to their original guidance document The committeersquos consensus was that ldquoit may be reasonable to consider use of CAC measurement in such patients [between 10 and 20 10-year risk of estimated coronary event]helliprdquo The committee did not recommend CAC measurement in low risk patients [lt10 10-year risk of estimated coronary event] or in high risk patients [gt20 10-year risk of estimate coronary event] (Greenland et al 2007]
D22 Cardiology
Resting EKG and Stress Tests
46
Chobanian AV Bakris GL Black HR Cushman WC Green LA Izzo JL Jr Jones DW Materson BJ Oparil S Wright JT Jr Roccella EJ the National High Blood Pressure Education Program Coordinating Committee [2003] The seventh report of the Joint National Committee [JNC-7] on Prevention Detection Evaluation and Treatment of High Blood Pressure JAMA 2892560ndash2571
Gibbons RJ Balady GJ Bricker JT Chaitman BR Fletcher GF Froelicher VF Mark DB McCallister BD Mooss AN OrsquoReilly MG Winters WL Jr [2002] ACCAHA 2002 guideline update for exercise testing summary article a report of the ACCAHA Task Force on Practice Guidelines (Committee to Update the 1997 Exercise Testing guidelines) J Am Coll Cardiol 401531ndash 1540
Greenland et al [2007] ACCFAHA 2007 Clinical Expert Consensus Document on Coronary Artery Calcium Scoring By Computed Tomography in Global Cardiovascular Risk Assessment and in Evaluation of Patients With Chest Pain A Report of the American College of Cardiology Foundation Clinical Expert Consensus Task Force (ACCFAHA Writing Committee to Update the 2000 Expert Consensus Document on Electron Beam Computed Tomography) J Am Coll Cardiol 49378-402
Kales SN Tsismenakis AJ Zhang C Soteriades ES [2009] Blood pressure in fire fighters police officers and other emergency responders Am J Hypertens 2211-20
Schlant RC Adolph RJ DiMarco JP Dreifus LS Dunn MI Fisch C Garson A Jr Haywood LJ Levine HJ Murray JA Noble RJ Ronan JA Jr [1992] Guidelines for electrocardiography A report of the American College of CardiologyAmerican Heart Association Task Force on Assessment of Diagnostic and Therapeutic Cardiovascular Procedures (Committee on Electrocardiography) Circulation 85(3)1221-1228
Soteriades ES Kales SN Liarokapis D Christiani DC [2003] Prospective surveillance of hypertension in firefighters J Clin Hypertens 5315-320
47
ATTACHMENT F
48
1
Current 1582 (2007) language in reference to pregnancy 43 (4) Report to the fire department physician any medical condition that could interfere with the ability of the individual to safely perform essential job tasks such as illness or injury use of prescription or nonprescription drugs and pregnancy 6112 Category B medical conditions shall include the following (1) Pregnancy for its duration A7792 (e) If HIV prophylaxis is to be given the following tests should be done i CBC ii Glucose renal and hepatic chemical function iii Pregnancy test for females B121 Pregnancy and Reproduction Federal regulations as well as many court decisions including the US Supreme Courtrsquos decision in International Union et al v Johnson Controls Inc [499 US 187 111 S Ct 1196 (1991)] have interpreted the requirements of Title VII with respect to pregnancy and reproduction The AHJ should seek the advice of counsel in resolving specific questions concerning these requirements as well as other requirements that can be imposed by state or local laws C211 (4) Review health status with the individual being evaluated Contraindications for evaluations shall be reviewed addressing any changes in the individualrsquos health status since their last medical evaluation that would warrant deferring the evaluation including (g) Pregnancy Recommendations to language enhancement
A female employee who is assigned to regular fire line duty shall report a pregnancy immediately to their respective Supervisor and the fire department physician The employee will then be given the option of a non-hazardous alternative duty position for the duration of her pregnancy (can we say this or is it even appropriate) Any pregnant employee wishing to remain on regular line duty shall be informed of the possible risks and consequences to herself and her fetus that are associated with continued line fire fighting duty Among those risk factors are exposure to teratogens known to have negative effects on the developing fetus such as smoke diesel fumes hazardous chemicals and extreme heat
49
Page 2
appendix It is recommended that the pregnant employee complete a release of liability form signed by herself and her health care provider utilizing NFPArsquos 13 critical tasks as a reference This will inform the health care provider of specific job-related tasks that will need to be performed in order to continue regular line duty These tasks are basic physical standards that any entry level firefighter would have to be able to complete competently The employeersquos health condition will be kept confidential by the department in accordance with HIPAA standards Employees are allowed to remain on active regular duty until they are no longer able to perform their duties in a reasonable manner andor their protective gear no longer fits correctly It is the responsibility of the health care provider to evaluate the pregnant employee If at any time the health care provider feels the pregnant employee can no longer perform the job related tasks this should be reported to the employer by the employee immediately
50
ATTACHMENT G
51
From GLENN BENARICKTo Sawyer SteveSubject RE RE 7743Date Monday August 30 2010 21633 PM
Yes thats my understanding
Glenn P Benarick 211 Winged Elm CircleAiken SC 29803803-644-7093gbenarprodigynet
--- On Mon 83010 Sawyer Steve ltssawyerNFPAorggt wrote
From Sawyer Steve ltssawyerNFPAorggtSubject RE RE 7743To GLENN BENARICK ltgbenarprodigynetgtDate Monday August 30 2010 212 PM
So it should be ldquoorrdquo instead of ldquoandrdquo for now
Steven F Sawyer
Senior Fire Service Specialist
Executive Secretary IFMAFire Service Section
NFPA
1 Batterymarch Park
Quincy MA 02169
6179847423
Fax 6179847056
ssawyernfpaorg
From GLENN BENARICK [mailtogbenarprodigynet] Sent Monday August 30 2010 1202 PMTo Sawyer SteveSubject Fw RE 7743
52
Steve a couple of our docs agree with April Boyer
Glenn P Benarick 211 Winged Elm Circle
Aiken SC 29803
803-644-7093
gbenarprodigynet
--- On Mon 83010 David Prezant ltprezandfdnynycgovgt wrote
From David Prezant ltprezandfdnynycgovgtSubject RE 7743To Thomas R (CDCNIOSHDSHEFS) Hales lttrh1cdcgovgt GLENNBENARICK ltgbenarprodigynetgtCc Sandy Bogucki ltsandyboguckiyaleedugtDate Monday August 30 2010 1004 AM
agree
we should change this to NHANES III rather than Knudson we should alsomodify this to allow not only for predicted cutoffs but all for use of thelower limit of normal cutoff This is important to prevent false-classificationof spirometry as abnormal in older groups and in taller grps The latter ofparticular import to firefighter occupational health surveillance
thanks
David Prezant MDChief Medical Officer Office of Medical AffairsCo-Director WTC Medical Monitoring amp Treatment ProgramsNew York City Fire Department9 Metrotech Center - Rm 4W-1Brooklyn NY 11201Phone 718-999-2696Fax 718-999-0665
Life is full of twists and turns
53
This email may contain confidential information If you are the unintendedrecipient of this email please send it back and delete from your directory
gtgtgt Hales Thomas R (CDCNIOSHDSHEFS) lttrh1cdcgovgt 8302010955 AM gtgtgt
Glen
This seems like a very reasonable comment and illustrates the importance of having clinicians providefeedback on the std Im not familiar with the software program of the various spirometers (NHANES IIIvs KnudsonATS vs both) Given the large role both Dave Prezant and Sandy Bogucki had for thepulmonary section let me forward to them for clarification
Tom
From GLENN BENARICK [mailtogbenarprodigynet] Sent Sunday August 29 2010 456 PMTo Hales Thomas R (CDCNIOSHDSHEFS)Subject FW 7743
Tom is April Boyer correct
Glenn P Benarick 211 Winged Elm Circle
Aiken SC 29803
803-644-7093
gbenarprodigynet
--- On Thu 82610 Sawyer Steve ltssawyerNFPAorggt wrote
From Sawyer Steve ltssawyerNFPAorggtSubject FW 7743To GLENN BENARICK ltgbenarprodigynetgtDate Thursday August 26 2010 925 PM
FYI Do you have any answer She is write
Steven
54
Steven F Sawyer
Senior Fire Service Specialist
Executive Secretary IFMAFire Service Section
NFPA
1 Batterymarch Park
Quincy MA 02169
6179847423
Fax 6179847056
ssawyernfpaorg
From April Boyer [mailtoaboyerbicclinicorg] Sent Thursday August 26 2010 232 PMTo Sawyer SteveCc RobinMWebbmilstateorusSubject 7743
Steven
The spirometry tests cannot be corrected according to both references as the NFPA states because thereferences are contradictory The first part of 7743 states to follow the ATS guidelines and use theKnudsen (we at Basin Immediate Care use the Nhanes III) The second part states to follow the ACOEMguidelines and use the Nhanes III in the occupational setting if available with your unit (which is availableon ours) 7743 does not use the word OR regarding both requirements it uses the word AND whenreferring to the first and second parts thence making 7743 contradictory I realize the NFPA 1582 hasnot been updated since 2007 unless I have just not received an updated version
Our question to you is which part of 7743 do you want us to follow the first or the second part Anyfacility that has an updated computerized spirometry system (as we do) will not be able to follow bothrequired parts for obvious reasons We can either follow the first part of 7743 and use an oldercorrected version of the Knudson by going into our system and changing out of the Nhanes III conversionOR we can follow the second part of 7743 and use the newer corrected version of Nhanes III which ourunit offers too
If you have any questions you may contact me at anytime and I also have many references in regards toboth parts of 7743 if you would like to see them
55
Thank you~
April
Confidentiality NoticeThis message may contain information that isconfidential or privileged
If you are not the intended recipientPlease advise the sender immediately and delete this message
56
ATTACHMENT H
57
NFPA 1582 771(7) Proposed revisions
Why
Preliminary results of two prospective randomized trials on the PSA test were published in 2009 These studies resulted in medical organizations that previously providing guidance to modify their recommendations
Current language
771 Blood Tests Blood tests shall be performed annually and shall include the following
(7) Prostate specific antigen (PSA) after age 40 for positive family history if African American or if otherwise clinically indicated after age 50 for all other male member
Suggested Revision
771 Blood Tests Blood tests shall be performed annually and shall include the following
(7) Prostate specific antigen (PSA) after age 40 for positive family history if African American or if otherwise clinically indicated after age 50 for all other male member
772 Prostate-Specific Antigen (PSA) test At age 50 fire fighters shall have an opportunity to make an informed decision with either the Fire Department physician or their health care provider concerning the PSA test For fire fighters at increased risk of prostate cancer (African-Americans or those with a first degree relative diagnosed with prostate cancer before age 65) shall have the opportunity for this informed decision at age 40
A772 The PSA as a screening test for prostate cancer in asymptomatic men is controversial controversial for two reasons First there is no consensus that PSA screening actually saves lives For example the PSA test may detect small cancers that would never become life threatening Second it is unclear that the benefits of PSA screening outweigh the risks of follow-up diagnostic tests and cancer treatments For example the prostate biopsy used to diagnose prostate cancer may cause bleeding and infection And prostate cancer treatments such as surgery and radiation therapy may cause incontinence (inability to control urine flow) erectile dysfunction (erections inadequate for intercourse) and other complications For these reasons it is important that the benefits and risks of prostate diagnostic procedures and treatment be taken into account when considering the PSA screening test These considerations can be taken account during discussions with the fire department physician or onersquos health care provider
D211 Cancer Screening
Smith R A C J Mettlin K J Davis and H Eyre 2000 ldquoAmerican Cancer Society guidelines for the early detection of cancerrdquo CA J Clin 50(1)34ndash49
Added references
58
Carroll P Albertsen PC Greene K et al [2010] Prostate-specific antigen best practice statement 2009 update Am Urological Assoc Available at httpwwwauanetorgcontentguidelines-and-quality-careclinical-guidelinesmain-reportspsa09pdf Date accessed September 2010
Ferrini R Woolf SH [2009] Screening for prostate cancer in American men American College of Preventive Medicine Practice Policy Statement Available at httpwwwacpmorgprostatehtm Date accessed September 2010
National Cancer Institute [2009] Prostate-specific antigen test National Cancer Institute Fact Sheet Available at httpwwwcancergovcancertopicsfactsheetDetectionPSA Date accessed September 2010
Wolf AMD Wender RC Etzioni RB et al [2010] American Cancer Society guideline for the early detection of prostate cancer Update 2010 Available at httpcaonlineamcancersocorgcgicontentfullcaac20066v1 Date accessed September 2010
59
NFPA 1582‐ HTN Draft 1
Reason for Revision
1) New classification of BP by the Joint National Commission [Chobanian et al 2002]
2) A high prevalence of FF have either HTN (~20) and Pre‐HTN (~20) [Soteriades et al 2003]
3) Among FF studies have shown a strong association between HTN and a number of adverse
cardiovascular events [Kales et al 2009]
4) A large percentage of on‐duty FF fatalities were found to have left ventricular hypertrophy a
complication of HTN at autopsy
Language in 2007 Edition with draft revisions in Red (Track changes)
611 The medical evaluation of a candidate shall include a medical history examination and any laboratory tests required to detect physical or medical condition(s) that could adversely affect hisher ability to safely perform the essential job tasks outlined in 511 A611 The medical history should include the candidates known health problems such as major illnesses surgeries medication use and allergies Symptom review is also important for detecting early signs of illness A medical history should also include a personal health history a family health history a health habit history an immunization history and a reproductive history
An occupational history should also be obtained to collect information about the persons past occupational and environmental exposures
(a) BP should be measured according to the Joint National Commission (JNC) -7 recommendations BP should be measured with a properly calibrated and validated instrument Patients should be seated quietly for at least 5 minutes in a chair with feet on the floor and arm supported at heart level An appropriate-sized cuff (cuff bladder encircling at least 80 of the arm) should be used to ensure accuracy At least 2 measurements should be made Systolic BP is the point at which the first of 2 or more sounds is heard (phase 1) and diastolic BP is the point before the disappearance of sounds (phase 5) [Chobanian et al 2003]
(2) Head eyes ears nose and throat
38
692 Vascular System 6921 Category A medical conditions shall include the following
(1) Uncontrolled or poorly controlled hypertension
(2) Hypertension with evidence of end organ damage
A6921(1) Uncontrolled or poorly controlled hypertension increases the risk of a sudden cardiac event This sudden cardiac event would cause sudden incapacitation which interferes with the safe performance of essential job tasks Uncontrolled or poorly controlled hypertension can be defined as the presence of end organ damage (see below) or stage 2 hypertension (BP systolic gt160 mmHg or BP diastolic gt100 mmHg) Individuals with pre- stage 1 or stage 2 hypertension should be referred to their primary care physician for evaluation lifestyle modification and treatment [QUESTION FOR GROUP _- WHAT ABOUT HAVING CANDIDATE RETURN IN ONE MONTH UNDER TREATMENT WITH NORMAL BP]
A6921(2)Chronic hypertension can damage the eye (retinopathy) the kidneys (nephropathy) the vascular system (stroke transient ischemic attack or peripheral artery disease) or the heart (left ventricular hypertrophy and heart failure) These hypertension complications are known as end organ damage The cardiac and vascular complications are associated with an increased risk of sudden incapacitation and sudden cardiac death (Koren et al 1991) Unfortunately the cardiac complications are frequently asymptomatic and valid screening tests are not fast and are not inexpensive Therefore determining who to screen for cardiac complications (such as echocardiogram for LVH or a measurement of left ventricular ejection fraction for heart failure) should be based on the severity and the duration of HTN
76 Physical Examination The annual physical examination shall include each of the following components
(a) BP shall be measured according to the Joint National Commission (JNC)-7 recommendations
A76(1)(a) BP should be measured with a properly calibrated and validated instrument Patients should be seated quietly for at least 5 minutes in a chair with feet on the floor and arm supported at heart level An appropriate-sized cuff (cuff bladder encircling at least 80 of the arm) should be used to ensure accuracy At least 2 measurements should be made Systolic BP is the point at which the first of 2 or more sounds is heard (phase 1) and diastolic BP is the point before the disappearance of sounds (phase 5) [Chobanian et al 2003]
(2) Head eyes ears nose and throat9420 Hypertension 94201 Physician Evaluation Members with Pre-hypertention (systolic 120-139 mmHg or diastolic 80-89 mmHg) Stage 1 hypertension (systolic 140-159 mmHg or diastolic 90-99 mmHg) or Stage 2 hypertension (systolic ge160 mmHg or diastolic ge100 mmHg) should be referred to their primary care physician for evaluation lifestyle modification and treatment
39
(1) Members with Stage I hypertension should be followed-up not only by their primary care physician but also by the FD physician every 3 to 6 months to ensure their blood pressure is under control and to determine whether screening tests for asymptomatic end organ damage are appropriate
(2) Members with Stage 2 hypertension or with end organ damage (retinopathy nephropathy vascular or cardiac complications) compromises the members ability to safely perform essential job tasks 1 5 7 9 and 130 and the physician shall report the applicable job limitations to the fire department
A94201 Chronic hypertension can damage the eye (retinopathy) the kidneys (nephropathy) the vascular system (stroke transient ischemic attack or peripheral artery disease) or the heart (left ventricular hypertrophy and heart failure) These hypertension complications are known as end organ damage The cardiac and vascular complications are associated with an increased risk of sudden incapacitation and sudden cardiac death (Koren et al 1991) Fortunately with proper evaluation life style modification and treatment these complications can be avoided Life style modification includes weight reduction DASH eating plan reduction in dietary sodium an increase in aerobic physical activity and moderation in alcohol consumption [Chobanian 2003]
A94201 (1) Members with Stage I hypertension whose BP returns to either pre-hypertenion or normal with lifestyle modification andor treatment can return to an annual medical evaluation For members with long-standing Stage I hypertension whose BP has not been reduced additional evaluation for possible end organ damage should be considered This evaluation could include any or all of the following
a) a compete patient history for symptoms of heart failure (eg shortness of breath upon exertion) or transient ischemic attacks (TIAs)
b) dilated eye examination for retinopathy
c) blood creatinine measurement for nephropathy
d) tests for left ventricular hypertrophy Unfortunately use of the resting EKG to detect left ventricular hypertrophy is very insensitive (eg 5 sensitivity) The echocardiogram is the best test for diagnosing left ventricular hypertrophy
A 94201 (2) Due to the high risk of a sudden cardiovascular event members with Stage 2 hypertension should be restricted until their BP can be brought under control Once the BP is brought under control they should be followed in the same manner as a member with Stage I hypertension
D22 Cardiology
40
Hypertension
Gibbons RJ Balady GJ Bricker JT Chaitman BR Fletcher GF Froelicher VF Mark DB McCallister BD Mooss AN OrsquoReilly MG Winters WL Jr [2002] ACCAHA 2002 guideline update for exercise testing summary article a report of the ACCAHA Task Force on Practice Guidelines (Committee to Update the 1997 Exercise Testing guidelines) J Am Coll Cardiol 401531ndash 40
Chobanian AV Bakris GL Black HR Cushman WC Green LA Izzo JL Jr Jones DW Materson BJ Oparil S Wright JT Jr Roccella EJ the National High Blood Pressure Education Program Coordinating Committee [2003] The seventh report of the Joint National Committee [JNC-7] on Prevention Detection Evaluation and Treatment of High Blood Pressure JAMA 2892560ndash2571
Soteriades ES Kales SN Liarokapis D Christiani DC [2003] Prospective surveillance of hypertension in firefighters J Clin Hypertens 5315-320
Kales SN Tsismenakis AJ Zhang C Soteriades ES [2009] Blood pressure in fire fighters police officers and other emergency responders Am J Hypertens 2211-20
41
NFPA 1582‐ Draft Revisions for CVDHTN
EKG and stress tests
Reason for Revision
1) Change requirement for annual resting EKG to periodically to be more consistent with ACCAHA
recommendation (Schlant et al 1992)
2) Add language to clarify what constitutes a positive ST
3) Make criteria for conducting diagnostic ST in asymptomatic patients consistent with the
ACCAHA
Language in 2007 Edition with draft revisions in Red (Track changes)
776 Electrocardiograms (EKG)) and Stress Tests 7761 A resting EKG shall be performed as part of the baseline medical evaluation and shall be obtained periodically (every 1 to 5 years) annually thereafter
A7761 A baseline resting EKGs shall be conducted Follow-up resting EKGs should be conducted as clinically indicated but at a minimum of every 1 to 5 years The frequency of these follow-up resting EKGs should increase as a members age increases or with increasing number andor severity of coronary heart disease risk factors Members above the age of 40 should have annual resting EKGs (Schlant et al 1992)
7762 The fire department physician or other qualified medical evaluator shall compare EKGs obtained during yearly evaluations with baseline and subsequent EKGs
7763 Stress testing EKG with or without echocardiography or radionuclide scanning shall be performed as clinically indicated by history or symptoms
A7761 Baseline electrocardiography should be conducted (Periodic resting electrocardiograms have not been shown to be useful but can be reasonable as a members agefactors increase)
A7763 No firm guidelines for stress testingelectrocardiography in asymptomatic individuals have been developed Stress testingelectrocardiography as a screening tool is used as part of an evaluation of aerobic capacity during the annual occupational fitness evaluation Submaximal stress testingelectrocardiography testing to 85 percent is commonly used as part of this screening
Submaximal stress electrocardiography testing should not be used for diagnostic purposes Cardiology evaluation with maximal stress testingelectrocardiography together with imaging techniques (eg echocardiography technetium Tc99m sestamibi study andor coronary angiography) is necessary for diagnosticprognostic purposes for the following
42
(1) Fire fighters with positive or questionably positive changes on screening submaximal stress tests
(2) Fire fighters with new onset chest pain or other symptoms suggestive of coronary artery disease (CAD)
(3) Fire fighters with diabetes mellitus who
(a) are gt35 years old or
(b) have type I diabetes for more than 15 years or
(c) have type II diabetes for more than 10 years or
(d) have any other CHD risk factor (see below) or
(e) have the presence of microvascular disease (proliferative retinopathy)
(4) Fire fighters over the age of 45 (for men) and 55 (for women) with onetwo or more risk factors for CAD Risk factors for CAD include hypercholesterolemia (total cholesterol greater than 240 mgdL) hypertension (systolic gt140 mmHg or diastolic gt90 mmHg) smoking or family history of premature CAD (heart attack or sudden cardiac death in a first degree relative less than 60 years of age)
as defined below if stress electrocardiography with imaging is negative then repeat as clinically indicated or at least every 5 years
(5) Fire fighters with a Framingham Risk Score gt10 Risk calculator is available at [httphp2010nhlbihinnetatpiiicalculatorasp]
(6) Fire fighters identified in 9431
Negative stress tests should be repeated as clinically indicated or at least every 2 to 5 years
Interpreting stress tests as ldquopositiverdquo or ldquonegativerdquo is beyond the scope of this document However factors that should be taken into consideration should include the individualrsquos exercise capacity symptoms blood pressure response heart rate response EKG changes and the presence of arrhythmias (Gibbon et al 2002)
Risk factors for CAD include hypercholesterolemia (total cholesterol greater than 240 mgdL) hypertension (systolic greater than 140 andor diastolic greater than 90) smoking diabetes mellitus or family history of premature CAD (heart attack or sudden cardiac death in a first degree relative less than 60 years of age)
There are other non-invasive tests to screen for coronary artery disease One of the most promising appears to be coronary artery calcium (CAD) scoring by computed tomography In 2007 an expert committee published an update to their original guidance document The committeersquos consensus was that ldquoit may be reasonable to consider use of CAC measurement in such patients [between 10 and 20 10-year risk of estimated coronary event]helliprdquo The committee did not recommend CAC measurement in low risk patients [lt10 10-year risk of estimated coronary event] or in high risk patients [gt20 10-year risk of estimate coronary event] (Greenland et al 2007]
43
D22 Cardiology
Chobanian AV Bakris GL Black HR Cushman WC Green LA Izzo JL Jr Jones DW Materson BJ Oparil S Wright JT Jr Roccella EJ the National High Blood Pressure Education Program Coordinating Committee [2003] The seventh report of the Joint National Committee [JNC-7] on Prevention Detection Evaluation and Treatment of High Blood Pressure JAMA 2892560ndash2571
Gibbons RJ Balady GJ Bricker JT Chaitman BR Fletcher GF Froelicher VF Mark DB McCallister BD Mooss AN OrsquoReilly MG Winters WL Jr [2002] ACCAHA 2002 guideline update for exercise testing summary article a report of the ACCAHA Task Force on Practice Guidelines (Committee to Update the 1997 Exercise Testing guidelines) J Am Coll Cardiol 401531ndash 1540
Greenland et al [2007] ACCFAHA 2007 Clinical Expert Consensus Document on Coronary Artery Calcium Scoring By Computed Tomography in Global Cardiovascular Risk Assessment and in Evaluation of Patients With Chest Pain A Report of the American College of Cardiology Foundation Clinical Expert Consensus Task Force (ACCFAHA Writing Committee to Update the 2000 Expert Consensus Document on Electron Beam Computed Tomography) J Am Coll Cardiol 49378-402
Kales SN Tsismenakis AJ Zhang C Soteriades ES [2009] Blood pressure in fire fighters police officers and other emergency responders Am J Hypertens 2211-20
Schlant RC Adolph RJ DiMarco JP Dreifus LS Dunn MI Fisch C Garson A Jr Haywood LJ Levine HJ Murray JA Noble RJ Ronan JA Jr [1992] Guidelines for electrocardiography A report of the American College of CardiologyAmerican Heart Association Task Force on Assessment of Diagnostic and Therapeutic Cardiovascular Procedures (Committee on Electrocardiography) Circulation 85(3)1221-1228
Soteriades ES Kales SN Liarokapis D Christiani DC [2003] Prospective surveillance of hypertension in firefighters J Clin Hypertens 5315-320
Formatted Font Italic
Formatted Line spacing single
Formatted Font Italic
Formatted Font Italic
44
NFPA 1582‐ Draft Revisions for CVDHTN
EKG and stress tests
Reason for Revision
1) Change requirement for annual resting EKG to periodically to be more consistent with ACCAHA
recommendation (Schlant et al 1992)
2) Add language to clarify what constitutes a positive ST
3) Make criteria for conducting diagnostic ST in asymptomatic patients consistent with the
ACCAHA
Language in 2007 Edition with draft revisions in Red (Track changes)
776 Electrocardiograms (EKG) and Stress Tests 7761 A resting EKG shall be performed as part of the baseline medical evaluation and shall be obtained periodically (every 1 to 5 years) thereafter
A7761 A baseline resting EKGs shall be conducted Follow-up resting EKGs should be conducted as clinically indicated but at a minimum of every 1 to 5 years The frequency of these follow-up resting EKGs should increase as a members age increases or with increasing number andor severity of coronary heart disease risk factors Members above the age of 40 should have annual resting EKGs (Schlant et al 1992)
7762 The fire department physician or other qualified medical evaluator shall compare baseline and subsequent EKGs
7763 Stress testing with or without echocardiography or radionuclide scanning shall be performed as clinically indicated by history or symptoms
A7763 No firm guidelines for stress testing in asymptomatic individuals have been developed Stress testing as a screening tool is used as part of an evaluation of aerobic capacity during the annual occupational fitness evaluation Submaximal stress testing testing to 85 percent is commonly used as part of this screening
Submaximal stress testing should not be used for diagnostic purposes Cardiology evaluation with maximal stress testing together with imaging techniques (eg echocardiography technetium Tc99m sestamibi study) is necessary for diagnosticprognostic purposes for the following
(1) Fire fighters with positive or questionably positive changes on screening submaximal stress tests
(2) Fire fighters with new onset chest pain or other symptoms suggestive of coronary artery disease (CAD)
45
(3) Fire fighters with diabetes mellitus who
(a) are gt35 years old or
(b) have type I diabetes for more than 15 years or
(c) have type II diabetes for more than 10 years or
(d) have any other CHD risk factor (see below) or
(e) have the presence of microvascular disease (proliferative retinopathy)
(4) Fire fighters over the age of 45 (for men) and 55 (for women) with one or more risk factors for CAD Risk factors for CAD include hypercholesterolemia (total cholesterol greater than 240 mgdL) hypertension (systolic gt140 mmHg or diastolic gt90 mmHg) smoking or family history of premature CAD (heart attack or sudden cardiac death in a first degree relative less than 60 years of age)
(5) Fire fighters with a Framingham Risk Score gt10 Risk calculator is available at [httphp2010nhlbihinnetatpiiicalculatorasp]
(6) Fire fighters identified in 9431
Negative stress tests should be repeated as clinically indicated or at least every 2 to 5 years
Interpreting stress tests as ldquopositiverdquo or ldquonegativerdquo is beyond the scope of this document However factors that should be taken into consideration should include the individualrsquos exercise capacity symptoms blood pressure response heart rate response EKG changes and the presence of arrhythmias (Gibbon et al 2002)
There are other non-invasive tests to screen for coronary artery disease One of the most promising appears to be coronary artery calcium (CAD) scoring by computed tomography In 2007 an expert committee published an update to their original guidance document The committeersquos consensus was that ldquoit may be reasonable to consider use of CAC measurement in such patients [between 10 and 20 10-year risk of estimated coronary event]helliprdquo The committee did not recommend CAC measurement in low risk patients [lt10 10-year risk of estimated coronary event] or in high risk patients [gt20 10-year risk of estimate coronary event] (Greenland et al 2007]
D22 Cardiology
Resting EKG and Stress Tests
46
Chobanian AV Bakris GL Black HR Cushman WC Green LA Izzo JL Jr Jones DW Materson BJ Oparil S Wright JT Jr Roccella EJ the National High Blood Pressure Education Program Coordinating Committee [2003] The seventh report of the Joint National Committee [JNC-7] on Prevention Detection Evaluation and Treatment of High Blood Pressure JAMA 2892560ndash2571
Gibbons RJ Balady GJ Bricker JT Chaitman BR Fletcher GF Froelicher VF Mark DB McCallister BD Mooss AN OrsquoReilly MG Winters WL Jr [2002] ACCAHA 2002 guideline update for exercise testing summary article a report of the ACCAHA Task Force on Practice Guidelines (Committee to Update the 1997 Exercise Testing guidelines) J Am Coll Cardiol 401531ndash 1540
Greenland et al [2007] ACCFAHA 2007 Clinical Expert Consensus Document on Coronary Artery Calcium Scoring By Computed Tomography in Global Cardiovascular Risk Assessment and in Evaluation of Patients With Chest Pain A Report of the American College of Cardiology Foundation Clinical Expert Consensus Task Force (ACCFAHA Writing Committee to Update the 2000 Expert Consensus Document on Electron Beam Computed Tomography) J Am Coll Cardiol 49378-402
Kales SN Tsismenakis AJ Zhang C Soteriades ES [2009] Blood pressure in fire fighters police officers and other emergency responders Am J Hypertens 2211-20
Schlant RC Adolph RJ DiMarco JP Dreifus LS Dunn MI Fisch C Garson A Jr Haywood LJ Levine HJ Murray JA Noble RJ Ronan JA Jr [1992] Guidelines for electrocardiography A report of the American College of CardiologyAmerican Heart Association Task Force on Assessment of Diagnostic and Therapeutic Cardiovascular Procedures (Committee on Electrocardiography) Circulation 85(3)1221-1228
Soteriades ES Kales SN Liarokapis D Christiani DC [2003] Prospective surveillance of hypertension in firefighters J Clin Hypertens 5315-320
47
ATTACHMENT F
48
1
Current 1582 (2007) language in reference to pregnancy 43 (4) Report to the fire department physician any medical condition that could interfere with the ability of the individual to safely perform essential job tasks such as illness or injury use of prescription or nonprescription drugs and pregnancy 6112 Category B medical conditions shall include the following (1) Pregnancy for its duration A7792 (e) If HIV prophylaxis is to be given the following tests should be done i CBC ii Glucose renal and hepatic chemical function iii Pregnancy test for females B121 Pregnancy and Reproduction Federal regulations as well as many court decisions including the US Supreme Courtrsquos decision in International Union et al v Johnson Controls Inc [499 US 187 111 S Ct 1196 (1991)] have interpreted the requirements of Title VII with respect to pregnancy and reproduction The AHJ should seek the advice of counsel in resolving specific questions concerning these requirements as well as other requirements that can be imposed by state or local laws C211 (4) Review health status with the individual being evaluated Contraindications for evaluations shall be reviewed addressing any changes in the individualrsquos health status since their last medical evaluation that would warrant deferring the evaluation including (g) Pregnancy Recommendations to language enhancement
A female employee who is assigned to regular fire line duty shall report a pregnancy immediately to their respective Supervisor and the fire department physician The employee will then be given the option of a non-hazardous alternative duty position for the duration of her pregnancy (can we say this or is it even appropriate) Any pregnant employee wishing to remain on regular line duty shall be informed of the possible risks and consequences to herself and her fetus that are associated with continued line fire fighting duty Among those risk factors are exposure to teratogens known to have negative effects on the developing fetus such as smoke diesel fumes hazardous chemicals and extreme heat
49
Page 2
appendix It is recommended that the pregnant employee complete a release of liability form signed by herself and her health care provider utilizing NFPArsquos 13 critical tasks as a reference This will inform the health care provider of specific job-related tasks that will need to be performed in order to continue regular line duty These tasks are basic physical standards that any entry level firefighter would have to be able to complete competently The employeersquos health condition will be kept confidential by the department in accordance with HIPAA standards Employees are allowed to remain on active regular duty until they are no longer able to perform their duties in a reasonable manner andor their protective gear no longer fits correctly It is the responsibility of the health care provider to evaluate the pregnant employee If at any time the health care provider feels the pregnant employee can no longer perform the job related tasks this should be reported to the employer by the employee immediately
50
ATTACHMENT G
51
From GLENN BENARICKTo Sawyer SteveSubject RE RE 7743Date Monday August 30 2010 21633 PM
Yes thats my understanding
Glenn P Benarick 211 Winged Elm CircleAiken SC 29803803-644-7093gbenarprodigynet
--- On Mon 83010 Sawyer Steve ltssawyerNFPAorggt wrote
From Sawyer Steve ltssawyerNFPAorggtSubject RE RE 7743To GLENN BENARICK ltgbenarprodigynetgtDate Monday August 30 2010 212 PM
So it should be ldquoorrdquo instead of ldquoandrdquo for now
Steven F Sawyer
Senior Fire Service Specialist
Executive Secretary IFMAFire Service Section
NFPA
1 Batterymarch Park
Quincy MA 02169
6179847423
Fax 6179847056
ssawyernfpaorg
From GLENN BENARICK [mailtogbenarprodigynet] Sent Monday August 30 2010 1202 PMTo Sawyer SteveSubject Fw RE 7743
52
Steve a couple of our docs agree with April Boyer
Glenn P Benarick 211 Winged Elm Circle
Aiken SC 29803
803-644-7093
gbenarprodigynet
--- On Mon 83010 David Prezant ltprezandfdnynycgovgt wrote
From David Prezant ltprezandfdnynycgovgtSubject RE 7743To Thomas R (CDCNIOSHDSHEFS) Hales lttrh1cdcgovgt GLENNBENARICK ltgbenarprodigynetgtCc Sandy Bogucki ltsandyboguckiyaleedugtDate Monday August 30 2010 1004 AM
agree
we should change this to NHANES III rather than Knudson we should alsomodify this to allow not only for predicted cutoffs but all for use of thelower limit of normal cutoff This is important to prevent false-classificationof spirometry as abnormal in older groups and in taller grps The latter ofparticular import to firefighter occupational health surveillance
thanks
David Prezant MDChief Medical Officer Office of Medical AffairsCo-Director WTC Medical Monitoring amp Treatment ProgramsNew York City Fire Department9 Metrotech Center - Rm 4W-1Brooklyn NY 11201Phone 718-999-2696Fax 718-999-0665
Life is full of twists and turns
53
This email may contain confidential information If you are the unintendedrecipient of this email please send it back and delete from your directory
gtgtgt Hales Thomas R (CDCNIOSHDSHEFS) lttrh1cdcgovgt 8302010955 AM gtgtgt
Glen
This seems like a very reasonable comment and illustrates the importance of having clinicians providefeedback on the std Im not familiar with the software program of the various spirometers (NHANES IIIvs KnudsonATS vs both) Given the large role both Dave Prezant and Sandy Bogucki had for thepulmonary section let me forward to them for clarification
Tom
From GLENN BENARICK [mailtogbenarprodigynet] Sent Sunday August 29 2010 456 PMTo Hales Thomas R (CDCNIOSHDSHEFS)Subject FW 7743
Tom is April Boyer correct
Glenn P Benarick 211 Winged Elm Circle
Aiken SC 29803
803-644-7093
gbenarprodigynet
--- On Thu 82610 Sawyer Steve ltssawyerNFPAorggt wrote
From Sawyer Steve ltssawyerNFPAorggtSubject FW 7743To GLENN BENARICK ltgbenarprodigynetgtDate Thursday August 26 2010 925 PM
FYI Do you have any answer She is write
Steven
54
Steven F Sawyer
Senior Fire Service Specialist
Executive Secretary IFMAFire Service Section
NFPA
1 Batterymarch Park
Quincy MA 02169
6179847423
Fax 6179847056
ssawyernfpaorg
From April Boyer [mailtoaboyerbicclinicorg] Sent Thursday August 26 2010 232 PMTo Sawyer SteveCc RobinMWebbmilstateorusSubject 7743
Steven
The spirometry tests cannot be corrected according to both references as the NFPA states because thereferences are contradictory The first part of 7743 states to follow the ATS guidelines and use theKnudsen (we at Basin Immediate Care use the Nhanes III) The second part states to follow the ACOEMguidelines and use the Nhanes III in the occupational setting if available with your unit (which is availableon ours) 7743 does not use the word OR regarding both requirements it uses the word AND whenreferring to the first and second parts thence making 7743 contradictory I realize the NFPA 1582 hasnot been updated since 2007 unless I have just not received an updated version
Our question to you is which part of 7743 do you want us to follow the first or the second part Anyfacility that has an updated computerized spirometry system (as we do) will not be able to follow bothrequired parts for obvious reasons We can either follow the first part of 7743 and use an oldercorrected version of the Knudson by going into our system and changing out of the Nhanes III conversionOR we can follow the second part of 7743 and use the newer corrected version of Nhanes III which ourunit offers too
If you have any questions you may contact me at anytime and I also have many references in regards toboth parts of 7743 if you would like to see them
55
Thank you~
April
Confidentiality NoticeThis message may contain information that isconfidential or privileged
If you are not the intended recipientPlease advise the sender immediately and delete this message
56
ATTACHMENT H
57
NFPA 1582 771(7) Proposed revisions
Why
Preliminary results of two prospective randomized trials on the PSA test were published in 2009 These studies resulted in medical organizations that previously providing guidance to modify their recommendations
Current language
771 Blood Tests Blood tests shall be performed annually and shall include the following
(7) Prostate specific antigen (PSA) after age 40 for positive family history if African American or if otherwise clinically indicated after age 50 for all other male member
Suggested Revision
771 Blood Tests Blood tests shall be performed annually and shall include the following
(7) Prostate specific antigen (PSA) after age 40 for positive family history if African American or if otherwise clinically indicated after age 50 for all other male member
772 Prostate-Specific Antigen (PSA) test At age 50 fire fighters shall have an opportunity to make an informed decision with either the Fire Department physician or their health care provider concerning the PSA test For fire fighters at increased risk of prostate cancer (African-Americans or those with a first degree relative diagnosed with prostate cancer before age 65) shall have the opportunity for this informed decision at age 40
A772 The PSA as a screening test for prostate cancer in asymptomatic men is controversial controversial for two reasons First there is no consensus that PSA screening actually saves lives For example the PSA test may detect small cancers that would never become life threatening Second it is unclear that the benefits of PSA screening outweigh the risks of follow-up diagnostic tests and cancer treatments For example the prostate biopsy used to diagnose prostate cancer may cause bleeding and infection And prostate cancer treatments such as surgery and radiation therapy may cause incontinence (inability to control urine flow) erectile dysfunction (erections inadequate for intercourse) and other complications For these reasons it is important that the benefits and risks of prostate diagnostic procedures and treatment be taken into account when considering the PSA screening test These considerations can be taken account during discussions with the fire department physician or onersquos health care provider
D211 Cancer Screening
Smith R A C J Mettlin K J Davis and H Eyre 2000 ldquoAmerican Cancer Society guidelines for the early detection of cancerrdquo CA J Clin 50(1)34ndash49
Added references
58
Carroll P Albertsen PC Greene K et al [2010] Prostate-specific antigen best practice statement 2009 update Am Urological Assoc Available at httpwwwauanetorgcontentguidelines-and-quality-careclinical-guidelinesmain-reportspsa09pdf Date accessed September 2010
Ferrini R Woolf SH [2009] Screening for prostate cancer in American men American College of Preventive Medicine Practice Policy Statement Available at httpwwwacpmorgprostatehtm Date accessed September 2010
National Cancer Institute [2009] Prostate-specific antigen test National Cancer Institute Fact Sheet Available at httpwwwcancergovcancertopicsfactsheetDetectionPSA Date accessed September 2010
Wolf AMD Wender RC Etzioni RB et al [2010] American Cancer Society guideline for the early detection of prostate cancer Update 2010 Available at httpcaonlineamcancersocorgcgicontentfullcaac20066v1 Date accessed September 2010
59
692 Vascular System 6921 Category A medical conditions shall include the following
(1) Uncontrolled or poorly controlled hypertension
(2) Hypertension with evidence of end organ damage
A6921(1) Uncontrolled or poorly controlled hypertension increases the risk of a sudden cardiac event This sudden cardiac event would cause sudden incapacitation which interferes with the safe performance of essential job tasks Uncontrolled or poorly controlled hypertension can be defined as the presence of end organ damage (see below) or stage 2 hypertension (BP systolic gt160 mmHg or BP diastolic gt100 mmHg) Individuals with pre- stage 1 or stage 2 hypertension should be referred to their primary care physician for evaluation lifestyle modification and treatment [QUESTION FOR GROUP _- WHAT ABOUT HAVING CANDIDATE RETURN IN ONE MONTH UNDER TREATMENT WITH NORMAL BP]
A6921(2)Chronic hypertension can damage the eye (retinopathy) the kidneys (nephropathy) the vascular system (stroke transient ischemic attack or peripheral artery disease) or the heart (left ventricular hypertrophy and heart failure) These hypertension complications are known as end organ damage The cardiac and vascular complications are associated with an increased risk of sudden incapacitation and sudden cardiac death (Koren et al 1991) Unfortunately the cardiac complications are frequently asymptomatic and valid screening tests are not fast and are not inexpensive Therefore determining who to screen for cardiac complications (such as echocardiogram for LVH or a measurement of left ventricular ejection fraction for heart failure) should be based on the severity and the duration of HTN
76 Physical Examination The annual physical examination shall include each of the following components
(a) BP shall be measured according to the Joint National Commission (JNC)-7 recommendations
A76(1)(a) BP should be measured with a properly calibrated and validated instrument Patients should be seated quietly for at least 5 minutes in a chair with feet on the floor and arm supported at heart level An appropriate-sized cuff (cuff bladder encircling at least 80 of the arm) should be used to ensure accuracy At least 2 measurements should be made Systolic BP is the point at which the first of 2 or more sounds is heard (phase 1) and diastolic BP is the point before the disappearance of sounds (phase 5) [Chobanian et al 2003]
(2) Head eyes ears nose and throat9420 Hypertension 94201 Physician Evaluation Members with Pre-hypertention (systolic 120-139 mmHg or diastolic 80-89 mmHg) Stage 1 hypertension (systolic 140-159 mmHg or diastolic 90-99 mmHg) or Stage 2 hypertension (systolic ge160 mmHg or diastolic ge100 mmHg) should be referred to their primary care physician for evaluation lifestyle modification and treatment
39
(1) Members with Stage I hypertension should be followed-up not only by their primary care physician but also by the FD physician every 3 to 6 months to ensure their blood pressure is under control and to determine whether screening tests for asymptomatic end organ damage are appropriate
(2) Members with Stage 2 hypertension or with end organ damage (retinopathy nephropathy vascular or cardiac complications) compromises the members ability to safely perform essential job tasks 1 5 7 9 and 130 and the physician shall report the applicable job limitations to the fire department
A94201 Chronic hypertension can damage the eye (retinopathy) the kidneys (nephropathy) the vascular system (stroke transient ischemic attack or peripheral artery disease) or the heart (left ventricular hypertrophy and heart failure) These hypertension complications are known as end organ damage The cardiac and vascular complications are associated with an increased risk of sudden incapacitation and sudden cardiac death (Koren et al 1991) Fortunately with proper evaluation life style modification and treatment these complications can be avoided Life style modification includes weight reduction DASH eating plan reduction in dietary sodium an increase in aerobic physical activity and moderation in alcohol consumption [Chobanian 2003]
A94201 (1) Members with Stage I hypertension whose BP returns to either pre-hypertenion or normal with lifestyle modification andor treatment can return to an annual medical evaluation For members with long-standing Stage I hypertension whose BP has not been reduced additional evaluation for possible end organ damage should be considered This evaluation could include any or all of the following
a) a compete patient history for symptoms of heart failure (eg shortness of breath upon exertion) or transient ischemic attacks (TIAs)
b) dilated eye examination for retinopathy
c) blood creatinine measurement for nephropathy
d) tests for left ventricular hypertrophy Unfortunately use of the resting EKG to detect left ventricular hypertrophy is very insensitive (eg 5 sensitivity) The echocardiogram is the best test for diagnosing left ventricular hypertrophy
A 94201 (2) Due to the high risk of a sudden cardiovascular event members with Stage 2 hypertension should be restricted until their BP can be brought under control Once the BP is brought under control they should be followed in the same manner as a member with Stage I hypertension
D22 Cardiology
40
Hypertension
Gibbons RJ Balady GJ Bricker JT Chaitman BR Fletcher GF Froelicher VF Mark DB McCallister BD Mooss AN OrsquoReilly MG Winters WL Jr [2002] ACCAHA 2002 guideline update for exercise testing summary article a report of the ACCAHA Task Force on Practice Guidelines (Committee to Update the 1997 Exercise Testing guidelines) J Am Coll Cardiol 401531ndash 40
Chobanian AV Bakris GL Black HR Cushman WC Green LA Izzo JL Jr Jones DW Materson BJ Oparil S Wright JT Jr Roccella EJ the National High Blood Pressure Education Program Coordinating Committee [2003] The seventh report of the Joint National Committee [JNC-7] on Prevention Detection Evaluation and Treatment of High Blood Pressure JAMA 2892560ndash2571
Soteriades ES Kales SN Liarokapis D Christiani DC [2003] Prospective surveillance of hypertension in firefighters J Clin Hypertens 5315-320
Kales SN Tsismenakis AJ Zhang C Soteriades ES [2009] Blood pressure in fire fighters police officers and other emergency responders Am J Hypertens 2211-20
41
NFPA 1582‐ Draft Revisions for CVDHTN
EKG and stress tests
Reason for Revision
1) Change requirement for annual resting EKG to periodically to be more consistent with ACCAHA
recommendation (Schlant et al 1992)
2) Add language to clarify what constitutes a positive ST
3) Make criteria for conducting diagnostic ST in asymptomatic patients consistent with the
ACCAHA
Language in 2007 Edition with draft revisions in Red (Track changes)
776 Electrocardiograms (EKG)) and Stress Tests 7761 A resting EKG shall be performed as part of the baseline medical evaluation and shall be obtained periodically (every 1 to 5 years) annually thereafter
A7761 A baseline resting EKGs shall be conducted Follow-up resting EKGs should be conducted as clinically indicated but at a minimum of every 1 to 5 years The frequency of these follow-up resting EKGs should increase as a members age increases or with increasing number andor severity of coronary heart disease risk factors Members above the age of 40 should have annual resting EKGs (Schlant et al 1992)
7762 The fire department physician or other qualified medical evaluator shall compare EKGs obtained during yearly evaluations with baseline and subsequent EKGs
7763 Stress testing EKG with or without echocardiography or radionuclide scanning shall be performed as clinically indicated by history or symptoms
A7761 Baseline electrocardiography should be conducted (Periodic resting electrocardiograms have not been shown to be useful but can be reasonable as a members agefactors increase)
A7763 No firm guidelines for stress testingelectrocardiography in asymptomatic individuals have been developed Stress testingelectrocardiography as a screening tool is used as part of an evaluation of aerobic capacity during the annual occupational fitness evaluation Submaximal stress testingelectrocardiography testing to 85 percent is commonly used as part of this screening
Submaximal stress electrocardiography testing should not be used for diagnostic purposes Cardiology evaluation with maximal stress testingelectrocardiography together with imaging techniques (eg echocardiography technetium Tc99m sestamibi study andor coronary angiography) is necessary for diagnosticprognostic purposes for the following
42
(1) Fire fighters with positive or questionably positive changes on screening submaximal stress tests
(2) Fire fighters with new onset chest pain or other symptoms suggestive of coronary artery disease (CAD)
(3) Fire fighters with diabetes mellitus who
(a) are gt35 years old or
(b) have type I diabetes for more than 15 years or
(c) have type II diabetes for more than 10 years or
(d) have any other CHD risk factor (see below) or
(e) have the presence of microvascular disease (proliferative retinopathy)
(4) Fire fighters over the age of 45 (for men) and 55 (for women) with onetwo or more risk factors for CAD Risk factors for CAD include hypercholesterolemia (total cholesterol greater than 240 mgdL) hypertension (systolic gt140 mmHg or diastolic gt90 mmHg) smoking or family history of premature CAD (heart attack or sudden cardiac death in a first degree relative less than 60 years of age)
as defined below if stress electrocardiography with imaging is negative then repeat as clinically indicated or at least every 5 years
(5) Fire fighters with a Framingham Risk Score gt10 Risk calculator is available at [httphp2010nhlbihinnetatpiiicalculatorasp]
(6) Fire fighters identified in 9431
Negative stress tests should be repeated as clinically indicated or at least every 2 to 5 years
Interpreting stress tests as ldquopositiverdquo or ldquonegativerdquo is beyond the scope of this document However factors that should be taken into consideration should include the individualrsquos exercise capacity symptoms blood pressure response heart rate response EKG changes and the presence of arrhythmias (Gibbon et al 2002)
Risk factors for CAD include hypercholesterolemia (total cholesterol greater than 240 mgdL) hypertension (systolic greater than 140 andor diastolic greater than 90) smoking diabetes mellitus or family history of premature CAD (heart attack or sudden cardiac death in a first degree relative less than 60 years of age)
There are other non-invasive tests to screen for coronary artery disease One of the most promising appears to be coronary artery calcium (CAD) scoring by computed tomography In 2007 an expert committee published an update to their original guidance document The committeersquos consensus was that ldquoit may be reasonable to consider use of CAC measurement in such patients [between 10 and 20 10-year risk of estimated coronary event]helliprdquo The committee did not recommend CAC measurement in low risk patients [lt10 10-year risk of estimated coronary event] or in high risk patients [gt20 10-year risk of estimate coronary event] (Greenland et al 2007]
43
D22 Cardiology
Chobanian AV Bakris GL Black HR Cushman WC Green LA Izzo JL Jr Jones DW Materson BJ Oparil S Wright JT Jr Roccella EJ the National High Blood Pressure Education Program Coordinating Committee [2003] The seventh report of the Joint National Committee [JNC-7] on Prevention Detection Evaluation and Treatment of High Blood Pressure JAMA 2892560ndash2571
Gibbons RJ Balady GJ Bricker JT Chaitman BR Fletcher GF Froelicher VF Mark DB McCallister BD Mooss AN OrsquoReilly MG Winters WL Jr [2002] ACCAHA 2002 guideline update for exercise testing summary article a report of the ACCAHA Task Force on Practice Guidelines (Committee to Update the 1997 Exercise Testing guidelines) J Am Coll Cardiol 401531ndash 1540
Greenland et al [2007] ACCFAHA 2007 Clinical Expert Consensus Document on Coronary Artery Calcium Scoring By Computed Tomography in Global Cardiovascular Risk Assessment and in Evaluation of Patients With Chest Pain A Report of the American College of Cardiology Foundation Clinical Expert Consensus Task Force (ACCFAHA Writing Committee to Update the 2000 Expert Consensus Document on Electron Beam Computed Tomography) J Am Coll Cardiol 49378-402
Kales SN Tsismenakis AJ Zhang C Soteriades ES [2009] Blood pressure in fire fighters police officers and other emergency responders Am J Hypertens 2211-20
Schlant RC Adolph RJ DiMarco JP Dreifus LS Dunn MI Fisch C Garson A Jr Haywood LJ Levine HJ Murray JA Noble RJ Ronan JA Jr [1992] Guidelines for electrocardiography A report of the American College of CardiologyAmerican Heart Association Task Force on Assessment of Diagnostic and Therapeutic Cardiovascular Procedures (Committee on Electrocardiography) Circulation 85(3)1221-1228
Soteriades ES Kales SN Liarokapis D Christiani DC [2003] Prospective surveillance of hypertension in firefighters J Clin Hypertens 5315-320
Formatted Font Italic
Formatted Line spacing single
Formatted Font Italic
Formatted Font Italic
44
NFPA 1582‐ Draft Revisions for CVDHTN
EKG and stress tests
Reason for Revision
1) Change requirement for annual resting EKG to periodically to be more consistent with ACCAHA
recommendation (Schlant et al 1992)
2) Add language to clarify what constitutes a positive ST
3) Make criteria for conducting diagnostic ST in asymptomatic patients consistent with the
ACCAHA
Language in 2007 Edition with draft revisions in Red (Track changes)
776 Electrocardiograms (EKG) and Stress Tests 7761 A resting EKG shall be performed as part of the baseline medical evaluation and shall be obtained periodically (every 1 to 5 years) thereafter
A7761 A baseline resting EKGs shall be conducted Follow-up resting EKGs should be conducted as clinically indicated but at a minimum of every 1 to 5 years The frequency of these follow-up resting EKGs should increase as a members age increases or with increasing number andor severity of coronary heart disease risk factors Members above the age of 40 should have annual resting EKGs (Schlant et al 1992)
7762 The fire department physician or other qualified medical evaluator shall compare baseline and subsequent EKGs
7763 Stress testing with or without echocardiography or radionuclide scanning shall be performed as clinically indicated by history or symptoms
A7763 No firm guidelines for stress testing in asymptomatic individuals have been developed Stress testing as a screening tool is used as part of an evaluation of aerobic capacity during the annual occupational fitness evaluation Submaximal stress testing testing to 85 percent is commonly used as part of this screening
Submaximal stress testing should not be used for diagnostic purposes Cardiology evaluation with maximal stress testing together with imaging techniques (eg echocardiography technetium Tc99m sestamibi study) is necessary for diagnosticprognostic purposes for the following
(1) Fire fighters with positive or questionably positive changes on screening submaximal stress tests
(2) Fire fighters with new onset chest pain or other symptoms suggestive of coronary artery disease (CAD)
45
(3) Fire fighters with diabetes mellitus who
(a) are gt35 years old or
(b) have type I diabetes for more than 15 years or
(c) have type II diabetes for more than 10 years or
(d) have any other CHD risk factor (see below) or
(e) have the presence of microvascular disease (proliferative retinopathy)
(4) Fire fighters over the age of 45 (for men) and 55 (for women) with one or more risk factors for CAD Risk factors for CAD include hypercholesterolemia (total cholesterol greater than 240 mgdL) hypertension (systolic gt140 mmHg or diastolic gt90 mmHg) smoking or family history of premature CAD (heart attack or sudden cardiac death in a first degree relative less than 60 years of age)
(5) Fire fighters with a Framingham Risk Score gt10 Risk calculator is available at [httphp2010nhlbihinnetatpiiicalculatorasp]
(6) Fire fighters identified in 9431
Negative stress tests should be repeated as clinically indicated or at least every 2 to 5 years
Interpreting stress tests as ldquopositiverdquo or ldquonegativerdquo is beyond the scope of this document However factors that should be taken into consideration should include the individualrsquos exercise capacity symptoms blood pressure response heart rate response EKG changes and the presence of arrhythmias (Gibbon et al 2002)
There are other non-invasive tests to screen for coronary artery disease One of the most promising appears to be coronary artery calcium (CAD) scoring by computed tomography In 2007 an expert committee published an update to their original guidance document The committeersquos consensus was that ldquoit may be reasonable to consider use of CAC measurement in such patients [between 10 and 20 10-year risk of estimated coronary event]helliprdquo The committee did not recommend CAC measurement in low risk patients [lt10 10-year risk of estimated coronary event] or in high risk patients [gt20 10-year risk of estimate coronary event] (Greenland et al 2007]
D22 Cardiology
Resting EKG and Stress Tests
46
Chobanian AV Bakris GL Black HR Cushman WC Green LA Izzo JL Jr Jones DW Materson BJ Oparil S Wright JT Jr Roccella EJ the National High Blood Pressure Education Program Coordinating Committee [2003] The seventh report of the Joint National Committee [JNC-7] on Prevention Detection Evaluation and Treatment of High Blood Pressure JAMA 2892560ndash2571
Gibbons RJ Balady GJ Bricker JT Chaitman BR Fletcher GF Froelicher VF Mark DB McCallister BD Mooss AN OrsquoReilly MG Winters WL Jr [2002] ACCAHA 2002 guideline update for exercise testing summary article a report of the ACCAHA Task Force on Practice Guidelines (Committee to Update the 1997 Exercise Testing guidelines) J Am Coll Cardiol 401531ndash 1540
Greenland et al [2007] ACCFAHA 2007 Clinical Expert Consensus Document on Coronary Artery Calcium Scoring By Computed Tomography in Global Cardiovascular Risk Assessment and in Evaluation of Patients With Chest Pain A Report of the American College of Cardiology Foundation Clinical Expert Consensus Task Force (ACCFAHA Writing Committee to Update the 2000 Expert Consensus Document on Electron Beam Computed Tomography) J Am Coll Cardiol 49378-402
Kales SN Tsismenakis AJ Zhang C Soteriades ES [2009] Blood pressure in fire fighters police officers and other emergency responders Am J Hypertens 2211-20
Schlant RC Adolph RJ DiMarco JP Dreifus LS Dunn MI Fisch C Garson A Jr Haywood LJ Levine HJ Murray JA Noble RJ Ronan JA Jr [1992] Guidelines for electrocardiography A report of the American College of CardiologyAmerican Heart Association Task Force on Assessment of Diagnostic and Therapeutic Cardiovascular Procedures (Committee on Electrocardiography) Circulation 85(3)1221-1228
Soteriades ES Kales SN Liarokapis D Christiani DC [2003] Prospective surveillance of hypertension in firefighters J Clin Hypertens 5315-320
47
ATTACHMENT F
48
1
Current 1582 (2007) language in reference to pregnancy 43 (4) Report to the fire department physician any medical condition that could interfere with the ability of the individual to safely perform essential job tasks such as illness or injury use of prescription or nonprescription drugs and pregnancy 6112 Category B medical conditions shall include the following (1) Pregnancy for its duration A7792 (e) If HIV prophylaxis is to be given the following tests should be done i CBC ii Glucose renal and hepatic chemical function iii Pregnancy test for females B121 Pregnancy and Reproduction Federal regulations as well as many court decisions including the US Supreme Courtrsquos decision in International Union et al v Johnson Controls Inc [499 US 187 111 S Ct 1196 (1991)] have interpreted the requirements of Title VII with respect to pregnancy and reproduction The AHJ should seek the advice of counsel in resolving specific questions concerning these requirements as well as other requirements that can be imposed by state or local laws C211 (4) Review health status with the individual being evaluated Contraindications for evaluations shall be reviewed addressing any changes in the individualrsquos health status since their last medical evaluation that would warrant deferring the evaluation including (g) Pregnancy Recommendations to language enhancement
A female employee who is assigned to regular fire line duty shall report a pregnancy immediately to their respective Supervisor and the fire department physician The employee will then be given the option of a non-hazardous alternative duty position for the duration of her pregnancy (can we say this or is it even appropriate) Any pregnant employee wishing to remain on regular line duty shall be informed of the possible risks and consequences to herself and her fetus that are associated with continued line fire fighting duty Among those risk factors are exposure to teratogens known to have negative effects on the developing fetus such as smoke diesel fumes hazardous chemicals and extreme heat
49
Page 2
appendix It is recommended that the pregnant employee complete a release of liability form signed by herself and her health care provider utilizing NFPArsquos 13 critical tasks as a reference This will inform the health care provider of specific job-related tasks that will need to be performed in order to continue regular line duty These tasks are basic physical standards that any entry level firefighter would have to be able to complete competently The employeersquos health condition will be kept confidential by the department in accordance with HIPAA standards Employees are allowed to remain on active regular duty until they are no longer able to perform their duties in a reasonable manner andor their protective gear no longer fits correctly It is the responsibility of the health care provider to evaluate the pregnant employee If at any time the health care provider feels the pregnant employee can no longer perform the job related tasks this should be reported to the employer by the employee immediately
50
ATTACHMENT G
51
From GLENN BENARICKTo Sawyer SteveSubject RE RE 7743Date Monday August 30 2010 21633 PM
Yes thats my understanding
Glenn P Benarick 211 Winged Elm CircleAiken SC 29803803-644-7093gbenarprodigynet
--- On Mon 83010 Sawyer Steve ltssawyerNFPAorggt wrote
From Sawyer Steve ltssawyerNFPAorggtSubject RE RE 7743To GLENN BENARICK ltgbenarprodigynetgtDate Monday August 30 2010 212 PM
So it should be ldquoorrdquo instead of ldquoandrdquo for now
Steven F Sawyer
Senior Fire Service Specialist
Executive Secretary IFMAFire Service Section
NFPA
1 Batterymarch Park
Quincy MA 02169
6179847423
Fax 6179847056
ssawyernfpaorg
From GLENN BENARICK [mailtogbenarprodigynet] Sent Monday August 30 2010 1202 PMTo Sawyer SteveSubject Fw RE 7743
52
Steve a couple of our docs agree with April Boyer
Glenn P Benarick 211 Winged Elm Circle
Aiken SC 29803
803-644-7093
gbenarprodigynet
--- On Mon 83010 David Prezant ltprezandfdnynycgovgt wrote
From David Prezant ltprezandfdnynycgovgtSubject RE 7743To Thomas R (CDCNIOSHDSHEFS) Hales lttrh1cdcgovgt GLENNBENARICK ltgbenarprodigynetgtCc Sandy Bogucki ltsandyboguckiyaleedugtDate Monday August 30 2010 1004 AM
agree
we should change this to NHANES III rather than Knudson we should alsomodify this to allow not only for predicted cutoffs but all for use of thelower limit of normal cutoff This is important to prevent false-classificationof spirometry as abnormal in older groups and in taller grps The latter ofparticular import to firefighter occupational health surveillance
thanks
David Prezant MDChief Medical Officer Office of Medical AffairsCo-Director WTC Medical Monitoring amp Treatment ProgramsNew York City Fire Department9 Metrotech Center - Rm 4W-1Brooklyn NY 11201Phone 718-999-2696Fax 718-999-0665
Life is full of twists and turns
53
This email may contain confidential information If you are the unintendedrecipient of this email please send it back and delete from your directory
gtgtgt Hales Thomas R (CDCNIOSHDSHEFS) lttrh1cdcgovgt 8302010955 AM gtgtgt
Glen
This seems like a very reasonable comment and illustrates the importance of having clinicians providefeedback on the std Im not familiar with the software program of the various spirometers (NHANES IIIvs KnudsonATS vs both) Given the large role both Dave Prezant and Sandy Bogucki had for thepulmonary section let me forward to them for clarification
Tom
From GLENN BENARICK [mailtogbenarprodigynet] Sent Sunday August 29 2010 456 PMTo Hales Thomas R (CDCNIOSHDSHEFS)Subject FW 7743
Tom is April Boyer correct
Glenn P Benarick 211 Winged Elm Circle
Aiken SC 29803
803-644-7093
gbenarprodigynet
--- On Thu 82610 Sawyer Steve ltssawyerNFPAorggt wrote
From Sawyer Steve ltssawyerNFPAorggtSubject FW 7743To GLENN BENARICK ltgbenarprodigynetgtDate Thursday August 26 2010 925 PM
FYI Do you have any answer She is write
Steven
54
Steven F Sawyer
Senior Fire Service Specialist
Executive Secretary IFMAFire Service Section
NFPA
1 Batterymarch Park
Quincy MA 02169
6179847423
Fax 6179847056
ssawyernfpaorg
From April Boyer [mailtoaboyerbicclinicorg] Sent Thursday August 26 2010 232 PMTo Sawyer SteveCc RobinMWebbmilstateorusSubject 7743
Steven
The spirometry tests cannot be corrected according to both references as the NFPA states because thereferences are contradictory The first part of 7743 states to follow the ATS guidelines and use theKnudsen (we at Basin Immediate Care use the Nhanes III) The second part states to follow the ACOEMguidelines and use the Nhanes III in the occupational setting if available with your unit (which is availableon ours) 7743 does not use the word OR regarding both requirements it uses the word AND whenreferring to the first and second parts thence making 7743 contradictory I realize the NFPA 1582 hasnot been updated since 2007 unless I have just not received an updated version
Our question to you is which part of 7743 do you want us to follow the first or the second part Anyfacility that has an updated computerized spirometry system (as we do) will not be able to follow bothrequired parts for obvious reasons We can either follow the first part of 7743 and use an oldercorrected version of the Knudson by going into our system and changing out of the Nhanes III conversionOR we can follow the second part of 7743 and use the newer corrected version of Nhanes III which ourunit offers too
If you have any questions you may contact me at anytime and I also have many references in regards toboth parts of 7743 if you would like to see them
55
Thank you~
April
Confidentiality NoticeThis message may contain information that isconfidential or privileged
If you are not the intended recipientPlease advise the sender immediately and delete this message
56
ATTACHMENT H
57
NFPA 1582 771(7) Proposed revisions
Why
Preliminary results of two prospective randomized trials on the PSA test were published in 2009 These studies resulted in medical organizations that previously providing guidance to modify their recommendations
Current language
771 Blood Tests Blood tests shall be performed annually and shall include the following
(7) Prostate specific antigen (PSA) after age 40 for positive family history if African American or if otherwise clinically indicated after age 50 for all other male member
Suggested Revision
771 Blood Tests Blood tests shall be performed annually and shall include the following
(7) Prostate specific antigen (PSA) after age 40 for positive family history if African American or if otherwise clinically indicated after age 50 for all other male member
772 Prostate-Specific Antigen (PSA) test At age 50 fire fighters shall have an opportunity to make an informed decision with either the Fire Department physician or their health care provider concerning the PSA test For fire fighters at increased risk of prostate cancer (African-Americans or those with a first degree relative diagnosed with prostate cancer before age 65) shall have the opportunity for this informed decision at age 40
A772 The PSA as a screening test for prostate cancer in asymptomatic men is controversial controversial for two reasons First there is no consensus that PSA screening actually saves lives For example the PSA test may detect small cancers that would never become life threatening Second it is unclear that the benefits of PSA screening outweigh the risks of follow-up diagnostic tests and cancer treatments For example the prostate biopsy used to diagnose prostate cancer may cause bleeding and infection And prostate cancer treatments such as surgery and radiation therapy may cause incontinence (inability to control urine flow) erectile dysfunction (erections inadequate for intercourse) and other complications For these reasons it is important that the benefits and risks of prostate diagnostic procedures and treatment be taken into account when considering the PSA screening test These considerations can be taken account during discussions with the fire department physician or onersquos health care provider
D211 Cancer Screening
Smith R A C J Mettlin K J Davis and H Eyre 2000 ldquoAmerican Cancer Society guidelines for the early detection of cancerrdquo CA J Clin 50(1)34ndash49
Added references
58
Carroll P Albertsen PC Greene K et al [2010] Prostate-specific antigen best practice statement 2009 update Am Urological Assoc Available at httpwwwauanetorgcontentguidelines-and-quality-careclinical-guidelinesmain-reportspsa09pdf Date accessed September 2010
Ferrini R Woolf SH [2009] Screening for prostate cancer in American men American College of Preventive Medicine Practice Policy Statement Available at httpwwwacpmorgprostatehtm Date accessed September 2010
National Cancer Institute [2009] Prostate-specific antigen test National Cancer Institute Fact Sheet Available at httpwwwcancergovcancertopicsfactsheetDetectionPSA Date accessed September 2010
Wolf AMD Wender RC Etzioni RB et al [2010] American Cancer Society guideline for the early detection of prostate cancer Update 2010 Available at httpcaonlineamcancersocorgcgicontentfullcaac20066v1 Date accessed September 2010
59
(1) Members with Stage I hypertension should be followed-up not only by their primary care physician but also by the FD physician every 3 to 6 months to ensure their blood pressure is under control and to determine whether screening tests for asymptomatic end organ damage are appropriate
(2) Members with Stage 2 hypertension or with end organ damage (retinopathy nephropathy vascular or cardiac complications) compromises the members ability to safely perform essential job tasks 1 5 7 9 and 130 and the physician shall report the applicable job limitations to the fire department
A94201 Chronic hypertension can damage the eye (retinopathy) the kidneys (nephropathy) the vascular system (stroke transient ischemic attack or peripheral artery disease) or the heart (left ventricular hypertrophy and heart failure) These hypertension complications are known as end organ damage The cardiac and vascular complications are associated with an increased risk of sudden incapacitation and sudden cardiac death (Koren et al 1991) Fortunately with proper evaluation life style modification and treatment these complications can be avoided Life style modification includes weight reduction DASH eating plan reduction in dietary sodium an increase in aerobic physical activity and moderation in alcohol consumption [Chobanian 2003]
A94201 (1) Members with Stage I hypertension whose BP returns to either pre-hypertenion or normal with lifestyle modification andor treatment can return to an annual medical evaluation For members with long-standing Stage I hypertension whose BP has not been reduced additional evaluation for possible end organ damage should be considered This evaluation could include any or all of the following
a) a compete patient history for symptoms of heart failure (eg shortness of breath upon exertion) or transient ischemic attacks (TIAs)
b) dilated eye examination for retinopathy
c) blood creatinine measurement for nephropathy
d) tests for left ventricular hypertrophy Unfortunately use of the resting EKG to detect left ventricular hypertrophy is very insensitive (eg 5 sensitivity) The echocardiogram is the best test for diagnosing left ventricular hypertrophy
A 94201 (2) Due to the high risk of a sudden cardiovascular event members with Stage 2 hypertension should be restricted until their BP can be brought under control Once the BP is brought under control they should be followed in the same manner as a member with Stage I hypertension
D22 Cardiology
40
Hypertension
Gibbons RJ Balady GJ Bricker JT Chaitman BR Fletcher GF Froelicher VF Mark DB McCallister BD Mooss AN OrsquoReilly MG Winters WL Jr [2002] ACCAHA 2002 guideline update for exercise testing summary article a report of the ACCAHA Task Force on Practice Guidelines (Committee to Update the 1997 Exercise Testing guidelines) J Am Coll Cardiol 401531ndash 40
Chobanian AV Bakris GL Black HR Cushman WC Green LA Izzo JL Jr Jones DW Materson BJ Oparil S Wright JT Jr Roccella EJ the National High Blood Pressure Education Program Coordinating Committee [2003] The seventh report of the Joint National Committee [JNC-7] on Prevention Detection Evaluation and Treatment of High Blood Pressure JAMA 2892560ndash2571
Soteriades ES Kales SN Liarokapis D Christiani DC [2003] Prospective surveillance of hypertension in firefighters J Clin Hypertens 5315-320
Kales SN Tsismenakis AJ Zhang C Soteriades ES [2009] Blood pressure in fire fighters police officers and other emergency responders Am J Hypertens 2211-20
41
NFPA 1582‐ Draft Revisions for CVDHTN
EKG and stress tests
Reason for Revision
1) Change requirement for annual resting EKG to periodically to be more consistent with ACCAHA
recommendation (Schlant et al 1992)
2) Add language to clarify what constitutes a positive ST
3) Make criteria for conducting diagnostic ST in asymptomatic patients consistent with the
ACCAHA
Language in 2007 Edition with draft revisions in Red (Track changes)
776 Electrocardiograms (EKG)) and Stress Tests 7761 A resting EKG shall be performed as part of the baseline medical evaluation and shall be obtained periodically (every 1 to 5 years) annually thereafter
A7761 A baseline resting EKGs shall be conducted Follow-up resting EKGs should be conducted as clinically indicated but at a minimum of every 1 to 5 years The frequency of these follow-up resting EKGs should increase as a members age increases or with increasing number andor severity of coronary heart disease risk factors Members above the age of 40 should have annual resting EKGs (Schlant et al 1992)
7762 The fire department physician or other qualified medical evaluator shall compare EKGs obtained during yearly evaluations with baseline and subsequent EKGs
7763 Stress testing EKG with or without echocardiography or radionuclide scanning shall be performed as clinically indicated by history or symptoms
A7761 Baseline electrocardiography should be conducted (Periodic resting electrocardiograms have not been shown to be useful but can be reasonable as a members agefactors increase)
A7763 No firm guidelines for stress testingelectrocardiography in asymptomatic individuals have been developed Stress testingelectrocardiography as a screening tool is used as part of an evaluation of aerobic capacity during the annual occupational fitness evaluation Submaximal stress testingelectrocardiography testing to 85 percent is commonly used as part of this screening
Submaximal stress electrocardiography testing should not be used for diagnostic purposes Cardiology evaluation with maximal stress testingelectrocardiography together with imaging techniques (eg echocardiography technetium Tc99m sestamibi study andor coronary angiography) is necessary for diagnosticprognostic purposes for the following
42
(1) Fire fighters with positive or questionably positive changes on screening submaximal stress tests
(2) Fire fighters with new onset chest pain or other symptoms suggestive of coronary artery disease (CAD)
(3) Fire fighters with diabetes mellitus who
(a) are gt35 years old or
(b) have type I diabetes for more than 15 years or
(c) have type II diabetes for more than 10 years or
(d) have any other CHD risk factor (see below) or
(e) have the presence of microvascular disease (proliferative retinopathy)
(4) Fire fighters over the age of 45 (for men) and 55 (for women) with onetwo or more risk factors for CAD Risk factors for CAD include hypercholesterolemia (total cholesterol greater than 240 mgdL) hypertension (systolic gt140 mmHg or diastolic gt90 mmHg) smoking or family history of premature CAD (heart attack or sudden cardiac death in a first degree relative less than 60 years of age)
as defined below if stress electrocardiography with imaging is negative then repeat as clinically indicated or at least every 5 years
(5) Fire fighters with a Framingham Risk Score gt10 Risk calculator is available at [httphp2010nhlbihinnetatpiiicalculatorasp]
(6) Fire fighters identified in 9431
Negative stress tests should be repeated as clinically indicated or at least every 2 to 5 years
Interpreting stress tests as ldquopositiverdquo or ldquonegativerdquo is beyond the scope of this document However factors that should be taken into consideration should include the individualrsquos exercise capacity symptoms blood pressure response heart rate response EKG changes and the presence of arrhythmias (Gibbon et al 2002)
Risk factors for CAD include hypercholesterolemia (total cholesterol greater than 240 mgdL) hypertension (systolic greater than 140 andor diastolic greater than 90) smoking diabetes mellitus or family history of premature CAD (heart attack or sudden cardiac death in a first degree relative less than 60 years of age)
There are other non-invasive tests to screen for coronary artery disease One of the most promising appears to be coronary artery calcium (CAD) scoring by computed tomography In 2007 an expert committee published an update to their original guidance document The committeersquos consensus was that ldquoit may be reasonable to consider use of CAC measurement in such patients [between 10 and 20 10-year risk of estimated coronary event]helliprdquo The committee did not recommend CAC measurement in low risk patients [lt10 10-year risk of estimated coronary event] or in high risk patients [gt20 10-year risk of estimate coronary event] (Greenland et al 2007]
43
D22 Cardiology
Chobanian AV Bakris GL Black HR Cushman WC Green LA Izzo JL Jr Jones DW Materson BJ Oparil S Wright JT Jr Roccella EJ the National High Blood Pressure Education Program Coordinating Committee [2003] The seventh report of the Joint National Committee [JNC-7] on Prevention Detection Evaluation and Treatment of High Blood Pressure JAMA 2892560ndash2571
Gibbons RJ Balady GJ Bricker JT Chaitman BR Fletcher GF Froelicher VF Mark DB McCallister BD Mooss AN OrsquoReilly MG Winters WL Jr [2002] ACCAHA 2002 guideline update for exercise testing summary article a report of the ACCAHA Task Force on Practice Guidelines (Committee to Update the 1997 Exercise Testing guidelines) J Am Coll Cardiol 401531ndash 1540
Greenland et al [2007] ACCFAHA 2007 Clinical Expert Consensus Document on Coronary Artery Calcium Scoring By Computed Tomography in Global Cardiovascular Risk Assessment and in Evaluation of Patients With Chest Pain A Report of the American College of Cardiology Foundation Clinical Expert Consensus Task Force (ACCFAHA Writing Committee to Update the 2000 Expert Consensus Document on Electron Beam Computed Tomography) J Am Coll Cardiol 49378-402
Kales SN Tsismenakis AJ Zhang C Soteriades ES [2009] Blood pressure in fire fighters police officers and other emergency responders Am J Hypertens 2211-20
Schlant RC Adolph RJ DiMarco JP Dreifus LS Dunn MI Fisch C Garson A Jr Haywood LJ Levine HJ Murray JA Noble RJ Ronan JA Jr [1992] Guidelines for electrocardiography A report of the American College of CardiologyAmerican Heart Association Task Force on Assessment of Diagnostic and Therapeutic Cardiovascular Procedures (Committee on Electrocardiography) Circulation 85(3)1221-1228
Soteriades ES Kales SN Liarokapis D Christiani DC [2003] Prospective surveillance of hypertension in firefighters J Clin Hypertens 5315-320
Formatted Font Italic
Formatted Line spacing single
Formatted Font Italic
Formatted Font Italic
44
NFPA 1582‐ Draft Revisions for CVDHTN
EKG and stress tests
Reason for Revision
1) Change requirement for annual resting EKG to periodically to be more consistent with ACCAHA
recommendation (Schlant et al 1992)
2) Add language to clarify what constitutes a positive ST
3) Make criteria for conducting diagnostic ST in asymptomatic patients consistent with the
ACCAHA
Language in 2007 Edition with draft revisions in Red (Track changes)
776 Electrocardiograms (EKG) and Stress Tests 7761 A resting EKG shall be performed as part of the baseline medical evaluation and shall be obtained periodically (every 1 to 5 years) thereafter
A7761 A baseline resting EKGs shall be conducted Follow-up resting EKGs should be conducted as clinically indicated but at a minimum of every 1 to 5 years The frequency of these follow-up resting EKGs should increase as a members age increases or with increasing number andor severity of coronary heart disease risk factors Members above the age of 40 should have annual resting EKGs (Schlant et al 1992)
7762 The fire department physician or other qualified medical evaluator shall compare baseline and subsequent EKGs
7763 Stress testing with or without echocardiography or radionuclide scanning shall be performed as clinically indicated by history or symptoms
A7763 No firm guidelines for stress testing in asymptomatic individuals have been developed Stress testing as a screening tool is used as part of an evaluation of aerobic capacity during the annual occupational fitness evaluation Submaximal stress testing testing to 85 percent is commonly used as part of this screening
Submaximal stress testing should not be used for diagnostic purposes Cardiology evaluation with maximal stress testing together with imaging techniques (eg echocardiography technetium Tc99m sestamibi study) is necessary for diagnosticprognostic purposes for the following
(1) Fire fighters with positive or questionably positive changes on screening submaximal stress tests
(2) Fire fighters with new onset chest pain or other symptoms suggestive of coronary artery disease (CAD)
45
(3) Fire fighters with diabetes mellitus who
(a) are gt35 years old or
(b) have type I diabetes for more than 15 years or
(c) have type II diabetes for more than 10 years or
(d) have any other CHD risk factor (see below) or
(e) have the presence of microvascular disease (proliferative retinopathy)
(4) Fire fighters over the age of 45 (for men) and 55 (for women) with one or more risk factors for CAD Risk factors for CAD include hypercholesterolemia (total cholesterol greater than 240 mgdL) hypertension (systolic gt140 mmHg or diastolic gt90 mmHg) smoking or family history of premature CAD (heart attack or sudden cardiac death in a first degree relative less than 60 years of age)
(5) Fire fighters with a Framingham Risk Score gt10 Risk calculator is available at [httphp2010nhlbihinnetatpiiicalculatorasp]
(6) Fire fighters identified in 9431
Negative stress tests should be repeated as clinically indicated or at least every 2 to 5 years
Interpreting stress tests as ldquopositiverdquo or ldquonegativerdquo is beyond the scope of this document However factors that should be taken into consideration should include the individualrsquos exercise capacity symptoms blood pressure response heart rate response EKG changes and the presence of arrhythmias (Gibbon et al 2002)
There are other non-invasive tests to screen for coronary artery disease One of the most promising appears to be coronary artery calcium (CAD) scoring by computed tomography In 2007 an expert committee published an update to their original guidance document The committeersquos consensus was that ldquoit may be reasonable to consider use of CAC measurement in such patients [between 10 and 20 10-year risk of estimated coronary event]helliprdquo The committee did not recommend CAC measurement in low risk patients [lt10 10-year risk of estimated coronary event] or in high risk patients [gt20 10-year risk of estimate coronary event] (Greenland et al 2007]
D22 Cardiology
Resting EKG and Stress Tests
46
Chobanian AV Bakris GL Black HR Cushman WC Green LA Izzo JL Jr Jones DW Materson BJ Oparil S Wright JT Jr Roccella EJ the National High Blood Pressure Education Program Coordinating Committee [2003] The seventh report of the Joint National Committee [JNC-7] on Prevention Detection Evaluation and Treatment of High Blood Pressure JAMA 2892560ndash2571
Gibbons RJ Balady GJ Bricker JT Chaitman BR Fletcher GF Froelicher VF Mark DB McCallister BD Mooss AN OrsquoReilly MG Winters WL Jr [2002] ACCAHA 2002 guideline update for exercise testing summary article a report of the ACCAHA Task Force on Practice Guidelines (Committee to Update the 1997 Exercise Testing guidelines) J Am Coll Cardiol 401531ndash 1540
Greenland et al [2007] ACCFAHA 2007 Clinical Expert Consensus Document on Coronary Artery Calcium Scoring By Computed Tomography in Global Cardiovascular Risk Assessment and in Evaluation of Patients With Chest Pain A Report of the American College of Cardiology Foundation Clinical Expert Consensus Task Force (ACCFAHA Writing Committee to Update the 2000 Expert Consensus Document on Electron Beam Computed Tomography) J Am Coll Cardiol 49378-402
Kales SN Tsismenakis AJ Zhang C Soteriades ES [2009] Blood pressure in fire fighters police officers and other emergency responders Am J Hypertens 2211-20
Schlant RC Adolph RJ DiMarco JP Dreifus LS Dunn MI Fisch C Garson A Jr Haywood LJ Levine HJ Murray JA Noble RJ Ronan JA Jr [1992] Guidelines for electrocardiography A report of the American College of CardiologyAmerican Heart Association Task Force on Assessment of Diagnostic and Therapeutic Cardiovascular Procedures (Committee on Electrocardiography) Circulation 85(3)1221-1228
Soteriades ES Kales SN Liarokapis D Christiani DC [2003] Prospective surveillance of hypertension in firefighters J Clin Hypertens 5315-320
47
ATTACHMENT F
48
1
Current 1582 (2007) language in reference to pregnancy 43 (4) Report to the fire department physician any medical condition that could interfere with the ability of the individual to safely perform essential job tasks such as illness or injury use of prescription or nonprescription drugs and pregnancy 6112 Category B medical conditions shall include the following (1) Pregnancy for its duration A7792 (e) If HIV prophylaxis is to be given the following tests should be done i CBC ii Glucose renal and hepatic chemical function iii Pregnancy test for females B121 Pregnancy and Reproduction Federal regulations as well as many court decisions including the US Supreme Courtrsquos decision in International Union et al v Johnson Controls Inc [499 US 187 111 S Ct 1196 (1991)] have interpreted the requirements of Title VII with respect to pregnancy and reproduction The AHJ should seek the advice of counsel in resolving specific questions concerning these requirements as well as other requirements that can be imposed by state or local laws C211 (4) Review health status with the individual being evaluated Contraindications for evaluations shall be reviewed addressing any changes in the individualrsquos health status since their last medical evaluation that would warrant deferring the evaluation including (g) Pregnancy Recommendations to language enhancement
A female employee who is assigned to regular fire line duty shall report a pregnancy immediately to their respective Supervisor and the fire department physician The employee will then be given the option of a non-hazardous alternative duty position for the duration of her pregnancy (can we say this or is it even appropriate) Any pregnant employee wishing to remain on regular line duty shall be informed of the possible risks and consequences to herself and her fetus that are associated with continued line fire fighting duty Among those risk factors are exposure to teratogens known to have negative effects on the developing fetus such as smoke diesel fumes hazardous chemicals and extreme heat
49
Page 2
appendix It is recommended that the pregnant employee complete a release of liability form signed by herself and her health care provider utilizing NFPArsquos 13 critical tasks as a reference This will inform the health care provider of specific job-related tasks that will need to be performed in order to continue regular line duty These tasks are basic physical standards that any entry level firefighter would have to be able to complete competently The employeersquos health condition will be kept confidential by the department in accordance with HIPAA standards Employees are allowed to remain on active regular duty until they are no longer able to perform their duties in a reasonable manner andor their protective gear no longer fits correctly It is the responsibility of the health care provider to evaluate the pregnant employee If at any time the health care provider feels the pregnant employee can no longer perform the job related tasks this should be reported to the employer by the employee immediately
50
ATTACHMENT G
51
From GLENN BENARICKTo Sawyer SteveSubject RE RE 7743Date Monday August 30 2010 21633 PM
Yes thats my understanding
Glenn P Benarick 211 Winged Elm CircleAiken SC 29803803-644-7093gbenarprodigynet
--- On Mon 83010 Sawyer Steve ltssawyerNFPAorggt wrote
From Sawyer Steve ltssawyerNFPAorggtSubject RE RE 7743To GLENN BENARICK ltgbenarprodigynetgtDate Monday August 30 2010 212 PM
So it should be ldquoorrdquo instead of ldquoandrdquo for now
Steven F Sawyer
Senior Fire Service Specialist
Executive Secretary IFMAFire Service Section
NFPA
1 Batterymarch Park
Quincy MA 02169
6179847423
Fax 6179847056
ssawyernfpaorg
From GLENN BENARICK [mailtogbenarprodigynet] Sent Monday August 30 2010 1202 PMTo Sawyer SteveSubject Fw RE 7743
52
Steve a couple of our docs agree with April Boyer
Glenn P Benarick 211 Winged Elm Circle
Aiken SC 29803
803-644-7093
gbenarprodigynet
--- On Mon 83010 David Prezant ltprezandfdnynycgovgt wrote
From David Prezant ltprezandfdnynycgovgtSubject RE 7743To Thomas R (CDCNIOSHDSHEFS) Hales lttrh1cdcgovgt GLENNBENARICK ltgbenarprodigynetgtCc Sandy Bogucki ltsandyboguckiyaleedugtDate Monday August 30 2010 1004 AM
agree
we should change this to NHANES III rather than Knudson we should alsomodify this to allow not only for predicted cutoffs but all for use of thelower limit of normal cutoff This is important to prevent false-classificationof spirometry as abnormal in older groups and in taller grps The latter ofparticular import to firefighter occupational health surveillance
thanks
David Prezant MDChief Medical Officer Office of Medical AffairsCo-Director WTC Medical Monitoring amp Treatment ProgramsNew York City Fire Department9 Metrotech Center - Rm 4W-1Brooklyn NY 11201Phone 718-999-2696Fax 718-999-0665
Life is full of twists and turns
53
This email may contain confidential information If you are the unintendedrecipient of this email please send it back and delete from your directory
gtgtgt Hales Thomas R (CDCNIOSHDSHEFS) lttrh1cdcgovgt 8302010955 AM gtgtgt
Glen
This seems like a very reasonable comment and illustrates the importance of having clinicians providefeedback on the std Im not familiar with the software program of the various spirometers (NHANES IIIvs KnudsonATS vs both) Given the large role both Dave Prezant and Sandy Bogucki had for thepulmonary section let me forward to them for clarification
Tom
From GLENN BENARICK [mailtogbenarprodigynet] Sent Sunday August 29 2010 456 PMTo Hales Thomas R (CDCNIOSHDSHEFS)Subject FW 7743
Tom is April Boyer correct
Glenn P Benarick 211 Winged Elm Circle
Aiken SC 29803
803-644-7093
gbenarprodigynet
--- On Thu 82610 Sawyer Steve ltssawyerNFPAorggt wrote
From Sawyer Steve ltssawyerNFPAorggtSubject FW 7743To GLENN BENARICK ltgbenarprodigynetgtDate Thursday August 26 2010 925 PM
FYI Do you have any answer She is write
Steven
54
Steven F Sawyer
Senior Fire Service Specialist
Executive Secretary IFMAFire Service Section
NFPA
1 Batterymarch Park
Quincy MA 02169
6179847423
Fax 6179847056
ssawyernfpaorg
From April Boyer [mailtoaboyerbicclinicorg] Sent Thursday August 26 2010 232 PMTo Sawyer SteveCc RobinMWebbmilstateorusSubject 7743
Steven
The spirometry tests cannot be corrected according to both references as the NFPA states because thereferences are contradictory The first part of 7743 states to follow the ATS guidelines and use theKnudsen (we at Basin Immediate Care use the Nhanes III) The second part states to follow the ACOEMguidelines and use the Nhanes III in the occupational setting if available with your unit (which is availableon ours) 7743 does not use the word OR regarding both requirements it uses the word AND whenreferring to the first and second parts thence making 7743 contradictory I realize the NFPA 1582 hasnot been updated since 2007 unless I have just not received an updated version
Our question to you is which part of 7743 do you want us to follow the first or the second part Anyfacility that has an updated computerized spirometry system (as we do) will not be able to follow bothrequired parts for obvious reasons We can either follow the first part of 7743 and use an oldercorrected version of the Knudson by going into our system and changing out of the Nhanes III conversionOR we can follow the second part of 7743 and use the newer corrected version of Nhanes III which ourunit offers too
If you have any questions you may contact me at anytime and I also have many references in regards toboth parts of 7743 if you would like to see them
55
Thank you~
April
Confidentiality NoticeThis message may contain information that isconfidential or privileged
If you are not the intended recipientPlease advise the sender immediately and delete this message
56
ATTACHMENT H
57
NFPA 1582 771(7) Proposed revisions
Why
Preliminary results of two prospective randomized trials on the PSA test were published in 2009 These studies resulted in medical organizations that previously providing guidance to modify their recommendations
Current language
771 Blood Tests Blood tests shall be performed annually and shall include the following
(7) Prostate specific antigen (PSA) after age 40 for positive family history if African American or if otherwise clinically indicated after age 50 for all other male member
Suggested Revision
771 Blood Tests Blood tests shall be performed annually and shall include the following
(7) Prostate specific antigen (PSA) after age 40 for positive family history if African American or if otherwise clinically indicated after age 50 for all other male member
772 Prostate-Specific Antigen (PSA) test At age 50 fire fighters shall have an opportunity to make an informed decision with either the Fire Department physician or their health care provider concerning the PSA test For fire fighters at increased risk of prostate cancer (African-Americans or those with a first degree relative diagnosed with prostate cancer before age 65) shall have the opportunity for this informed decision at age 40
A772 The PSA as a screening test for prostate cancer in asymptomatic men is controversial controversial for two reasons First there is no consensus that PSA screening actually saves lives For example the PSA test may detect small cancers that would never become life threatening Second it is unclear that the benefits of PSA screening outweigh the risks of follow-up diagnostic tests and cancer treatments For example the prostate biopsy used to diagnose prostate cancer may cause bleeding and infection And prostate cancer treatments such as surgery and radiation therapy may cause incontinence (inability to control urine flow) erectile dysfunction (erections inadequate for intercourse) and other complications For these reasons it is important that the benefits and risks of prostate diagnostic procedures and treatment be taken into account when considering the PSA screening test These considerations can be taken account during discussions with the fire department physician or onersquos health care provider
D211 Cancer Screening
Smith R A C J Mettlin K J Davis and H Eyre 2000 ldquoAmerican Cancer Society guidelines for the early detection of cancerrdquo CA J Clin 50(1)34ndash49
Added references
58
Carroll P Albertsen PC Greene K et al [2010] Prostate-specific antigen best practice statement 2009 update Am Urological Assoc Available at httpwwwauanetorgcontentguidelines-and-quality-careclinical-guidelinesmain-reportspsa09pdf Date accessed September 2010
Ferrini R Woolf SH [2009] Screening for prostate cancer in American men American College of Preventive Medicine Practice Policy Statement Available at httpwwwacpmorgprostatehtm Date accessed September 2010
National Cancer Institute [2009] Prostate-specific antigen test National Cancer Institute Fact Sheet Available at httpwwwcancergovcancertopicsfactsheetDetectionPSA Date accessed September 2010
Wolf AMD Wender RC Etzioni RB et al [2010] American Cancer Society guideline for the early detection of prostate cancer Update 2010 Available at httpcaonlineamcancersocorgcgicontentfullcaac20066v1 Date accessed September 2010
59
Hypertension
Gibbons RJ Balady GJ Bricker JT Chaitman BR Fletcher GF Froelicher VF Mark DB McCallister BD Mooss AN OrsquoReilly MG Winters WL Jr [2002] ACCAHA 2002 guideline update for exercise testing summary article a report of the ACCAHA Task Force on Practice Guidelines (Committee to Update the 1997 Exercise Testing guidelines) J Am Coll Cardiol 401531ndash 40
Chobanian AV Bakris GL Black HR Cushman WC Green LA Izzo JL Jr Jones DW Materson BJ Oparil S Wright JT Jr Roccella EJ the National High Blood Pressure Education Program Coordinating Committee [2003] The seventh report of the Joint National Committee [JNC-7] on Prevention Detection Evaluation and Treatment of High Blood Pressure JAMA 2892560ndash2571
Soteriades ES Kales SN Liarokapis D Christiani DC [2003] Prospective surveillance of hypertension in firefighters J Clin Hypertens 5315-320
Kales SN Tsismenakis AJ Zhang C Soteriades ES [2009] Blood pressure in fire fighters police officers and other emergency responders Am J Hypertens 2211-20
41
NFPA 1582‐ Draft Revisions for CVDHTN
EKG and stress tests
Reason for Revision
1) Change requirement for annual resting EKG to periodically to be more consistent with ACCAHA
recommendation (Schlant et al 1992)
2) Add language to clarify what constitutes a positive ST
3) Make criteria for conducting diagnostic ST in asymptomatic patients consistent with the
ACCAHA
Language in 2007 Edition with draft revisions in Red (Track changes)
776 Electrocardiograms (EKG)) and Stress Tests 7761 A resting EKG shall be performed as part of the baseline medical evaluation and shall be obtained periodically (every 1 to 5 years) annually thereafter
A7761 A baseline resting EKGs shall be conducted Follow-up resting EKGs should be conducted as clinically indicated but at a minimum of every 1 to 5 years The frequency of these follow-up resting EKGs should increase as a members age increases or with increasing number andor severity of coronary heart disease risk factors Members above the age of 40 should have annual resting EKGs (Schlant et al 1992)
7762 The fire department physician or other qualified medical evaluator shall compare EKGs obtained during yearly evaluations with baseline and subsequent EKGs
7763 Stress testing EKG with or without echocardiography or radionuclide scanning shall be performed as clinically indicated by history or symptoms
A7761 Baseline electrocardiography should be conducted (Periodic resting electrocardiograms have not been shown to be useful but can be reasonable as a members agefactors increase)
A7763 No firm guidelines for stress testingelectrocardiography in asymptomatic individuals have been developed Stress testingelectrocardiography as a screening tool is used as part of an evaluation of aerobic capacity during the annual occupational fitness evaluation Submaximal stress testingelectrocardiography testing to 85 percent is commonly used as part of this screening
Submaximal stress electrocardiography testing should not be used for diagnostic purposes Cardiology evaluation with maximal stress testingelectrocardiography together with imaging techniques (eg echocardiography technetium Tc99m sestamibi study andor coronary angiography) is necessary for diagnosticprognostic purposes for the following
42
(1) Fire fighters with positive or questionably positive changes on screening submaximal stress tests
(2) Fire fighters with new onset chest pain or other symptoms suggestive of coronary artery disease (CAD)
(3) Fire fighters with diabetes mellitus who
(a) are gt35 years old or
(b) have type I diabetes for more than 15 years or
(c) have type II diabetes for more than 10 years or
(d) have any other CHD risk factor (see below) or
(e) have the presence of microvascular disease (proliferative retinopathy)
(4) Fire fighters over the age of 45 (for men) and 55 (for women) with onetwo or more risk factors for CAD Risk factors for CAD include hypercholesterolemia (total cholesterol greater than 240 mgdL) hypertension (systolic gt140 mmHg or diastolic gt90 mmHg) smoking or family history of premature CAD (heart attack or sudden cardiac death in a first degree relative less than 60 years of age)
as defined below if stress electrocardiography with imaging is negative then repeat as clinically indicated or at least every 5 years
(5) Fire fighters with a Framingham Risk Score gt10 Risk calculator is available at [httphp2010nhlbihinnetatpiiicalculatorasp]
(6) Fire fighters identified in 9431
Negative stress tests should be repeated as clinically indicated or at least every 2 to 5 years
Interpreting stress tests as ldquopositiverdquo or ldquonegativerdquo is beyond the scope of this document However factors that should be taken into consideration should include the individualrsquos exercise capacity symptoms blood pressure response heart rate response EKG changes and the presence of arrhythmias (Gibbon et al 2002)
Risk factors for CAD include hypercholesterolemia (total cholesterol greater than 240 mgdL) hypertension (systolic greater than 140 andor diastolic greater than 90) smoking diabetes mellitus or family history of premature CAD (heart attack or sudden cardiac death in a first degree relative less than 60 years of age)
There are other non-invasive tests to screen for coronary artery disease One of the most promising appears to be coronary artery calcium (CAD) scoring by computed tomography In 2007 an expert committee published an update to their original guidance document The committeersquos consensus was that ldquoit may be reasonable to consider use of CAC measurement in such patients [between 10 and 20 10-year risk of estimated coronary event]helliprdquo The committee did not recommend CAC measurement in low risk patients [lt10 10-year risk of estimated coronary event] or in high risk patients [gt20 10-year risk of estimate coronary event] (Greenland et al 2007]
43
D22 Cardiology
Chobanian AV Bakris GL Black HR Cushman WC Green LA Izzo JL Jr Jones DW Materson BJ Oparil S Wright JT Jr Roccella EJ the National High Blood Pressure Education Program Coordinating Committee [2003] The seventh report of the Joint National Committee [JNC-7] on Prevention Detection Evaluation and Treatment of High Blood Pressure JAMA 2892560ndash2571
Gibbons RJ Balady GJ Bricker JT Chaitman BR Fletcher GF Froelicher VF Mark DB McCallister BD Mooss AN OrsquoReilly MG Winters WL Jr [2002] ACCAHA 2002 guideline update for exercise testing summary article a report of the ACCAHA Task Force on Practice Guidelines (Committee to Update the 1997 Exercise Testing guidelines) J Am Coll Cardiol 401531ndash 1540
Greenland et al [2007] ACCFAHA 2007 Clinical Expert Consensus Document on Coronary Artery Calcium Scoring By Computed Tomography in Global Cardiovascular Risk Assessment and in Evaluation of Patients With Chest Pain A Report of the American College of Cardiology Foundation Clinical Expert Consensus Task Force (ACCFAHA Writing Committee to Update the 2000 Expert Consensus Document on Electron Beam Computed Tomography) J Am Coll Cardiol 49378-402
Kales SN Tsismenakis AJ Zhang C Soteriades ES [2009] Blood pressure in fire fighters police officers and other emergency responders Am J Hypertens 2211-20
Schlant RC Adolph RJ DiMarco JP Dreifus LS Dunn MI Fisch C Garson A Jr Haywood LJ Levine HJ Murray JA Noble RJ Ronan JA Jr [1992] Guidelines for electrocardiography A report of the American College of CardiologyAmerican Heart Association Task Force on Assessment of Diagnostic and Therapeutic Cardiovascular Procedures (Committee on Electrocardiography) Circulation 85(3)1221-1228
Soteriades ES Kales SN Liarokapis D Christiani DC [2003] Prospective surveillance of hypertension in firefighters J Clin Hypertens 5315-320
Formatted Font Italic
Formatted Line spacing single
Formatted Font Italic
Formatted Font Italic
44
NFPA 1582‐ Draft Revisions for CVDHTN
EKG and stress tests
Reason for Revision
1) Change requirement for annual resting EKG to periodically to be more consistent with ACCAHA
recommendation (Schlant et al 1992)
2) Add language to clarify what constitutes a positive ST
3) Make criteria for conducting diagnostic ST in asymptomatic patients consistent with the
ACCAHA
Language in 2007 Edition with draft revisions in Red (Track changes)
776 Electrocardiograms (EKG) and Stress Tests 7761 A resting EKG shall be performed as part of the baseline medical evaluation and shall be obtained periodically (every 1 to 5 years) thereafter
A7761 A baseline resting EKGs shall be conducted Follow-up resting EKGs should be conducted as clinically indicated but at a minimum of every 1 to 5 years The frequency of these follow-up resting EKGs should increase as a members age increases or with increasing number andor severity of coronary heart disease risk factors Members above the age of 40 should have annual resting EKGs (Schlant et al 1992)
7762 The fire department physician or other qualified medical evaluator shall compare baseline and subsequent EKGs
7763 Stress testing with or without echocardiography or radionuclide scanning shall be performed as clinically indicated by history or symptoms
A7763 No firm guidelines for stress testing in asymptomatic individuals have been developed Stress testing as a screening tool is used as part of an evaluation of aerobic capacity during the annual occupational fitness evaluation Submaximal stress testing testing to 85 percent is commonly used as part of this screening
Submaximal stress testing should not be used for diagnostic purposes Cardiology evaluation with maximal stress testing together with imaging techniques (eg echocardiography technetium Tc99m sestamibi study) is necessary for diagnosticprognostic purposes for the following
(1) Fire fighters with positive or questionably positive changes on screening submaximal stress tests
(2) Fire fighters with new onset chest pain or other symptoms suggestive of coronary artery disease (CAD)
45
(3) Fire fighters with diabetes mellitus who
(a) are gt35 years old or
(b) have type I diabetes for more than 15 years or
(c) have type II diabetes for more than 10 years or
(d) have any other CHD risk factor (see below) or
(e) have the presence of microvascular disease (proliferative retinopathy)
(4) Fire fighters over the age of 45 (for men) and 55 (for women) with one or more risk factors for CAD Risk factors for CAD include hypercholesterolemia (total cholesterol greater than 240 mgdL) hypertension (systolic gt140 mmHg or diastolic gt90 mmHg) smoking or family history of premature CAD (heart attack or sudden cardiac death in a first degree relative less than 60 years of age)
(5) Fire fighters with a Framingham Risk Score gt10 Risk calculator is available at [httphp2010nhlbihinnetatpiiicalculatorasp]
(6) Fire fighters identified in 9431
Negative stress tests should be repeated as clinically indicated or at least every 2 to 5 years
Interpreting stress tests as ldquopositiverdquo or ldquonegativerdquo is beyond the scope of this document However factors that should be taken into consideration should include the individualrsquos exercise capacity symptoms blood pressure response heart rate response EKG changes and the presence of arrhythmias (Gibbon et al 2002)
There are other non-invasive tests to screen for coronary artery disease One of the most promising appears to be coronary artery calcium (CAD) scoring by computed tomography In 2007 an expert committee published an update to their original guidance document The committeersquos consensus was that ldquoit may be reasonable to consider use of CAC measurement in such patients [between 10 and 20 10-year risk of estimated coronary event]helliprdquo The committee did not recommend CAC measurement in low risk patients [lt10 10-year risk of estimated coronary event] or in high risk patients [gt20 10-year risk of estimate coronary event] (Greenland et al 2007]
D22 Cardiology
Resting EKG and Stress Tests
46
Chobanian AV Bakris GL Black HR Cushman WC Green LA Izzo JL Jr Jones DW Materson BJ Oparil S Wright JT Jr Roccella EJ the National High Blood Pressure Education Program Coordinating Committee [2003] The seventh report of the Joint National Committee [JNC-7] on Prevention Detection Evaluation and Treatment of High Blood Pressure JAMA 2892560ndash2571
Gibbons RJ Balady GJ Bricker JT Chaitman BR Fletcher GF Froelicher VF Mark DB McCallister BD Mooss AN OrsquoReilly MG Winters WL Jr [2002] ACCAHA 2002 guideline update for exercise testing summary article a report of the ACCAHA Task Force on Practice Guidelines (Committee to Update the 1997 Exercise Testing guidelines) J Am Coll Cardiol 401531ndash 1540
Greenland et al [2007] ACCFAHA 2007 Clinical Expert Consensus Document on Coronary Artery Calcium Scoring By Computed Tomography in Global Cardiovascular Risk Assessment and in Evaluation of Patients With Chest Pain A Report of the American College of Cardiology Foundation Clinical Expert Consensus Task Force (ACCFAHA Writing Committee to Update the 2000 Expert Consensus Document on Electron Beam Computed Tomography) J Am Coll Cardiol 49378-402
Kales SN Tsismenakis AJ Zhang C Soteriades ES [2009] Blood pressure in fire fighters police officers and other emergency responders Am J Hypertens 2211-20
Schlant RC Adolph RJ DiMarco JP Dreifus LS Dunn MI Fisch C Garson A Jr Haywood LJ Levine HJ Murray JA Noble RJ Ronan JA Jr [1992] Guidelines for electrocardiography A report of the American College of CardiologyAmerican Heart Association Task Force on Assessment of Diagnostic and Therapeutic Cardiovascular Procedures (Committee on Electrocardiography) Circulation 85(3)1221-1228
Soteriades ES Kales SN Liarokapis D Christiani DC [2003] Prospective surveillance of hypertension in firefighters J Clin Hypertens 5315-320
47
ATTACHMENT F
48
1
Current 1582 (2007) language in reference to pregnancy 43 (4) Report to the fire department physician any medical condition that could interfere with the ability of the individual to safely perform essential job tasks such as illness or injury use of prescription or nonprescription drugs and pregnancy 6112 Category B medical conditions shall include the following (1) Pregnancy for its duration A7792 (e) If HIV prophylaxis is to be given the following tests should be done i CBC ii Glucose renal and hepatic chemical function iii Pregnancy test for females B121 Pregnancy and Reproduction Federal regulations as well as many court decisions including the US Supreme Courtrsquos decision in International Union et al v Johnson Controls Inc [499 US 187 111 S Ct 1196 (1991)] have interpreted the requirements of Title VII with respect to pregnancy and reproduction The AHJ should seek the advice of counsel in resolving specific questions concerning these requirements as well as other requirements that can be imposed by state or local laws C211 (4) Review health status with the individual being evaluated Contraindications for evaluations shall be reviewed addressing any changes in the individualrsquos health status since their last medical evaluation that would warrant deferring the evaluation including (g) Pregnancy Recommendations to language enhancement
A female employee who is assigned to regular fire line duty shall report a pregnancy immediately to their respective Supervisor and the fire department physician The employee will then be given the option of a non-hazardous alternative duty position for the duration of her pregnancy (can we say this or is it even appropriate) Any pregnant employee wishing to remain on regular line duty shall be informed of the possible risks and consequences to herself and her fetus that are associated with continued line fire fighting duty Among those risk factors are exposure to teratogens known to have negative effects on the developing fetus such as smoke diesel fumes hazardous chemicals and extreme heat
49
Page 2
appendix It is recommended that the pregnant employee complete a release of liability form signed by herself and her health care provider utilizing NFPArsquos 13 critical tasks as a reference This will inform the health care provider of specific job-related tasks that will need to be performed in order to continue regular line duty These tasks are basic physical standards that any entry level firefighter would have to be able to complete competently The employeersquos health condition will be kept confidential by the department in accordance with HIPAA standards Employees are allowed to remain on active regular duty until they are no longer able to perform their duties in a reasonable manner andor their protective gear no longer fits correctly It is the responsibility of the health care provider to evaluate the pregnant employee If at any time the health care provider feels the pregnant employee can no longer perform the job related tasks this should be reported to the employer by the employee immediately
50
ATTACHMENT G
51
From GLENN BENARICKTo Sawyer SteveSubject RE RE 7743Date Monday August 30 2010 21633 PM
Yes thats my understanding
Glenn P Benarick 211 Winged Elm CircleAiken SC 29803803-644-7093gbenarprodigynet
--- On Mon 83010 Sawyer Steve ltssawyerNFPAorggt wrote
From Sawyer Steve ltssawyerNFPAorggtSubject RE RE 7743To GLENN BENARICK ltgbenarprodigynetgtDate Monday August 30 2010 212 PM
So it should be ldquoorrdquo instead of ldquoandrdquo for now
Steven F Sawyer
Senior Fire Service Specialist
Executive Secretary IFMAFire Service Section
NFPA
1 Batterymarch Park
Quincy MA 02169
6179847423
Fax 6179847056
ssawyernfpaorg
From GLENN BENARICK [mailtogbenarprodigynet] Sent Monday August 30 2010 1202 PMTo Sawyer SteveSubject Fw RE 7743
52
Steve a couple of our docs agree with April Boyer
Glenn P Benarick 211 Winged Elm Circle
Aiken SC 29803
803-644-7093
gbenarprodigynet
--- On Mon 83010 David Prezant ltprezandfdnynycgovgt wrote
From David Prezant ltprezandfdnynycgovgtSubject RE 7743To Thomas R (CDCNIOSHDSHEFS) Hales lttrh1cdcgovgt GLENNBENARICK ltgbenarprodigynetgtCc Sandy Bogucki ltsandyboguckiyaleedugtDate Monday August 30 2010 1004 AM
agree
we should change this to NHANES III rather than Knudson we should alsomodify this to allow not only for predicted cutoffs but all for use of thelower limit of normal cutoff This is important to prevent false-classificationof spirometry as abnormal in older groups and in taller grps The latter ofparticular import to firefighter occupational health surveillance
thanks
David Prezant MDChief Medical Officer Office of Medical AffairsCo-Director WTC Medical Monitoring amp Treatment ProgramsNew York City Fire Department9 Metrotech Center - Rm 4W-1Brooklyn NY 11201Phone 718-999-2696Fax 718-999-0665
Life is full of twists and turns
53
This email may contain confidential information If you are the unintendedrecipient of this email please send it back and delete from your directory
gtgtgt Hales Thomas R (CDCNIOSHDSHEFS) lttrh1cdcgovgt 8302010955 AM gtgtgt
Glen
This seems like a very reasonable comment and illustrates the importance of having clinicians providefeedback on the std Im not familiar with the software program of the various spirometers (NHANES IIIvs KnudsonATS vs both) Given the large role both Dave Prezant and Sandy Bogucki had for thepulmonary section let me forward to them for clarification
Tom
From GLENN BENARICK [mailtogbenarprodigynet] Sent Sunday August 29 2010 456 PMTo Hales Thomas R (CDCNIOSHDSHEFS)Subject FW 7743
Tom is April Boyer correct
Glenn P Benarick 211 Winged Elm Circle
Aiken SC 29803
803-644-7093
gbenarprodigynet
--- On Thu 82610 Sawyer Steve ltssawyerNFPAorggt wrote
From Sawyer Steve ltssawyerNFPAorggtSubject FW 7743To GLENN BENARICK ltgbenarprodigynetgtDate Thursday August 26 2010 925 PM
FYI Do you have any answer She is write
Steven
54
Steven F Sawyer
Senior Fire Service Specialist
Executive Secretary IFMAFire Service Section
NFPA
1 Batterymarch Park
Quincy MA 02169
6179847423
Fax 6179847056
ssawyernfpaorg
From April Boyer [mailtoaboyerbicclinicorg] Sent Thursday August 26 2010 232 PMTo Sawyer SteveCc RobinMWebbmilstateorusSubject 7743
Steven
The spirometry tests cannot be corrected according to both references as the NFPA states because thereferences are contradictory The first part of 7743 states to follow the ATS guidelines and use theKnudsen (we at Basin Immediate Care use the Nhanes III) The second part states to follow the ACOEMguidelines and use the Nhanes III in the occupational setting if available with your unit (which is availableon ours) 7743 does not use the word OR regarding both requirements it uses the word AND whenreferring to the first and second parts thence making 7743 contradictory I realize the NFPA 1582 hasnot been updated since 2007 unless I have just not received an updated version
Our question to you is which part of 7743 do you want us to follow the first or the second part Anyfacility that has an updated computerized spirometry system (as we do) will not be able to follow bothrequired parts for obvious reasons We can either follow the first part of 7743 and use an oldercorrected version of the Knudson by going into our system and changing out of the Nhanes III conversionOR we can follow the second part of 7743 and use the newer corrected version of Nhanes III which ourunit offers too
If you have any questions you may contact me at anytime and I also have many references in regards toboth parts of 7743 if you would like to see them
55
Thank you~
April
Confidentiality NoticeThis message may contain information that isconfidential or privileged
If you are not the intended recipientPlease advise the sender immediately and delete this message
56
ATTACHMENT H
57
NFPA 1582 771(7) Proposed revisions
Why
Preliminary results of two prospective randomized trials on the PSA test were published in 2009 These studies resulted in medical organizations that previously providing guidance to modify their recommendations
Current language
771 Blood Tests Blood tests shall be performed annually and shall include the following
(7) Prostate specific antigen (PSA) after age 40 for positive family history if African American or if otherwise clinically indicated after age 50 for all other male member
Suggested Revision
771 Blood Tests Blood tests shall be performed annually and shall include the following
(7) Prostate specific antigen (PSA) after age 40 for positive family history if African American or if otherwise clinically indicated after age 50 for all other male member
772 Prostate-Specific Antigen (PSA) test At age 50 fire fighters shall have an opportunity to make an informed decision with either the Fire Department physician or their health care provider concerning the PSA test For fire fighters at increased risk of prostate cancer (African-Americans or those with a first degree relative diagnosed with prostate cancer before age 65) shall have the opportunity for this informed decision at age 40
A772 The PSA as a screening test for prostate cancer in asymptomatic men is controversial controversial for two reasons First there is no consensus that PSA screening actually saves lives For example the PSA test may detect small cancers that would never become life threatening Second it is unclear that the benefits of PSA screening outweigh the risks of follow-up diagnostic tests and cancer treatments For example the prostate biopsy used to diagnose prostate cancer may cause bleeding and infection And prostate cancer treatments such as surgery and radiation therapy may cause incontinence (inability to control urine flow) erectile dysfunction (erections inadequate for intercourse) and other complications For these reasons it is important that the benefits and risks of prostate diagnostic procedures and treatment be taken into account when considering the PSA screening test These considerations can be taken account during discussions with the fire department physician or onersquos health care provider
D211 Cancer Screening
Smith R A C J Mettlin K J Davis and H Eyre 2000 ldquoAmerican Cancer Society guidelines for the early detection of cancerrdquo CA J Clin 50(1)34ndash49
Added references
58
Carroll P Albertsen PC Greene K et al [2010] Prostate-specific antigen best practice statement 2009 update Am Urological Assoc Available at httpwwwauanetorgcontentguidelines-and-quality-careclinical-guidelinesmain-reportspsa09pdf Date accessed September 2010
Ferrini R Woolf SH [2009] Screening for prostate cancer in American men American College of Preventive Medicine Practice Policy Statement Available at httpwwwacpmorgprostatehtm Date accessed September 2010
National Cancer Institute [2009] Prostate-specific antigen test National Cancer Institute Fact Sheet Available at httpwwwcancergovcancertopicsfactsheetDetectionPSA Date accessed September 2010
Wolf AMD Wender RC Etzioni RB et al [2010] American Cancer Society guideline for the early detection of prostate cancer Update 2010 Available at httpcaonlineamcancersocorgcgicontentfullcaac20066v1 Date accessed September 2010
59
NFPA 1582‐ Draft Revisions for CVDHTN
EKG and stress tests
Reason for Revision
1) Change requirement for annual resting EKG to periodically to be more consistent with ACCAHA
recommendation (Schlant et al 1992)
2) Add language to clarify what constitutes a positive ST
3) Make criteria for conducting diagnostic ST in asymptomatic patients consistent with the
ACCAHA
Language in 2007 Edition with draft revisions in Red (Track changes)
776 Electrocardiograms (EKG)) and Stress Tests 7761 A resting EKG shall be performed as part of the baseline medical evaluation and shall be obtained periodically (every 1 to 5 years) annually thereafter
A7761 A baseline resting EKGs shall be conducted Follow-up resting EKGs should be conducted as clinically indicated but at a minimum of every 1 to 5 years The frequency of these follow-up resting EKGs should increase as a members age increases or with increasing number andor severity of coronary heart disease risk factors Members above the age of 40 should have annual resting EKGs (Schlant et al 1992)
7762 The fire department physician or other qualified medical evaluator shall compare EKGs obtained during yearly evaluations with baseline and subsequent EKGs
7763 Stress testing EKG with or without echocardiography or radionuclide scanning shall be performed as clinically indicated by history or symptoms
A7761 Baseline electrocardiography should be conducted (Periodic resting electrocardiograms have not been shown to be useful but can be reasonable as a members agefactors increase)
A7763 No firm guidelines for stress testingelectrocardiography in asymptomatic individuals have been developed Stress testingelectrocardiography as a screening tool is used as part of an evaluation of aerobic capacity during the annual occupational fitness evaluation Submaximal stress testingelectrocardiography testing to 85 percent is commonly used as part of this screening
Submaximal stress electrocardiography testing should not be used for diagnostic purposes Cardiology evaluation with maximal stress testingelectrocardiography together with imaging techniques (eg echocardiography technetium Tc99m sestamibi study andor coronary angiography) is necessary for diagnosticprognostic purposes for the following
42
(1) Fire fighters with positive or questionably positive changes on screening submaximal stress tests
(2) Fire fighters with new onset chest pain or other symptoms suggestive of coronary artery disease (CAD)
(3) Fire fighters with diabetes mellitus who
(a) are gt35 years old or
(b) have type I diabetes for more than 15 years or
(c) have type II diabetes for more than 10 years or
(d) have any other CHD risk factor (see below) or
(e) have the presence of microvascular disease (proliferative retinopathy)
(4) Fire fighters over the age of 45 (for men) and 55 (for women) with onetwo or more risk factors for CAD Risk factors for CAD include hypercholesterolemia (total cholesterol greater than 240 mgdL) hypertension (systolic gt140 mmHg or diastolic gt90 mmHg) smoking or family history of premature CAD (heart attack or sudden cardiac death in a first degree relative less than 60 years of age)
as defined below if stress electrocardiography with imaging is negative then repeat as clinically indicated or at least every 5 years
(5) Fire fighters with a Framingham Risk Score gt10 Risk calculator is available at [httphp2010nhlbihinnetatpiiicalculatorasp]
(6) Fire fighters identified in 9431
Negative stress tests should be repeated as clinically indicated or at least every 2 to 5 years
Interpreting stress tests as ldquopositiverdquo or ldquonegativerdquo is beyond the scope of this document However factors that should be taken into consideration should include the individualrsquos exercise capacity symptoms blood pressure response heart rate response EKG changes and the presence of arrhythmias (Gibbon et al 2002)
Risk factors for CAD include hypercholesterolemia (total cholesterol greater than 240 mgdL) hypertension (systolic greater than 140 andor diastolic greater than 90) smoking diabetes mellitus or family history of premature CAD (heart attack or sudden cardiac death in a first degree relative less than 60 years of age)
There are other non-invasive tests to screen for coronary artery disease One of the most promising appears to be coronary artery calcium (CAD) scoring by computed tomography In 2007 an expert committee published an update to their original guidance document The committeersquos consensus was that ldquoit may be reasonable to consider use of CAC measurement in such patients [between 10 and 20 10-year risk of estimated coronary event]helliprdquo The committee did not recommend CAC measurement in low risk patients [lt10 10-year risk of estimated coronary event] or in high risk patients [gt20 10-year risk of estimate coronary event] (Greenland et al 2007]
43
D22 Cardiology
Chobanian AV Bakris GL Black HR Cushman WC Green LA Izzo JL Jr Jones DW Materson BJ Oparil S Wright JT Jr Roccella EJ the National High Blood Pressure Education Program Coordinating Committee [2003] The seventh report of the Joint National Committee [JNC-7] on Prevention Detection Evaluation and Treatment of High Blood Pressure JAMA 2892560ndash2571
Gibbons RJ Balady GJ Bricker JT Chaitman BR Fletcher GF Froelicher VF Mark DB McCallister BD Mooss AN OrsquoReilly MG Winters WL Jr [2002] ACCAHA 2002 guideline update for exercise testing summary article a report of the ACCAHA Task Force on Practice Guidelines (Committee to Update the 1997 Exercise Testing guidelines) J Am Coll Cardiol 401531ndash 1540
Greenland et al [2007] ACCFAHA 2007 Clinical Expert Consensus Document on Coronary Artery Calcium Scoring By Computed Tomography in Global Cardiovascular Risk Assessment and in Evaluation of Patients With Chest Pain A Report of the American College of Cardiology Foundation Clinical Expert Consensus Task Force (ACCFAHA Writing Committee to Update the 2000 Expert Consensus Document on Electron Beam Computed Tomography) J Am Coll Cardiol 49378-402
Kales SN Tsismenakis AJ Zhang C Soteriades ES [2009] Blood pressure in fire fighters police officers and other emergency responders Am J Hypertens 2211-20
Schlant RC Adolph RJ DiMarco JP Dreifus LS Dunn MI Fisch C Garson A Jr Haywood LJ Levine HJ Murray JA Noble RJ Ronan JA Jr [1992] Guidelines for electrocardiography A report of the American College of CardiologyAmerican Heart Association Task Force on Assessment of Diagnostic and Therapeutic Cardiovascular Procedures (Committee on Electrocardiography) Circulation 85(3)1221-1228
Soteriades ES Kales SN Liarokapis D Christiani DC [2003] Prospective surveillance of hypertension in firefighters J Clin Hypertens 5315-320
Formatted Font Italic
Formatted Line spacing single
Formatted Font Italic
Formatted Font Italic
44
NFPA 1582‐ Draft Revisions for CVDHTN
EKG and stress tests
Reason for Revision
1) Change requirement for annual resting EKG to periodically to be more consistent with ACCAHA
recommendation (Schlant et al 1992)
2) Add language to clarify what constitutes a positive ST
3) Make criteria for conducting diagnostic ST in asymptomatic patients consistent with the
ACCAHA
Language in 2007 Edition with draft revisions in Red (Track changes)
776 Electrocardiograms (EKG) and Stress Tests 7761 A resting EKG shall be performed as part of the baseline medical evaluation and shall be obtained periodically (every 1 to 5 years) thereafter
A7761 A baseline resting EKGs shall be conducted Follow-up resting EKGs should be conducted as clinically indicated but at a minimum of every 1 to 5 years The frequency of these follow-up resting EKGs should increase as a members age increases or with increasing number andor severity of coronary heart disease risk factors Members above the age of 40 should have annual resting EKGs (Schlant et al 1992)
7762 The fire department physician or other qualified medical evaluator shall compare baseline and subsequent EKGs
7763 Stress testing with or without echocardiography or radionuclide scanning shall be performed as clinically indicated by history or symptoms
A7763 No firm guidelines for stress testing in asymptomatic individuals have been developed Stress testing as a screening tool is used as part of an evaluation of aerobic capacity during the annual occupational fitness evaluation Submaximal stress testing testing to 85 percent is commonly used as part of this screening
Submaximal stress testing should not be used for diagnostic purposes Cardiology evaluation with maximal stress testing together with imaging techniques (eg echocardiography technetium Tc99m sestamibi study) is necessary for diagnosticprognostic purposes for the following
(1) Fire fighters with positive or questionably positive changes on screening submaximal stress tests
(2) Fire fighters with new onset chest pain or other symptoms suggestive of coronary artery disease (CAD)
45
(3) Fire fighters with diabetes mellitus who
(a) are gt35 years old or
(b) have type I diabetes for more than 15 years or
(c) have type II diabetes for more than 10 years or
(d) have any other CHD risk factor (see below) or
(e) have the presence of microvascular disease (proliferative retinopathy)
(4) Fire fighters over the age of 45 (for men) and 55 (for women) with one or more risk factors for CAD Risk factors for CAD include hypercholesterolemia (total cholesterol greater than 240 mgdL) hypertension (systolic gt140 mmHg or diastolic gt90 mmHg) smoking or family history of premature CAD (heart attack or sudden cardiac death in a first degree relative less than 60 years of age)
(5) Fire fighters with a Framingham Risk Score gt10 Risk calculator is available at [httphp2010nhlbihinnetatpiiicalculatorasp]
(6) Fire fighters identified in 9431
Negative stress tests should be repeated as clinically indicated or at least every 2 to 5 years
Interpreting stress tests as ldquopositiverdquo or ldquonegativerdquo is beyond the scope of this document However factors that should be taken into consideration should include the individualrsquos exercise capacity symptoms blood pressure response heart rate response EKG changes and the presence of arrhythmias (Gibbon et al 2002)
There are other non-invasive tests to screen for coronary artery disease One of the most promising appears to be coronary artery calcium (CAD) scoring by computed tomography In 2007 an expert committee published an update to their original guidance document The committeersquos consensus was that ldquoit may be reasonable to consider use of CAC measurement in such patients [between 10 and 20 10-year risk of estimated coronary event]helliprdquo The committee did not recommend CAC measurement in low risk patients [lt10 10-year risk of estimated coronary event] or in high risk patients [gt20 10-year risk of estimate coronary event] (Greenland et al 2007]
D22 Cardiology
Resting EKG and Stress Tests
46
Chobanian AV Bakris GL Black HR Cushman WC Green LA Izzo JL Jr Jones DW Materson BJ Oparil S Wright JT Jr Roccella EJ the National High Blood Pressure Education Program Coordinating Committee [2003] The seventh report of the Joint National Committee [JNC-7] on Prevention Detection Evaluation and Treatment of High Blood Pressure JAMA 2892560ndash2571
Gibbons RJ Balady GJ Bricker JT Chaitman BR Fletcher GF Froelicher VF Mark DB McCallister BD Mooss AN OrsquoReilly MG Winters WL Jr [2002] ACCAHA 2002 guideline update for exercise testing summary article a report of the ACCAHA Task Force on Practice Guidelines (Committee to Update the 1997 Exercise Testing guidelines) J Am Coll Cardiol 401531ndash 1540
Greenland et al [2007] ACCFAHA 2007 Clinical Expert Consensus Document on Coronary Artery Calcium Scoring By Computed Tomography in Global Cardiovascular Risk Assessment and in Evaluation of Patients With Chest Pain A Report of the American College of Cardiology Foundation Clinical Expert Consensus Task Force (ACCFAHA Writing Committee to Update the 2000 Expert Consensus Document on Electron Beam Computed Tomography) J Am Coll Cardiol 49378-402
Kales SN Tsismenakis AJ Zhang C Soteriades ES [2009] Blood pressure in fire fighters police officers and other emergency responders Am J Hypertens 2211-20
Schlant RC Adolph RJ DiMarco JP Dreifus LS Dunn MI Fisch C Garson A Jr Haywood LJ Levine HJ Murray JA Noble RJ Ronan JA Jr [1992] Guidelines for electrocardiography A report of the American College of CardiologyAmerican Heart Association Task Force on Assessment of Diagnostic and Therapeutic Cardiovascular Procedures (Committee on Electrocardiography) Circulation 85(3)1221-1228
Soteriades ES Kales SN Liarokapis D Christiani DC [2003] Prospective surveillance of hypertension in firefighters J Clin Hypertens 5315-320
47
ATTACHMENT F
48
1
Current 1582 (2007) language in reference to pregnancy 43 (4) Report to the fire department physician any medical condition that could interfere with the ability of the individual to safely perform essential job tasks such as illness or injury use of prescription or nonprescription drugs and pregnancy 6112 Category B medical conditions shall include the following (1) Pregnancy for its duration A7792 (e) If HIV prophylaxis is to be given the following tests should be done i CBC ii Glucose renal and hepatic chemical function iii Pregnancy test for females B121 Pregnancy and Reproduction Federal regulations as well as many court decisions including the US Supreme Courtrsquos decision in International Union et al v Johnson Controls Inc [499 US 187 111 S Ct 1196 (1991)] have interpreted the requirements of Title VII with respect to pregnancy and reproduction The AHJ should seek the advice of counsel in resolving specific questions concerning these requirements as well as other requirements that can be imposed by state or local laws C211 (4) Review health status with the individual being evaluated Contraindications for evaluations shall be reviewed addressing any changes in the individualrsquos health status since their last medical evaluation that would warrant deferring the evaluation including (g) Pregnancy Recommendations to language enhancement
A female employee who is assigned to regular fire line duty shall report a pregnancy immediately to their respective Supervisor and the fire department physician The employee will then be given the option of a non-hazardous alternative duty position for the duration of her pregnancy (can we say this or is it even appropriate) Any pregnant employee wishing to remain on regular line duty shall be informed of the possible risks and consequences to herself and her fetus that are associated with continued line fire fighting duty Among those risk factors are exposure to teratogens known to have negative effects on the developing fetus such as smoke diesel fumes hazardous chemicals and extreme heat
49
Page 2
appendix It is recommended that the pregnant employee complete a release of liability form signed by herself and her health care provider utilizing NFPArsquos 13 critical tasks as a reference This will inform the health care provider of specific job-related tasks that will need to be performed in order to continue regular line duty These tasks are basic physical standards that any entry level firefighter would have to be able to complete competently The employeersquos health condition will be kept confidential by the department in accordance with HIPAA standards Employees are allowed to remain on active regular duty until they are no longer able to perform their duties in a reasonable manner andor their protective gear no longer fits correctly It is the responsibility of the health care provider to evaluate the pregnant employee If at any time the health care provider feels the pregnant employee can no longer perform the job related tasks this should be reported to the employer by the employee immediately
50
ATTACHMENT G
51
From GLENN BENARICKTo Sawyer SteveSubject RE RE 7743Date Monday August 30 2010 21633 PM
Yes thats my understanding
Glenn P Benarick 211 Winged Elm CircleAiken SC 29803803-644-7093gbenarprodigynet
--- On Mon 83010 Sawyer Steve ltssawyerNFPAorggt wrote
From Sawyer Steve ltssawyerNFPAorggtSubject RE RE 7743To GLENN BENARICK ltgbenarprodigynetgtDate Monday August 30 2010 212 PM
So it should be ldquoorrdquo instead of ldquoandrdquo for now
Steven F Sawyer
Senior Fire Service Specialist
Executive Secretary IFMAFire Service Section
NFPA
1 Batterymarch Park
Quincy MA 02169
6179847423
Fax 6179847056
ssawyernfpaorg
From GLENN BENARICK [mailtogbenarprodigynet] Sent Monday August 30 2010 1202 PMTo Sawyer SteveSubject Fw RE 7743
52
Steve a couple of our docs agree with April Boyer
Glenn P Benarick 211 Winged Elm Circle
Aiken SC 29803
803-644-7093
gbenarprodigynet
--- On Mon 83010 David Prezant ltprezandfdnynycgovgt wrote
From David Prezant ltprezandfdnynycgovgtSubject RE 7743To Thomas R (CDCNIOSHDSHEFS) Hales lttrh1cdcgovgt GLENNBENARICK ltgbenarprodigynetgtCc Sandy Bogucki ltsandyboguckiyaleedugtDate Monday August 30 2010 1004 AM
agree
we should change this to NHANES III rather than Knudson we should alsomodify this to allow not only for predicted cutoffs but all for use of thelower limit of normal cutoff This is important to prevent false-classificationof spirometry as abnormal in older groups and in taller grps The latter ofparticular import to firefighter occupational health surveillance
thanks
David Prezant MDChief Medical Officer Office of Medical AffairsCo-Director WTC Medical Monitoring amp Treatment ProgramsNew York City Fire Department9 Metrotech Center - Rm 4W-1Brooklyn NY 11201Phone 718-999-2696Fax 718-999-0665
Life is full of twists and turns
53
This email may contain confidential information If you are the unintendedrecipient of this email please send it back and delete from your directory
gtgtgt Hales Thomas R (CDCNIOSHDSHEFS) lttrh1cdcgovgt 8302010955 AM gtgtgt
Glen
This seems like a very reasonable comment and illustrates the importance of having clinicians providefeedback on the std Im not familiar with the software program of the various spirometers (NHANES IIIvs KnudsonATS vs both) Given the large role both Dave Prezant and Sandy Bogucki had for thepulmonary section let me forward to them for clarification
Tom
From GLENN BENARICK [mailtogbenarprodigynet] Sent Sunday August 29 2010 456 PMTo Hales Thomas R (CDCNIOSHDSHEFS)Subject FW 7743
Tom is April Boyer correct
Glenn P Benarick 211 Winged Elm Circle
Aiken SC 29803
803-644-7093
gbenarprodigynet
--- On Thu 82610 Sawyer Steve ltssawyerNFPAorggt wrote
From Sawyer Steve ltssawyerNFPAorggtSubject FW 7743To GLENN BENARICK ltgbenarprodigynetgtDate Thursday August 26 2010 925 PM
FYI Do you have any answer She is write
Steven
54
Steven F Sawyer
Senior Fire Service Specialist
Executive Secretary IFMAFire Service Section
NFPA
1 Batterymarch Park
Quincy MA 02169
6179847423
Fax 6179847056
ssawyernfpaorg
From April Boyer [mailtoaboyerbicclinicorg] Sent Thursday August 26 2010 232 PMTo Sawyer SteveCc RobinMWebbmilstateorusSubject 7743
Steven
The spirometry tests cannot be corrected according to both references as the NFPA states because thereferences are contradictory The first part of 7743 states to follow the ATS guidelines and use theKnudsen (we at Basin Immediate Care use the Nhanes III) The second part states to follow the ACOEMguidelines and use the Nhanes III in the occupational setting if available with your unit (which is availableon ours) 7743 does not use the word OR regarding both requirements it uses the word AND whenreferring to the first and second parts thence making 7743 contradictory I realize the NFPA 1582 hasnot been updated since 2007 unless I have just not received an updated version
Our question to you is which part of 7743 do you want us to follow the first or the second part Anyfacility that has an updated computerized spirometry system (as we do) will not be able to follow bothrequired parts for obvious reasons We can either follow the first part of 7743 and use an oldercorrected version of the Knudson by going into our system and changing out of the Nhanes III conversionOR we can follow the second part of 7743 and use the newer corrected version of Nhanes III which ourunit offers too
If you have any questions you may contact me at anytime and I also have many references in regards toboth parts of 7743 if you would like to see them
55
Thank you~
April
Confidentiality NoticeThis message may contain information that isconfidential or privileged
If you are not the intended recipientPlease advise the sender immediately and delete this message
56
ATTACHMENT H
57
NFPA 1582 771(7) Proposed revisions
Why
Preliminary results of two prospective randomized trials on the PSA test were published in 2009 These studies resulted in medical organizations that previously providing guidance to modify their recommendations
Current language
771 Blood Tests Blood tests shall be performed annually and shall include the following
(7) Prostate specific antigen (PSA) after age 40 for positive family history if African American or if otherwise clinically indicated after age 50 for all other male member
Suggested Revision
771 Blood Tests Blood tests shall be performed annually and shall include the following
(7) Prostate specific antigen (PSA) after age 40 for positive family history if African American or if otherwise clinically indicated after age 50 for all other male member
772 Prostate-Specific Antigen (PSA) test At age 50 fire fighters shall have an opportunity to make an informed decision with either the Fire Department physician or their health care provider concerning the PSA test For fire fighters at increased risk of prostate cancer (African-Americans or those with a first degree relative diagnosed with prostate cancer before age 65) shall have the opportunity for this informed decision at age 40
A772 The PSA as a screening test for prostate cancer in asymptomatic men is controversial controversial for two reasons First there is no consensus that PSA screening actually saves lives For example the PSA test may detect small cancers that would never become life threatening Second it is unclear that the benefits of PSA screening outweigh the risks of follow-up diagnostic tests and cancer treatments For example the prostate biopsy used to diagnose prostate cancer may cause bleeding and infection And prostate cancer treatments such as surgery and radiation therapy may cause incontinence (inability to control urine flow) erectile dysfunction (erections inadequate for intercourse) and other complications For these reasons it is important that the benefits and risks of prostate diagnostic procedures and treatment be taken into account when considering the PSA screening test These considerations can be taken account during discussions with the fire department physician or onersquos health care provider
D211 Cancer Screening
Smith R A C J Mettlin K J Davis and H Eyre 2000 ldquoAmerican Cancer Society guidelines for the early detection of cancerrdquo CA J Clin 50(1)34ndash49
Added references
58
Carroll P Albertsen PC Greene K et al [2010] Prostate-specific antigen best practice statement 2009 update Am Urological Assoc Available at httpwwwauanetorgcontentguidelines-and-quality-careclinical-guidelinesmain-reportspsa09pdf Date accessed September 2010
Ferrini R Woolf SH [2009] Screening for prostate cancer in American men American College of Preventive Medicine Practice Policy Statement Available at httpwwwacpmorgprostatehtm Date accessed September 2010
National Cancer Institute [2009] Prostate-specific antigen test National Cancer Institute Fact Sheet Available at httpwwwcancergovcancertopicsfactsheetDetectionPSA Date accessed September 2010
Wolf AMD Wender RC Etzioni RB et al [2010] American Cancer Society guideline for the early detection of prostate cancer Update 2010 Available at httpcaonlineamcancersocorgcgicontentfullcaac20066v1 Date accessed September 2010
59
(1) Fire fighters with positive or questionably positive changes on screening submaximal stress tests
(2) Fire fighters with new onset chest pain or other symptoms suggestive of coronary artery disease (CAD)
(3) Fire fighters with diabetes mellitus who
(a) are gt35 years old or
(b) have type I diabetes for more than 15 years or
(c) have type II diabetes for more than 10 years or
(d) have any other CHD risk factor (see below) or
(e) have the presence of microvascular disease (proliferative retinopathy)
(4) Fire fighters over the age of 45 (for men) and 55 (for women) with onetwo or more risk factors for CAD Risk factors for CAD include hypercholesterolemia (total cholesterol greater than 240 mgdL) hypertension (systolic gt140 mmHg or diastolic gt90 mmHg) smoking or family history of premature CAD (heart attack or sudden cardiac death in a first degree relative less than 60 years of age)
as defined below if stress electrocardiography with imaging is negative then repeat as clinically indicated or at least every 5 years
(5) Fire fighters with a Framingham Risk Score gt10 Risk calculator is available at [httphp2010nhlbihinnetatpiiicalculatorasp]
(6) Fire fighters identified in 9431
Negative stress tests should be repeated as clinically indicated or at least every 2 to 5 years
Interpreting stress tests as ldquopositiverdquo or ldquonegativerdquo is beyond the scope of this document However factors that should be taken into consideration should include the individualrsquos exercise capacity symptoms blood pressure response heart rate response EKG changes and the presence of arrhythmias (Gibbon et al 2002)
Risk factors for CAD include hypercholesterolemia (total cholesterol greater than 240 mgdL) hypertension (systolic greater than 140 andor diastolic greater than 90) smoking diabetes mellitus or family history of premature CAD (heart attack or sudden cardiac death in a first degree relative less than 60 years of age)
There are other non-invasive tests to screen for coronary artery disease One of the most promising appears to be coronary artery calcium (CAD) scoring by computed tomography In 2007 an expert committee published an update to their original guidance document The committeersquos consensus was that ldquoit may be reasonable to consider use of CAC measurement in such patients [between 10 and 20 10-year risk of estimated coronary event]helliprdquo The committee did not recommend CAC measurement in low risk patients [lt10 10-year risk of estimated coronary event] or in high risk patients [gt20 10-year risk of estimate coronary event] (Greenland et al 2007]
43
D22 Cardiology
Chobanian AV Bakris GL Black HR Cushman WC Green LA Izzo JL Jr Jones DW Materson BJ Oparil S Wright JT Jr Roccella EJ the National High Blood Pressure Education Program Coordinating Committee [2003] The seventh report of the Joint National Committee [JNC-7] on Prevention Detection Evaluation and Treatment of High Blood Pressure JAMA 2892560ndash2571
Gibbons RJ Balady GJ Bricker JT Chaitman BR Fletcher GF Froelicher VF Mark DB McCallister BD Mooss AN OrsquoReilly MG Winters WL Jr [2002] ACCAHA 2002 guideline update for exercise testing summary article a report of the ACCAHA Task Force on Practice Guidelines (Committee to Update the 1997 Exercise Testing guidelines) J Am Coll Cardiol 401531ndash 1540
Greenland et al [2007] ACCFAHA 2007 Clinical Expert Consensus Document on Coronary Artery Calcium Scoring By Computed Tomography in Global Cardiovascular Risk Assessment and in Evaluation of Patients With Chest Pain A Report of the American College of Cardiology Foundation Clinical Expert Consensus Task Force (ACCFAHA Writing Committee to Update the 2000 Expert Consensus Document on Electron Beam Computed Tomography) J Am Coll Cardiol 49378-402
Kales SN Tsismenakis AJ Zhang C Soteriades ES [2009] Blood pressure in fire fighters police officers and other emergency responders Am J Hypertens 2211-20
Schlant RC Adolph RJ DiMarco JP Dreifus LS Dunn MI Fisch C Garson A Jr Haywood LJ Levine HJ Murray JA Noble RJ Ronan JA Jr [1992] Guidelines for electrocardiography A report of the American College of CardiologyAmerican Heart Association Task Force on Assessment of Diagnostic and Therapeutic Cardiovascular Procedures (Committee on Electrocardiography) Circulation 85(3)1221-1228
Soteriades ES Kales SN Liarokapis D Christiani DC [2003] Prospective surveillance of hypertension in firefighters J Clin Hypertens 5315-320
Formatted Font Italic
Formatted Line spacing single
Formatted Font Italic
Formatted Font Italic
44
NFPA 1582‐ Draft Revisions for CVDHTN
EKG and stress tests
Reason for Revision
1) Change requirement for annual resting EKG to periodically to be more consistent with ACCAHA
recommendation (Schlant et al 1992)
2) Add language to clarify what constitutes a positive ST
3) Make criteria for conducting diagnostic ST in asymptomatic patients consistent with the
ACCAHA
Language in 2007 Edition with draft revisions in Red (Track changes)
776 Electrocardiograms (EKG) and Stress Tests 7761 A resting EKG shall be performed as part of the baseline medical evaluation and shall be obtained periodically (every 1 to 5 years) thereafter
A7761 A baseline resting EKGs shall be conducted Follow-up resting EKGs should be conducted as clinically indicated but at a minimum of every 1 to 5 years The frequency of these follow-up resting EKGs should increase as a members age increases or with increasing number andor severity of coronary heart disease risk factors Members above the age of 40 should have annual resting EKGs (Schlant et al 1992)
7762 The fire department physician or other qualified medical evaluator shall compare baseline and subsequent EKGs
7763 Stress testing with or without echocardiography or radionuclide scanning shall be performed as clinically indicated by history or symptoms
A7763 No firm guidelines for stress testing in asymptomatic individuals have been developed Stress testing as a screening tool is used as part of an evaluation of aerobic capacity during the annual occupational fitness evaluation Submaximal stress testing testing to 85 percent is commonly used as part of this screening
Submaximal stress testing should not be used for diagnostic purposes Cardiology evaluation with maximal stress testing together with imaging techniques (eg echocardiography technetium Tc99m sestamibi study) is necessary for diagnosticprognostic purposes for the following
(1) Fire fighters with positive or questionably positive changes on screening submaximal stress tests
(2) Fire fighters with new onset chest pain or other symptoms suggestive of coronary artery disease (CAD)
45
(3) Fire fighters with diabetes mellitus who
(a) are gt35 years old or
(b) have type I diabetes for more than 15 years or
(c) have type II diabetes for more than 10 years or
(d) have any other CHD risk factor (see below) or
(e) have the presence of microvascular disease (proliferative retinopathy)
(4) Fire fighters over the age of 45 (for men) and 55 (for women) with one or more risk factors for CAD Risk factors for CAD include hypercholesterolemia (total cholesterol greater than 240 mgdL) hypertension (systolic gt140 mmHg or diastolic gt90 mmHg) smoking or family history of premature CAD (heart attack or sudden cardiac death in a first degree relative less than 60 years of age)
(5) Fire fighters with a Framingham Risk Score gt10 Risk calculator is available at [httphp2010nhlbihinnetatpiiicalculatorasp]
(6) Fire fighters identified in 9431
Negative stress tests should be repeated as clinically indicated or at least every 2 to 5 years
Interpreting stress tests as ldquopositiverdquo or ldquonegativerdquo is beyond the scope of this document However factors that should be taken into consideration should include the individualrsquos exercise capacity symptoms blood pressure response heart rate response EKG changes and the presence of arrhythmias (Gibbon et al 2002)
There are other non-invasive tests to screen for coronary artery disease One of the most promising appears to be coronary artery calcium (CAD) scoring by computed tomography In 2007 an expert committee published an update to their original guidance document The committeersquos consensus was that ldquoit may be reasonable to consider use of CAC measurement in such patients [between 10 and 20 10-year risk of estimated coronary event]helliprdquo The committee did not recommend CAC measurement in low risk patients [lt10 10-year risk of estimated coronary event] or in high risk patients [gt20 10-year risk of estimate coronary event] (Greenland et al 2007]
D22 Cardiology
Resting EKG and Stress Tests
46
Chobanian AV Bakris GL Black HR Cushman WC Green LA Izzo JL Jr Jones DW Materson BJ Oparil S Wright JT Jr Roccella EJ the National High Blood Pressure Education Program Coordinating Committee [2003] The seventh report of the Joint National Committee [JNC-7] on Prevention Detection Evaluation and Treatment of High Blood Pressure JAMA 2892560ndash2571
Gibbons RJ Balady GJ Bricker JT Chaitman BR Fletcher GF Froelicher VF Mark DB McCallister BD Mooss AN OrsquoReilly MG Winters WL Jr [2002] ACCAHA 2002 guideline update for exercise testing summary article a report of the ACCAHA Task Force on Practice Guidelines (Committee to Update the 1997 Exercise Testing guidelines) J Am Coll Cardiol 401531ndash 1540
Greenland et al [2007] ACCFAHA 2007 Clinical Expert Consensus Document on Coronary Artery Calcium Scoring By Computed Tomography in Global Cardiovascular Risk Assessment and in Evaluation of Patients With Chest Pain A Report of the American College of Cardiology Foundation Clinical Expert Consensus Task Force (ACCFAHA Writing Committee to Update the 2000 Expert Consensus Document on Electron Beam Computed Tomography) J Am Coll Cardiol 49378-402
Kales SN Tsismenakis AJ Zhang C Soteriades ES [2009] Blood pressure in fire fighters police officers and other emergency responders Am J Hypertens 2211-20
Schlant RC Adolph RJ DiMarco JP Dreifus LS Dunn MI Fisch C Garson A Jr Haywood LJ Levine HJ Murray JA Noble RJ Ronan JA Jr [1992] Guidelines for electrocardiography A report of the American College of CardiologyAmerican Heart Association Task Force on Assessment of Diagnostic and Therapeutic Cardiovascular Procedures (Committee on Electrocardiography) Circulation 85(3)1221-1228
Soteriades ES Kales SN Liarokapis D Christiani DC [2003] Prospective surveillance of hypertension in firefighters J Clin Hypertens 5315-320
47
ATTACHMENT F
48
1
Current 1582 (2007) language in reference to pregnancy 43 (4) Report to the fire department physician any medical condition that could interfere with the ability of the individual to safely perform essential job tasks such as illness or injury use of prescription or nonprescription drugs and pregnancy 6112 Category B medical conditions shall include the following (1) Pregnancy for its duration A7792 (e) If HIV prophylaxis is to be given the following tests should be done i CBC ii Glucose renal and hepatic chemical function iii Pregnancy test for females B121 Pregnancy and Reproduction Federal regulations as well as many court decisions including the US Supreme Courtrsquos decision in International Union et al v Johnson Controls Inc [499 US 187 111 S Ct 1196 (1991)] have interpreted the requirements of Title VII with respect to pregnancy and reproduction The AHJ should seek the advice of counsel in resolving specific questions concerning these requirements as well as other requirements that can be imposed by state or local laws C211 (4) Review health status with the individual being evaluated Contraindications for evaluations shall be reviewed addressing any changes in the individualrsquos health status since their last medical evaluation that would warrant deferring the evaluation including (g) Pregnancy Recommendations to language enhancement
A female employee who is assigned to regular fire line duty shall report a pregnancy immediately to their respective Supervisor and the fire department physician The employee will then be given the option of a non-hazardous alternative duty position for the duration of her pregnancy (can we say this or is it even appropriate) Any pregnant employee wishing to remain on regular line duty shall be informed of the possible risks and consequences to herself and her fetus that are associated with continued line fire fighting duty Among those risk factors are exposure to teratogens known to have negative effects on the developing fetus such as smoke diesel fumes hazardous chemicals and extreme heat
49
Page 2
appendix It is recommended that the pregnant employee complete a release of liability form signed by herself and her health care provider utilizing NFPArsquos 13 critical tasks as a reference This will inform the health care provider of specific job-related tasks that will need to be performed in order to continue regular line duty These tasks are basic physical standards that any entry level firefighter would have to be able to complete competently The employeersquos health condition will be kept confidential by the department in accordance with HIPAA standards Employees are allowed to remain on active regular duty until they are no longer able to perform their duties in a reasonable manner andor their protective gear no longer fits correctly It is the responsibility of the health care provider to evaluate the pregnant employee If at any time the health care provider feels the pregnant employee can no longer perform the job related tasks this should be reported to the employer by the employee immediately
50
ATTACHMENT G
51
From GLENN BENARICKTo Sawyer SteveSubject RE RE 7743Date Monday August 30 2010 21633 PM
Yes thats my understanding
Glenn P Benarick 211 Winged Elm CircleAiken SC 29803803-644-7093gbenarprodigynet
--- On Mon 83010 Sawyer Steve ltssawyerNFPAorggt wrote
From Sawyer Steve ltssawyerNFPAorggtSubject RE RE 7743To GLENN BENARICK ltgbenarprodigynetgtDate Monday August 30 2010 212 PM
So it should be ldquoorrdquo instead of ldquoandrdquo for now
Steven F Sawyer
Senior Fire Service Specialist
Executive Secretary IFMAFire Service Section
NFPA
1 Batterymarch Park
Quincy MA 02169
6179847423
Fax 6179847056
ssawyernfpaorg
From GLENN BENARICK [mailtogbenarprodigynet] Sent Monday August 30 2010 1202 PMTo Sawyer SteveSubject Fw RE 7743
52
Steve a couple of our docs agree with April Boyer
Glenn P Benarick 211 Winged Elm Circle
Aiken SC 29803
803-644-7093
gbenarprodigynet
--- On Mon 83010 David Prezant ltprezandfdnynycgovgt wrote
From David Prezant ltprezandfdnynycgovgtSubject RE 7743To Thomas R (CDCNIOSHDSHEFS) Hales lttrh1cdcgovgt GLENNBENARICK ltgbenarprodigynetgtCc Sandy Bogucki ltsandyboguckiyaleedugtDate Monday August 30 2010 1004 AM
agree
we should change this to NHANES III rather than Knudson we should alsomodify this to allow not only for predicted cutoffs but all for use of thelower limit of normal cutoff This is important to prevent false-classificationof spirometry as abnormal in older groups and in taller grps The latter ofparticular import to firefighter occupational health surveillance
thanks
David Prezant MDChief Medical Officer Office of Medical AffairsCo-Director WTC Medical Monitoring amp Treatment ProgramsNew York City Fire Department9 Metrotech Center - Rm 4W-1Brooklyn NY 11201Phone 718-999-2696Fax 718-999-0665
Life is full of twists and turns
53
This email may contain confidential information If you are the unintendedrecipient of this email please send it back and delete from your directory
gtgtgt Hales Thomas R (CDCNIOSHDSHEFS) lttrh1cdcgovgt 8302010955 AM gtgtgt
Glen
This seems like a very reasonable comment and illustrates the importance of having clinicians providefeedback on the std Im not familiar with the software program of the various spirometers (NHANES IIIvs KnudsonATS vs both) Given the large role both Dave Prezant and Sandy Bogucki had for thepulmonary section let me forward to them for clarification
Tom
From GLENN BENARICK [mailtogbenarprodigynet] Sent Sunday August 29 2010 456 PMTo Hales Thomas R (CDCNIOSHDSHEFS)Subject FW 7743
Tom is April Boyer correct
Glenn P Benarick 211 Winged Elm Circle
Aiken SC 29803
803-644-7093
gbenarprodigynet
--- On Thu 82610 Sawyer Steve ltssawyerNFPAorggt wrote
From Sawyer Steve ltssawyerNFPAorggtSubject FW 7743To GLENN BENARICK ltgbenarprodigynetgtDate Thursday August 26 2010 925 PM
FYI Do you have any answer She is write
Steven
54
Steven F Sawyer
Senior Fire Service Specialist
Executive Secretary IFMAFire Service Section
NFPA
1 Batterymarch Park
Quincy MA 02169
6179847423
Fax 6179847056
ssawyernfpaorg
From April Boyer [mailtoaboyerbicclinicorg] Sent Thursday August 26 2010 232 PMTo Sawyer SteveCc RobinMWebbmilstateorusSubject 7743
Steven
The spirometry tests cannot be corrected according to both references as the NFPA states because thereferences are contradictory The first part of 7743 states to follow the ATS guidelines and use theKnudsen (we at Basin Immediate Care use the Nhanes III) The second part states to follow the ACOEMguidelines and use the Nhanes III in the occupational setting if available with your unit (which is availableon ours) 7743 does not use the word OR regarding both requirements it uses the word AND whenreferring to the first and second parts thence making 7743 contradictory I realize the NFPA 1582 hasnot been updated since 2007 unless I have just not received an updated version
Our question to you is which part of 7743 do you want us to follow the first or the second part Anyfacility that has an updated computerized spirometry system (as we do) will not be able to follow bothrequired parts for obvious reasons We can either follow the first part of 7743 and use an oldercorrected version of the Knudson by going into our system and changing out of the Nhanes III conversionOR we can follow the second part of 7743 and use the newer corrected version of Nhanes III which ourunit offers too
If you have any questions you may contact me at anytime and I also have many references in regards toboth parts of 7743 if you would like to see them
55
Thank you~
April
Confidentiality NoticeThis message may contain information that isconfidential or privileged
If you are not the intended recipientPlease advise the sender immediately and delete this message
56
ATTACHMENT H
57
NFPA 1582 771(7) Proposed revisions
Why
Preliminary results of two prospective randomized trials on the PSA test were published in 2009 These studies resulted in medical organizations that previously providing guidance to modify their recommendations
Current language
771 Blood Tests Blood tests shall be performed annually and shall include the following
(7) Prostate specific antigen (PSA) after age 40 for positive family history if African American or if otherwise clinically indicated after age 50 for all other male member
Suggested Revision
771 Blood Tests Blood tests shall be performed annually and shall include the following
(7) Prostate specific antigen (PSA) after age 40 for positive family history if African American or if otherwise clinically indicated after age 50 for all other male member
772 Prostate-Specific Antigen (PSA) test At age 50 fire fighters shall have an opportunity to make an informed decision with either the Fire Department physician or their health care provider concerning the PSA test For fire fighters at increased risk of prostate cancer (African-Americans or those with a first degree relative diagnosed with prostate cancer before age 65) shall have the opportunity for this informed decision at age 40
A772 The PSA as a screening test for prostate cancer in asymptomatic men is controversial controversial for two reasons First there is no consensus that PSA screening actually saves lives For example the PSA test may detect small cancers that would never become life threatening Second it is unclear that the benefits of PSA screening outweigh the risks of follow-up diagnostic tests and cancer treatments For example the prostate biopsy used to diagnose prostate cancer may cause bleeding and infection And prostate cancer treatments such as surgery and radiation therapy may cause incontinence (inability to control urine flow) erectile dysfunction (erections inadequate for intercourse) and other complications For these reasons it is important that the benefits and risks of prostate diagnostic procedures and treatment be taken into account when considering the PSA screening test These considerations can be taken account during discussions with the fire department physician or onersquos health care provider
D211 Cancer Screening
Smith R A C J Mettlin K J Davis and H Eyre 2000 ldquoAmerican Cancer Society guidelines for the early detection of cancerrdquo CA J Clin 50(1)34ndash49
Added references
58
Carroll P Albertsen PC Greene K et al [2010] Prostate-specific antigen best practice statement 2009 update Am Urological Assoc Available at httpwwwauanetorgcontentguidelines-and-quality-careclinical-guidelinesmain-reportspsa09pdf Date accessed September 2010
Ferrini R Woolf SH [2009] Screening for prostate cancer in American men American College of Preventive Medicine Practice Policy Statement Available at httpwwwacpmorgprostatehtm Date accessed September 2010
National Cancer Institute [2009] Prostate-specific antigen test National Cancer Institute Fact Sheet Available at httpwwwcancergovcancertopicsfactsheetDetectionPSA Date accessed September 2010
Wolf AMD Wender RC Etzioni RB et al [2010] American Cancer Society guideline for the early detection of prostate cancer Update 2010 Available at httpcaonlineamcancersocorgcgicontentfullcaac20066v1 Date accessed September 2010
59
D22 Cardiology
Chobanian AV Bakris GL Black HR Cushman WC Green LA Izzo JL Jr Jones DW Materson BJ Oparil S Wright JT Jr Roccella EJ the National High Blood Pressure Education Program Coordinating Committee [2003] The seventh report of the Joint National Committee [JNC-7] on Prevention Detection Evaluation and Treatment of High Blood Pressure JAMA 2892560ndash2571
Gibbons RJ Balady GJ Bricker JT Chaitman BR Fletcher GF Froelicher VF Mark DB McCallister BD Mooss AN OrsquoReilly MG Winters WL Jr [2002] ACCAHA 2002 guideline update for exercise testing summary article a report of the ACCAHA Task Force on Practice Guidelines (Committee to Update the 1997 Exercise Testing guidelines) J Am Coll Cardiol 401531ndash 1540
Greenland et al [2007] ACCFAHA 2007 Clinical Expert Consensus Document on Coronary Artery Calcium Scoring By Computed Tomography in Global Cardiovascular Risk Assessment and in Evaluation of Patients With Chest Pain A Report of the American College of Cardiology Foundation Clinical Expert Consensus Task Force (ACCFAHA Writing Committee to Update the 2000 Expert Consensus Document on Electron Beam Computed Tomography) J Am Coll Cardiol 49378-402
Kales SN Tsismenakis AJ Zhang C Soteriades ES [2009] Blood pressure in fire fighters police officers and other emergency responders Am J Hypertens 2211-20
Schlant RC Adolph RJ DiMarco JP Dreifus LS Dunn MI Fisch C Garson A Jr Haywood LJ Levine HJ Murray JA Noble RJ Ronan JA Jr [1992] Guidelines for electrocardiography A report of the American College of CardiologyAmerican Heart Association Task Force on Assessment of Diagnostic and Therapeutic Cardiovascular Procedures (Committee on Electrocardiography) Circulation 85(3)1221-1228
Soteriades ES Kales SN Liarokapis D Christiani DC [2003] Prospective surveillance of hypertension in firefighters J Clin Hypertens 5315-320
Formatted Font Italic
Formatted Line spacing single
Formatted Font Italic
Formatted Font Italic
44
NFPA 1582‐ Draft Revisions for CVDHTN
EKG and stress tests
Reason for Revision
1) Change requirement for annual resting EKG to periodically to be more consistent with ACCAHA
recommendation (Schlant et al 1992)
2) Add language to clarify what constitutes a positive ST
3) Make criteria for conducting diagnostic ST in asymptomatic patients consistent with the
ACCAHA
Language in 2007 Edition with draft revisions in Red (Track changes)
776 Electrocardiograms (EKG) and Stress Tests 7761 A resting EKG shall be performed as part of the baseline medical evaluation and shall be obtained periodically (every 1 to 5 years) thereafter
A7761 A baseline resting EKGs shall be conducted Follow-up resting EKGs should be conducted as clinically indicated but at a minimum of every 1 to 5 years The frequency of these follow-up resting EKGs should increase as a members age increases or with increasing number andor severity of coronary heart disease risk factors Members above the age of 40 should have annual resting EKGs (Schlant et al 1992)
7762 The fire department physician or other qualified medical evaluator shall compare baseline and subsequent EKGs
7763 Stress testing with or without echocardiography or radionuclide scanning shall be performed as clinically indicated by history or symptoms
A7763 No firm guidelines for stress testing in asymptomatic individuals have been developed Stress testing as a screening tool is used as part of an evaluation of aerobic capacity during the annual occupational fitness evaluation Submaximal stress testing testing to 85 percent is commonly used as part of this screening
Submaximal stress testing should not be used for diagnostic purposes Cardiology evaluation with maximal stress testing together with imaging techniques (eg echocardiography technetium Tc99m sestamibi study) is necessary for diagnosticprognostic purposes for the following
(1) Fire fighters with positive or questionably positive changes on screening submaximal stress tests
(2) Fire fighters with new onset chest pain or other symptoms suggestive of coronary artery disease (CAD)
45
(3) Fire fighters with diabetes mellitus who
(a) are gt35 years old or
(b) have type I diabetes for more than 15 years or
(c) have type II diabetes for more than 10 years or
(d) have any other CHD risk factor (see below) or
(e) have the presence of microvascular disease (proliferative retinopathy)
(4) Fire fighters over the age of 45 (for men) and 55 (for women) with one or more risk factors for CAD Risk factors for CAD include hypercholesterolemia (total cholesterol greater than 240 mgdL) hypertension (systolic gt140 mmHg or diastolic gt90 mmHg) smoking or family history of premature CAD (heart attack or sudden cardiac death in a first degree relative less than 60 years of age)
(5) Fire fighters with a Framingham Risk Score gt10 Risk calculator is available at [httphp2010nhlbihinnetatpiiicalculatorasp]
(6) Fire fighters identified in 9431
Negative stress tests should be repeated as clinically indicated or at least every 2 to 5 years
Interpreting stress tests as ldquopositiverdquo or ldquonegativerdquo is beyond the scope of this document However factors that should be taken into consideration should include the individualrsquos exercise capacity symptoms blood pressure response heart rate response EKG changes and the presence of arrhythmias (Gibbon et al 2002)
There are other non-invasive tests to screen for coronary artery disease One of the most promising appears to be coronary artery calcium (CAD) scoring by computed tomography In 2007 an expert committee published an update to their original guidance document The committeersquos consensus was that ldquoit may be reasonable to consider use of CAC measurement in such patients [between 10 and 20 10-year risk of estimated coronary event]helliprdquo The committee did not recommend CAC measurement in low risk patients [lt10 10-year risk of estimated coronary event] or in high risk patients [gt20 10-year risk of estimate coronary event] (Greenland et al 2007]
D22 Cardiology
Resting EKG and Stress Tests
46
Chobanian AV Bakris GL Black HR Cushman WC Green LA Izzo JL Jr Jones DW Materson BJ Oparil S Wright JT Jr Roccella EJ the National High Blood Pressure Education Program Coordinating Committee [2003] The seventh report of the Joint National Committee [JNC-7] on Prevention Detection Evaluation and Treatment of High Blood Pressure JAMA 2892560ndash2571
Gibbons RJ Balady GJ Bricker JT Chaitman BR Fletcher GF Froelicher VF Mark DB McCallister BD Mooss AN OrsquoReilly MG Winters WL Jr [2002] ACCAHA 2002 guideline update for exercise testing summary article a report of the ACCAHA Task Force on Practice Guidelines (Committee to Update the 1997 Exercise Testing guidelines) J Am Coll Cardiol 401531ndash 1540
Greenland et al [2007] ACCFAHA 2007 Clinical Expert Consensus Document on Coronary Artery Calcium Scoring By Computed Tomography in Global Cardiovascular Risk Assessment and in Evaluation of Patients With Chest Pain A Report of the American College of Cardiology Foundation Clinical Expert Consensus Task Force (ACCFAHA Writing Committee to Update the 2000 Expert Consensus Document on Electron Beam Computed Tomography) J Am Coll Cardiol 49378-402
Kales SN Tsismenakis AJ Zhang C Soteriades ES [2009] Blood pressure in fire fighters police officers and other emergency responders Am J Hypertens 2211-20
Schlant RC Adolph RJ DiMarco JP Dreifus LS Dunn MI Fisch C Garson A Jr Haywood LJ Levine HJ Murray JA Noble RJ Ronan JA Jr [1992] Guidelines for electrocardiography A report of the American College of CardiologyAmerican Heart Association Task Force on Assessment of Diagnostic and Therapeutic Cardiovascular Procedures (Committee on Electrocardiography) Circulation 85(3)1221-1228
Soteriades ES Kales SN Liarokapis D Christiani DC [2003] Prospective surveillance of hypertension in firefighters J Clin Hypertens 5315-320
47
ATTACHMENT F
48
1
Current 1582 (2007) language in reference to pregnancy 43 (4) Report to the fire department physician any medical condition that could interfere with the ability of the individual to safely perform essential job tasks such as illness or injury use of prescription or nonprescription drugs and pregnancy 6112 Category B medical conditions shall include the following (1) Pregnancy for its duration A7792 (e) If HIV prophylaxis is to be given the following tests should be done i CBC ii Glucose renal and hepatic chemical function iii Pregnancy test for females B121 Pregnancy and Reproduction Federal regulations as well as many court decisions including the US Supreme Courtrsquos decision in International Union et al v Johnson Controls Inc [499 US 187 111 S Ct 1196 (1991)] have interpreted the requirements of Title VII with respect to pregnancy and reproduction The AHJ should seek the advice of counsel in resolving specific questions concerning these requirements as well as other requirements that can be imposed by state or local laws C211 (4) Review health status with the individual being evaluated Contraindications for evaluations shall be reviewed addressing any changes in the individualrsquos health status since their last medical evaluation that would warrant deferring the evaluation including (g) Pregnancy Recommendations to language enhancement
A female employee who is assigned to regular fire line duty shall report a pregnancy immediately to their respective Supervisor and the fire department physician The employee will then be given the option of a non-hazardous alternative duty position for the duration of her pregnancy (can we say this or is it even appropriate) Any pregnant employee wishing to remain on regular line duty shall be informed of the possible risks and consequences to herself and her fetus that are associated with continued line fire fighting duty Among those risk factors are exposure to teratogens known to have negative effects on the developing fetus such as smoke diesel fumes hazardous chemicals and extreme heat
49
Page 2
appendix It is recommended that the pregnant employee complete a release of liability form signed by herself and her health care provider utilizing NFPArsquos 13 critical tasks as a reference This will inform the health care provider of specific job-related tasks that will need to be performed in order to continue regular line duty These tasks are basic physical standards that any entry level firefighter would have to be able to complete competently The employeersquos health condition will be kept confidential by the department in accordance with HIPAA standards Employees are allowed to remain on active regular duty until they are no longer able to perform their duties in a reasonable manner andor their protective gear no longer fits correctly It is the responsibility of the health care provider to evaluate the pregnant employee If at any time the health care provider feels the pregnant employee can no longer perform the job related tasks this should be reported to the employer by the employee immediately
50
ATTACHMENT G
51
From GLENN BENARICKTo Sawyer SteveSubject RE RE 7743Date Monday August 30 2010 21633 PM
Yes thats my understanding
Glenn P Benarick 211 Winged Elm CircleAiken SC 29803803-644-7093gbenarprodigynet
--- On Mon 83010 Sawyer Steve ltssawyerNFPAorggt wrote
From Sawyer Steve ltssawyerNFPAorggtSubject RE RE 7743To GLENN BENARICK ltgbenarprodigynetgtDate Monday August 30 2010 212 PM
So it should be ldquoorrdquo instead of ldquoandrdquo for now
Steven F Sawyer
Senior Fire Service Specialist
Executive Secretary IFMAFire Service Section
NFPA
1 Batterymarch Park
Quincy MA 02169
6179847423
Fax 6179847056
ssawyernfpaorg
From GLENN BENARICK [mailtogbenarprodigynet] Sent Monday August 30 2010 1202 PMTo Sawyer SteveSubject Fw RE 7743
52
Steve a couple of our docs agree with April Boyer
Glenn P Benarick 211 Winged Elm Circle
Aiken SC 29803
803-644-7093
gbenarprodigynet
--- On Mon 83010 David Prezant ltprezandfdnynycgovgt wrote
From David Prezant ltprezandfdnynycgovgtSubject RE 7743To Thomas R (CDCNIOSHDSHEFS) Hales lttrh1cdcgovgt GLENNBENARICK ltgbenarprodigynetgtCc Sandy Bogucki ltsandyboguckiyaleedugtDate Monday August 30 2010 1004 AM
agree
we should change this to NHANES III rather than Knudson we should alsomodify this to allow not only for predicted cutoffs but all for use of thelower limit of normal cutoff This is important to prevent false-classificationof spirometry as abnormal in older groups and in taller grps The latter ofparticular import to firefighter occupational health surveillance
thanks
David Prezant MDChief Medical Officer Office of Medical AffairsCo-Director WTC Medical Monitoring amp Treatment ProgramsNew York City Fire Department9 Metrotech Center - Rm 4W-1Brooklyn NY 11201Phone 718-999-2696Fax 718-999-0665
Life is full of twists and turns
53
This email may contain confidential information If you are the unintendedrecipient of this email please send it back and delete from your directory
gtgtgt Hales Thomas R (CDCNIOSHDSHEFS) lttrh1cdcgovgt 8302010955 AM gtgtgt
Glen
This seems like a very reasonable comment and illustrates the importance of having clinicians providefeedback on the std Im not familiar with the software program of the various spirometers (NHANES IIIvs KnudsonATS vs both) Given the large role both Dave Prezant and Sandy Bogucki had for thepulmonary section let me forward to them for clarification
Tom
From GLENN BENARICK [mailtogbenarprodigynet] Sent Sunday August 29 2010 456 PMTo Hales Thomas R (CDCNIOSHDSHEFS)Subject FW 7743
Tom is April Boyer correct
Glenn P Benarick 211 Winged Elm Circle
Aiken SC 29803
803-644-7093
gbenarprodigynet
--- On Thu 82610 Sawyer Steve ltssawyerNFPAorggt wrote
From Sawyer Steve ltssawyerNFPAorggtSubject FW 7743To GLENN BENARICK ltgbenarprodigynetgtDate Thursday August 26 2010 925 PM
FYI Do you have any answer She is write
Steven
54
Steven F Sawyer
Senior Fire Service Specialist
Executive Secretary IFMAFire Service Section
NFPA
1 Batterymarch Park
Quincy MA 02169
6179847423
Fax 6179847056
ssawyernfpaorg
From April Boyer [mailtoaboyerbicclinicorg] Sent Thursday August 26 2010 232 PMTo Sawyer SteveCc RobinMWebbmilstateorusSubject 7743
Steven
The spirometry tests cannot be corrected according to both references as the NFPA states because thereferences are contradictory The first part of 7743 states to follow the ATS guidelines and use theKnudsen (we at Basin Immediate Care use the Nhanes III) The second part states to follow the ACOEMguidelines and use the Nhanes III in the occupational setting if available with your unit (which is availableon ours) 7743 does not use the word OR regarding both requirements it uses the word AND whenreferring to the first and second parts thence making 7743 contradictory I realize the NFPA 1582 hasnot been updated since 2007 unless I have just not received an updated version
Our question to you is which part of 7743 do you want us to follow the first or the second part Anyfacility that has an updated computerized spirometry system (as we do) will not be able to follow bothrequired parts for obvious reasons We can either follow the first part of 7743 and use an oldercorrected version of the Knudson by going into our system and changing out of the Nhanes III conversionOR we can follow the second part of 7743 and use the newer corrected version of Nhanes III which ourunit offers too
If you have any questions you may contact me at anytime and I also have many references in regards toboth parts of 7743 if you would like to see them
55
Thank you~
April
Confidentiality NoticeThis message may contain information that isconfidential or privileged
If you are not the intended recipientPlease advise the sender immediately and delete this message
56
ATTACHMENT H
57
NFPA 1582 771(7) Proposed revisions
Why
Preliminary results of two prospective randomized trials on the PSA test were published in 2009 These studies resulted in medical organizations that previously providing guidance to modify their recommendations
Current language
771 Blood Tests Blood tests shall be performed annually and shall include the following
(7) Prostate specific antigen (PSA) after age 40 for positive family history if African American or if otherwise clinically indicated after age 50 for all other male member
Suggested Revision
771 Blood Tests Blood tests shall be performed annually and shall include the following
(7) Prostate specific antigen (PSA) after age 40 for positive family history if African American or if otherwise clinically indicated after age 50 for all other male member
772 Prostate-Specific Antigen (PSA) test At age 50 fire fighters shall have an opportunity to make an informed decision with either the Fire Department physician or their health care provider concerning the PSA test For fire fighters at increased risk of prostate cancer (African-Americans or those with a first degree relative diagnosed with prostate cancer before age 65) shall have the opportunity for this informed decision at age 40
A772 The PSA as a screening test for prostate cancer in asymptomatic men is controversial controversial for two reasons First there is no consensus that PSA screening actually saves lives For example the PSA test may detect small cancers that would never become life threatening Second it is unclear that the benefits of PSA screening outweigh the risks of follow-up diagnostic tests and cancer treatments For example the prostate biopsy used to diagnose prostate cancer may cause bleeding and infection And prostate cancer treatments such as surgery and radiation therapy may cause incontinence (inability to control urine flow) erectile dysfunction (erections inadequate for intercourse) and other complications For these reasons it is important that the benefits and risks of prostate diagnostic procedures and treatment be taken into account when considering the PSA screening test These considerations can be taken account during discussions with the fire department physician or onersquos health care provider
D211 Cancer Screening
Smith R A C J Mettlin K J Davis and H Eyre 2000 ldquoAmerican Cancer Society guidelines for the early detection of cancerrdquo CA J Clin 50(1)34ndash49
Added references
58
Carroll P Albertsen PC Greene K et al [2010] Prostate-specific antigen best practice statement 2009 update Am Urological Assoc Available at httpwwwauanetorgcontentguidelines-and-quality-careclinical-guidelinesmain-reportspsa09pdf Date accessed September 2010
Ferrini R Woolf SH [2009] Screening for prostate cancer in American men American College of Preventive Medicine Practice Policy Statement Available at httpwwwacpmorgprostatehtm Date accessed September 2010
National Cancer Institute [2009] Prostate-specific antigen test National Cancer Institute Fact Sheet Available at httpwwwcancergovcancertopicsfactsheetDetectionPSA Date accessed September 2010
Wolf AMD Wender RC Etzioni RB et al [2010] American Cancer Society guideline for the early detection of prostate cancer Update 2010 Available at httpcaonlineamcancersocorgcgicontentfullcaac20066v1 Date accessed September 2010
59
NFPA 1582‐ Draft Revisions for CVDHTN
EKG and stress tests
Reason for Revision
1) Change requirement for annual resting EKG to periodically to be more consistent with ACCAHA
recommendation (Schlant et al 1992)
2) Add language to clarify what constitutes a positive ST
3) Make criteria for conducting diagnostic ST in asymptomatic patients consistent with the
ACCAHA
Language in 2007 Edition with draft revisions in Red (Track changes)
776 Electrocardiograms (EKG) and Stress Tests 7761 A resting EKG shall be performed as part of the baseline medical evaluation and shall be obtained periodically (every 1 to 5 years) thereafter
A7761 A baseline resting EKGs shall be conducted Follow-up resting EKGs should be conducted as clinically indicated but at a minimum of every 1 to 5 years The frequency of these follow-up resting EKGs should increase as a members age increases or with increasing number andor severity of coronary heart disease risk factors Members above the age of 40 should have annual resting EKGs (Schlant et al 1992)
7762 The fire department physician or other qualified medical evaluator shall compare baseline and subsequent EKGs
7763 Stress testing with or without echocardiography or radionuclide scanning shall be performed as clinically indicated by history or symptoms
A7763 No firm guidelines for stress testing in asymptomatic individuals have been developed Stress testing as a screening tool is used as part of an evaluation of aerobic capacity during the annual occupational fitness evaluation Submaximal stress testing testing to 85 percent is commonly used as part of this screening
Submaximal stress testing should not be used for diagnostic purposes Cardiology evaluation with maximal stress testing together with imaging techniques (eg echocardiography technetium Tc99m sestamibi study) is necessary for diagnosticprognostic purposes for the following
(1) Fire fighters with positive or questionably positive changes on screening submaximal stress tests
(2) Fire fighters with new onset chest pain or other symptoms suggestive of coronary artery disease (CAD)
45
(3) Fire fighters with diabetes mellitus who
(a) are gt35 years old or
(b) have type I diabetes for more than 15 years or
(c) have type II diabetes for more than 10 years or
(d) have any other CHD risk factor (see below) or
(e) have the presence of microvascular disease (proliferative retinopathy)
(4) Fire fighters over the age of 45 (for men) and 55 (for women) with one or more risk factors for CAD Risk factors for CAD include hypercholesterolemia (total cholesterol greater than 240 mgdL) hypertension (systolic gt140 mmHg or diastolic gt90 mmHg) smoking or family history of premature CAD (heart attack or sudden cardiac death in a first degree relative less than 60 years of age)
(5) Fire fighters with a Framingham Risk Score gt10 Risk calculator is available at [httphp2010nhlbihinnetatpiiicalculatorasp]
(6) Fire fighters identified in 9431
Negative stress tests should be repeated as clinically indicated or at least every 2 to 5 years
Interpreting stress tests as ldquopositiverdquo or ldquonegativerdquo is beyond the scope of this document However factors that should be taken into consideration should include the individualrsquos exercise capacity symptoms blood pressure response heart rate response EKG changes and the presence of arrhythmias (Gibbon et al 2002)
There are other non-invasive tests to screen for coronary artery disease One of the most promising appears to be coronary artery calcium (CAD) scoring by computed tomography In 2007 an expert committee published an update to their original guidance document The committeersquos consensus was that ldquoit may be reasonable to consider use of CAC measurement in such patients [between 10 and 20 10-year risk of estimated coronary event]helliprdquo The committee did not recommend CAC measurement in low risk patients [lt10 10-year risk of estimated coronary event] or in high risk patients [gt20 10-year risk of estimate coronary event] (Greenland et al 2007]
D22 Cardiology
Resting EKG and Stress Tests
46
Chobanian AV Bakris GL Black HR Cushman WC Green LA Izzo JL Jr Jones DW Materson BJ Oparil S Wright JT Jr Roccella EJ the National High Blood Pressure Education Program Coordinating Committee [2003] The seventh report of the Joint National Committee [JNC-7] on Prevention Detection Evaluation and Treatment of High Blood Pressure JAMA 2892560ndash2571
Gibbons RJ Balady GJ Bricker JT Chaitman BR Fletcher GF Froelicher VF Mark DB McCallister BD Mooss AN OrsquoReilly MG Winters WL Jr [2002] ACCAHA 2002 guideline update for exercise testing summary article a report of the ACCAHA Task Force on Practice Guidelines (Committee to Update the 1997 Exercise Testing guidelines) J Am Coll Cardiol 401531ndash 1540
Greenland et al [2007] ACCFAHA 2007 Clinical Expert Consensus Document on Coronary Artery Calcium Scoring By Computed Tomography in Global Cardiovascular Risk Assessment and in Evaluation of Patients With Chest Pain A Report of the American College of Cardiology Foundation Clinical Expert Consensus Task Force (ACCFAHA Writing Committee to Update the 2000 Expert Consensus Document on Electron Beam Computed Tomography) J Am Coll Cardiol 49378-402
Kales SN Tsismenakis AJ Zhang C Soteriades ES [2009] Blood pressure in fire fighters police officers and other emergency responders Am J Hypertens 2211-20
Schlant RC Adolph RJ DiMarco JP Dreifus LS Dunn MI Fisch C Garson A Jr Haywood LJ Levine HJ Murray JA Noble RJ Ronan JA Jr [1992] Guidelines for electrocardiography A report of the American College of CardiologyAmerican Heart Association Task Force on Assessment of Diagnostic and Therapeutic Cardiovascular Procedures (Committee on Electrocardiography) Circulation 85(3)1221-1228
Soteriades ES Kales SN Liarokapis D Christiani DC [2003] Prospective surveillance of hypertension in firefighters J Clin Hypertens 5315-320
47
ATTACHMENT F
48
1
Current 1582 (2007) language in reference to pregnancy 43 (4) Report to the fire department physician any medical condition that could interfere with the ability of the individual to safely perform essential job tasks such as illness or injury use of prescription or nonprescription drugs and pregnancy 6112 Category B medical conditions shall include the following (1) Pregnancy for its duration A7792 (e) If HIV prophylaxis is to be given the following tests should be done i CBC ii Glucose renal and hepatic chemical function iii Pregnancy test for females B121 Pregnancy and Reproduction Federal regulations as well as many court decisions including the US Supreme Courtrsquos decision in International Union et al v Johnson Controls Inc [499 US 187 111 S Ct 1196 (1991)] have interpreted the requirements of Title VII with respect to pregnancy and reproduction The AHJ should seek the advice of counsel in resolving specific questions concerning these requirements as well as other requirements that can be imposed by state or local laws C211 (4) Review health status with the individual being evaluated Contraindications for evaluations shall be reviewed addressing any changes in the individualrsquos health status since their last medical evaluation that would warrant deferring the evaluation including (g) Pregnancy Recommendations to language enhancement
A female employee who is assigned to regular fire line duty shall report a pregnancy immediately to their respective Supervisor and the fire department physician The employee will then be given the option of a non-hazardous alternative duty position for the duration of her pregnancy (can we say this or is it even appropriate) Any pregnant employee wishing to remain on regular line duty shall be informed of the possible risks and consequences to herself and her fetus that are associated with continued line fire fighting duty Among those risk factors are exposure to teratogens known to have negative effects on the developing fetus such as smoke diesel fumes hazardous chemicals and extreme heat
49
Page 2
appendix It is recommended that the pregnant employee complete a release of liability form signed by herself and her health care provider utilizing NFPArsquos 13 critical tasks as a reference This will inform the health care provider of specific job-related tasks that will need to be performed in order to continue regular line duty These tasks are basic physical standards that any entry level firefighter would have to be able to complete competently The employeersquos health condition will be kept confidential by the department in accordance with HIPAA standards Employees are allowed to remain on active regular duty until they are no longer able to perform their duties in a reasonable manner andor their protective gear no longer fits correctly It is the responsibility of the health care provider to evaluate the pregnant employee If at any time the health care provider feels the pregnant employee can no longer perform the job related tasks this should be reported to the employer by the employee immediately
50
ATTACHMENT G
51
From GLENN BENARICKTo Sawyer SteveSubject RE RE 7743Date Monday August 30 2010 21633 PM
Yes thats my understanding
Glenn P Benarick 211 Winged Elm CircleAiken SC 29803803-644-7093gbenarprodigynet
--- On Mon 83010 Sawyer Steve ltssawyerNFPAorggt wrote
From Sawyer Steve ltssawyerNFPAorggtSubject RE RE 7743To GLENN BENARICK ltgbenarprodigynetgtDate Monday August 30 2010 212 PM
So it should be ldquoorrdquo instead of ldquoandrdquo for now
Steven F Sawyer
Senior Fire Service Specialist
Executive Secretary IFMAFire Service Section
NFPA
1 Batterymarch Park
Quincy MA 02169
6179847423
Fax 6179847056
ssawyernfpaorg
From GLENN BENARICK [mailtogbenarprodigynet] Sent Monday August 30 2010 1202 PMTo Sawyer SteveSubject Fw RE 7743
52
Steve a couple of our docs agree with April Boyer
Glenn P Benarick 211 Winged Elm Circle
Aiken SC 29803
803-644-7093
gbenarprodigynet
--- On Mon 83010 David Prezant ltprezandfdnynycgovgt wrote
From David Prezant ltprezandfdnynycgovgtSubject RE 7743To Thomas R (CDCNIOSHDSHEFS) Hales lttrh1cdcgovgt GLENNBENARICK ltgbenarprodigynetgtCc Sandy Bogucki ltsandyboguckiyaleedugtDate Monday August 30 2010 1004 AM
agree
we should change this to NHANES III rather than Knudson we should alsomodify this to allow not only for predicted cutoffs but all for use of thelower limit of normal cutoff This is important to prevent false-classificationof spirometry as abnormal in older groups and in taller grps The latter ofparticular import to firefighter occupational health surveillance
thanks
David Prezant MDChief Medical Officer Office of Medical AffairsCo-Director WTC Medical Monitoring amp Treatment ProgramsNew York City Fire Department9 Metrotech Center - Rm 4W-1Brooklyn NY 11201Phone 718-999-2696Fax 718-999-0665
Life is full of twists and turns
53
This email may contain confidential information If you are the unintendedrecipient of this email please send it back and delete from your directory
gtgtgt Hales Thomas R (CDCNIOSHDSHEFS) lttrh1cdcgovgt 8302010955 AM gtgtgt
Glen
This seems like a very reasonable comment and illustrates the importance of having clinicians providefeedback on the std Im not familiar with the software program of the various spirometers (NHANES IIIvs KnudsonATS vs both) Given the large role both Dave Prezant and Sandy Bogucki had for thepulmonary section let me forward to them for clarification
Tom
From GLENN BENARICK [mailtogbenarprodigynet] Sent Sunday August 29 2010 456 PMTo Hales Thomas R (CDCNIOSHDSHEFS)Subject FW 7743
Tom is April Boyer correct
Glenn P Benarick 211 Winged Elm Circle
Aiken SC 29803
803-644-7093
gbenarprodigynet
--- On Thu 82610 Sawyer Steve ltssawyerNFPAorggt wrote
From Sawyer Steve ltssawyerNFPAorggtSubject FW 7743To GLENN BENARICK ltgbenarprodigynetgtDate Thursday August 26 2010 925 PM
FYI Do you have any answer She is write
Steven
54
Steven F Sawyer
Senior Fire Service Specialist
Executive Secretary IFMAFire Service Section
NFPA
1 Batterymarch Park
Quincy MA 02169
6179847423
Fax 6179847056
ssawyernfpaorg
From April Boyer [mailtoaboyerbicclinicorg] Sent Thursday August 26 2010 232 PMTo Sawyer SteveCc RobinMWebbmilstateorusSubject 7743
Steven
The spirometry tests cannot be corrected according to both references as the NFPA states because thereferences are contradictory The first part of 7743 states to follow the ATS guidelines and use theKnudsen (we at Basin Immediate Care use the Nhanes III) The second part states to follow the ACOEMguidelines and use the Nhanes III in the occupational setting if available with your unit (which is availableon ours) 7743 does not use the word OR regarding both requirements it uses the word AND whenreferring to the first and second parts thence making 7743 contradictory I realize the NFPA 1582 hasnot been updated since 2007 unless I have just not received an updated version
Our question to you is which part of 7743 do you want us to follow the first or the second part Anyfacility that has an updated computerized spirometry system (as we do) will not be able to follow bothrequired parts for obvious reasons We can either follow the first part of 7743 and use an oldercorrected version of the Knudson by going into our system and changing out of the Nhanes III conversionOR we can follow the second part of 7743 and use the newer corrected version of Nhanes III which ourunit offers too
If you have any questions you may contact me at anytime and I also have many references in regards toboth parts of 7743 if you would like to see them
55
Thank you~
April
Confidentiality NoticeThis message may contain information that isconfidential or privileged
If you are not the intended recipientPlease advise the sender immediately and delete this message
56
ATTACHMENT H
57
NFPA 1582 771(7) Proposed revisions
Why
Preliminary results of two prospective randomized trials on the PSA test were published in 2009 These studies resulted in medical organizations that previously providing guidance to modify their recommendations
Current language
771 Blood Tests Blood tests shall be performed annually and shall include the following
(7) Prostate specific antigen (PSA) after age 40 for positive family history if African American or if otherwise clinically indicated after age 50 for all other male member
Suggested Revision
771 Blood Tests Blood tests shall be performed annually and shall include the following
(7) Prostate specific antigen (PSA) after age 40 for positive family history if African American or if otherwise clinically indicated after age 50 for all other male member
772 Prostate-Specific Antigen (PSA) test At age 50 fire fighters shall have an opportunity to make an informed decision with either the Fire Department physician or their health care provider concerning the PSA test For fire fighters at increased risk of prostate cancer (African-Americans or those with a first degree relative diagnosed with prostate cancer before age 65) shall have the opportunity for this informed decision at age 40
A772 The PSA as a screening test for prostate cancer in asymptomatic men is controversial controversial for two reasons First there is no consensus that PSA screening actually saves lives For example the PSA test may detect small cancers that would never become life threatening Second it is unclear that the benefits of PSA screening outweigh the risks of follow-up diagnostic tests and cancer treatments For example the prostate biopsy used to diagnose prostate cancer may cause bleeding and infection And prostate cancer treatments such as surgery and radiation therapy may cause incontinence (inability to control urine flow) erectile dysfunction (erections inadequate for intercourse) and other complications For these reasons it is important that the benefits and risks of prostate diagnostic procedures and treatment be taken into account when considering the PSA screening test These considerations can be taken account during discussions with the fire department physician or onersquos health care provider
D211 Cancer Screening
Smith R A C J Mettlin K J Davis and H Eyre 2000 ldquoAmerican Cancer Society guidelines for the early detection of cancerrdquo CA J Clin 50(1)34ndash49
Added references
58
Carroll P Albertsen PC Greene K et al [2010] Prostate-specific antigen best practice statement 2009 update Am Urological Assoc Available at httpwwwauanetorgcontentguidelines-and-quality-careclinical-guidelinesmain-reportspsa09pdf Date accessed September 2010
Ferrini R Woolf SH [2009] Screening for prostate cancer in American men American College of Preventive Medicine Practice Policy Statement Available at httpwwwacpmorgprostatehtm Date accessed September 2010
National Cancer Institute [2009] Prostate-specific antigen test National Cancer Institute Fact Sheet Available at httpwwwcancergovcancertopicsfactsheetDetectionPSA Date accessed September 2010
Wolf AMD Wender RC Etzioni RB et al [2010] American Cancer Society guideline for the early detection of prostate cancer Update 2010 Available at httpcaonlineamcancersocorgcgicontentfullcaac20066v1 Date accessed September 2010
59
(3) Fire fighters with diabetes mellitus who
(a) are gt35 years old or
(b) have type I diabetes for more than 15 years or
(c) have type II diabetes for more than 10 years or
(d) have any other CHD risk factor (see below) or
(e) have the presence of microvascular disease (proliferative retinopathy)
(4) Fire fighters over the age of 45 (for men) and 55 (for women) with one or more risk factors for CAD Risk factors for CAD include hypercholesterolemia (total cholesterol greater than 240 mgdL) hypertension (systolic gt140 mmHg or diastolic gt90 mmHg) smoking or family history of premature CAD (heart attack or sudden cardiac death in a first degree relative less than 60 years of age)
(5) Fire fighters with a Framingham Risk Score gt10 Risk calculator is available at [httphp2010nhlbihinnetatpiiicalculatorasp]
(6) Fire fighters identified in 9431
Negative stress tests should be repeated as clinically indicated or at least every 2 to 5 years
Interpreting stress tests as ldquopositiverdquo or ldquonegativerdquo is beyond the scope of this document However factors that should be taken into consideration should include the individualrsquos exercise capacity symptoms blood pressure response heart rate response EKG changes and the presence of arrhythmias (Gibbon et al 2002)
There are other non-invasive tests to screen for coronary artery disease One of the most promising appears to be coronary artery calcium (CAD) scoring by computed tomography In 2007 an expert committee published an update to their original guidance document The committeersquos consensus was that ldquoit may be reasonable to consider use of CAC measurement in such patients [between 10 and 20 10-year risk of estimated coronary event]helliprdquo The committee did not recommend CAC measurement in low risk patients [lt10 10-year risk of estimated coronary event] or in high risk patients [gt20 10-year risk of estimate coronary event] (Greenland et al 2007]
D22 Cardiology
Resting EKG and Stress Tests
46
Chobanian AV Bakris GL Black HR Cushman WC Green LA Izzo JL Jr Jones DW Materson BJ Oparil S Wright JT Jr Roccella EJ the National High Blood Pressure Education Program Coordinating Committee [2003] The seventh report of the Joint National Committee [JNC-7] on Prevention Detection Evaluation and Treatment of High Blood Pressure JAMA 2892560ndash2571
Gibbons RJ Balady GJ Bricker JT Chaitman BR Fletcher GF Froelicher VF Mark DB McCallister BD Mooss AN OrsquoReilly MG Winters WL Jr [2002] ACCAHA 2002 guideline update for exercise testing summary article a report of the ACCAHA Task Force on Practice Guidelines (Committee to Update the 1997 Exercise Testing guidelines) J Am Coll Cardiol 401531ndash 1540
Greenland et al [2007] ACCFAHA 2007 Clinical Expert Consensus Document on Coronary Artery Calcium Scoring By Computed Tomography in Global Cardiovascular Risk Assessment and in Evaluation of Patients With Chest Pain A Report of the American College of Cardiology Foundation Clinical Expert Consensus Task Force (ACCFAHA Writing Committee to Update the 2000 Expert Consensus Document on Electron Beam Computed Tomography) J Am Coll Cardiol 49378-402
Kales SN Tsismenakis AJ Zhang C Soteriades ES [2009] Blood pressure in fire fighters police officers and other emergency responders Am J Hypertens 2211-20
Schlant RC Adolph RJ DiMarco JP Dreifus LS Dunn MI Fisch C Garson A Jr Haywood LJ Levine HJ Murray JA Noble RJ Ronan JA Jr [1992] Guidelines for electrocardiography A report of the American College of CardiologyAmerican Heart Association Task Force on Assessment of Diagnostic and Therapeutic Cardiovascular Procedures (Committee on Electrocardiography) Circulation 85(3)1221-1228
Soteriades ES Kales SN Liarokapis D Christiani DC [2003] Prospective surveillance of hypertension in firefighters J Clin Hypertens 5315-320
47
ATTACHMENT F
48
1
Current 1582 (2007) language in reference to pregnancy 43 (4) Report to the fire department physician any medical condition that could interfere with the ability of the individual to safely perform essential job tasks such as illness or injury use of prescription or nonprescription drugs and pregnancy 6112 Category B medical conditions shall include the following (1) Pregnancy for its duration A7792 (e) If HIV prophylaxis is to be given the following tests should be done i CBC ii Glucose renal and hepatic chemical function iii Pregnancy test for females B121 Pregnancy and Reproduction Federal regulations as well as many court decisions including the US Supreme Courtrsquos decision in International Union et al v Johnson Controls Inc [499 US 187 111 S Ct 1196 (1991)] have interpreted the requirements of Title VII with respect to pregnancy and reproduction The AHJ should seek the advice of counsel in resolving specific questions concerning these requirements as well as other requirements that can be imposed by state or local laws C211 (4) Review health status with the individual being evaluated Contraindications for evaluations shall be reviewed addressing any changes in the individualrsquos health status since their last medical evaluation that would warrant deferring the evaluation including (g) Pregnancy Recommendations to language enhancement
A female employee who is assigned to regular fire line duty shall report a pregnancy immediately to their respective Supervisor and the fire department physician The employee will then be given the option of a non-hazardous alternative duty position for the duration of her pregnancy (can we say this or is it even appropriate) Any pregnant employee wishing to remain on regular line duty shall be informed of the possible risks and consequences to herself and her fetus that are associated with continued line fire fighting duty Among those risk factors are exposure to teratogens known to have negative effects on the developing fetus such as smoke diesel fumes hazardous chemicals and extreme heat
49
Page 2
appendix It is recommended that the pregnant employee complete a release of liability form signed by herself and her health care provider utilizing NFPArsquos 13 critical tasks as a reference This will inform the health care provider of specific job-related tasks that will need to be performed in order to continue regular line duty These tasks are basic physical standards that any entry level firefighter would have to be able to complete competently The employeersquos health condition will be kept confidential by the department in accordance with HIPAA standards Employees are allowed to remain on active regular duty until they are no longer able to perform their duties in a reasonable manner andor their protective gear no longer fits correctly It is the responsibility of the health care provider to evaluate the pregnant employee If at any time the health care provider feels the pregnant employee can no longer perform the job related tasks this should be reported to the employer by the employee immediately
50
ATTACHMENT G
51
From GLENN BENARICKTo Sawyer SteveSubject RE RE 7743Date Monday August 30 2010 21633 PM
Yes thats my understanding
Glenn P Benarick 211 Winged Elm CircleAiken SC 29803803-644-7093gbenarprodigynet
--- On Mon 83010 Sawyer Steve ltssawyerNFPAorggt wrote
From Sawyer Steve ltssawyerNFPAorggtSubject RE RE 7743To GLENN BENARICK ltgbenarprodigynetgtDate Monday August 30 2010 212 PM
So it should be ldquoorrdquo instead of ldquoandrdquo for now
Steven F Sawyer
Senior Fire Service Specialist
Executive Secretary IFMAFire Service Section
NFPA
1 Batterymarch Park
Quincy MA 02169
6179847423
Fax 6179847056
ssawyernfpaorg
From GLENN BENARICK [mailtogbenarprodigynet] Sent Monday August 30 2010 1202 PMTo Sawyer SteveSubject Fw RE 7743
52
Steve a couple of our docs agree with April Boyer
Glenn P Benarick 211 Winged Elm Circle
Aiken SC 29803
803-644-7093
gbenarprodigynet
--- On Mon 83010 David Prezant ltprezandfdnynycgovgt wrote
From David Prezant ltprezandfdnynycgovgtSubject RE 7743To Thomas R (CDCNIOSHDSHEFS) Hales lttrh1cdcgovgt GLENNBENARICK ltgbenarprodigynetgtCc Sandy Bogucki ltsandyboguckiyaleedugtDate Monday August 30 2010 1004 AM
agree
we should change this to NHANES III rather than Knudson we should alsomodify this to allow not only for predicted cutoffs but all for use of thelower limit of normal cutoff This is important to prevent false-classificationof spirometry as abnormal in older groups and in taller grps The latter ofparticular import to firefighter occupational health surveillance
thanks
David Prezant MDChief Medical Officer Office of Medical AffairsCo-Director WTC Medical Monitoring amp Treatment ProgramsNew York City Fire Department9 Metrotech Center - Rm 4W-1Brooklyn NY 11201Phone 718-999-2696Fax 718-999-0665
Life is full of twists and turns
53
This email may contain confidential information If you are the unintendedrecipient of this email please send it back and delete from your directory
gtgtgt Hales Thomas R (CDCNIOSHDSHEFS) lttrh1cdcgovgt 8302010955 AM gtgtgt
Glen
This seems like a very reasonable comment and illustrates the importance of having clinicians providefeedback on the std Im not familiar with the software program of the various spirometers (NHANES IIIvs KnudsonATS vs both) Given the large role both Dave Prezant and Sandy Bogucki had for thepulmonary section let me forward to them for clarification
Tom
From GLENN BENARICK [mailtogbenarprodigynet] Sent Sunday August 29 2010 456 PMTo Hales Thomas R (CDCNIOSHDSHEFS)Subject FW 7743
Tom is April Boyer correct
Glenn P Benarick 211 Winged Elm Circle
Aiken SC 29803
803-644-7093
gbenarprodigynet
--- On Thu 82610 Sawyer Steve ltssawyerNFPAorggt wrote
From Sawyer Steve ltssawyerNFPAorggtSubject FW 7743To GLENN BENARICK ltgbenarprodigynetgtDate Thursday August 26 2010 925 PM
FYI Do you have any answer She is write
Steven
54
Steven F Sawyer
Senior Fire Service Specialist
Executive Secretary IFMAFire Service Section
NFPA
1 Batterymarch Park
Quincy MA 02169
6179847423
Fax 6179847056
ssawyernfpaorg
From April Boyer [mailtoaboyerbicclinicorg] Sent Thursday August 26 2010 232 PMTo Sawyer SteveCc RobinMWebbmilstateorusSubject 7743
Steven
The spirometry tests cannot be corrected according to both references as the NFPA states because thereferences are contradictory The first part of 7743 states to follow the ATS guidelines and use theKnudsen (we at Basin Immediate Care use the Nhanes III) The second part states to follow the ACOEMguidelines and use the Nhanes III in the occupational setting if available with your unit (which is availableon ours) 7743 does not use the word OR regarding both requirements it uses the word AND whenreferring to the first and second parts thence making 7743 contradictory I realize the NFPA 1582 hasnot been updated since 2007 unless I have just not received an updated version
Our question to you is which part of 7743 do you want us to follow the first or the second part Anyfacility that has an updated computerized spirometry system (as we do) will not be able to follow bothrequired parts for obvious reasons We can either follow the first part of 7743 and use an oldercorrected version of the Knudson by going into our system and changing out of the Nhanes III conversionOR we can follow the second part of 7743 and use the newer corrected version of Nhanes III which ourunit offers too
If you have any questions you may contact me at anytime and I also have many references in regards toboth parts of 7743 if you would like to see them
55
Thank you~
April
Confidentiality NoticeThis message may contain information that isconfidential or privileged
If you are not the intended recipientPlease advise the sender immediately and delete this message
56
ATTACHMENT H
57
NFPA 1582 771(7) Proposed revisions
Why
Preliminary results of two prospective randomized trials on the PSA test were published in 2009 These studies resulted in medical organizations that previously providing guidance to modify their recommendations
Current language
771 Blood Tests Blood tests shall be performed annually and shall include the following
(7) Prostate specific antigen (PSA) after age 40 for positive family history if African American or if otherwise clinically indicated after age 50 for all other male member
Suggested Revision
771 Blood Tests Blood tests shall be performed annually and shall include the following
(7) Prostate specific antigen (PSA) after age 40 for positive family history if African American or if otherwise clinically indicated after age 50 for all other male member
772 Prostate-Specific Antigen (PSA) test At age 50 fire fighters shall have an opportunity to make an informed decision with either the Fire Department physician or their health care provider concerning the PSA test For fire fighters at increased risk of prostate cancer (African-Americans or those with a first degree relative diagnosed with prostate cancer before age 65) shall have the opportunity for this informed decision at age 40
A772 The PSA as a screening test for prostate cancer in asymptomatic men is controversial controversial for two reasons First there is no consensus that PSA screening actually saves lives For example the PSA test may detect small cancers that would never become life threatening Second it is unclear that the benefits of PSA screening outweigh the risks of follow-up diagnostic tests and cancer treatments For example the prostate biopsy used to diagnose prostate cancer may cause bleeding and infection And prostate cancer treatments such as surgery and radiation therapy may cause incontinence (inability to control urine flow) erectile dysfunction (erections inadequate for intercourse) and other complications For these reasons it is important that the benefits and risks of prostate diagnostic procedures and treatment be taken into account when considering the PSA screening test These considerations can be taken account during discussions with the fire department physician or onersquos health care provider
D211 Cancer Screening
Smith R A C J Mettlin K J Davis and H Eyre 2000 ldquoAmerican Cancer Society guidelines for the early detection of cancerrdquo CA J Clin 50(1)34ndash49
Added references
58
Carroll P Albertsen PC Greene K et al [2010] Prostate-specific antigen best practice statement 2009 update Am Urological Assoc Available at httpwwwauanetorgcontentguidelines-and-quality-careclinical-guidelinesmain-reportspsa09pdf Date accessed September 2010
Ferrini R Woolf SH [2009] Screening for prostate cancer in American men American College of Preventive Medicine Practice Policy Statement Available at httpwwwacpmorgprostatehtm Date accessed September 2010
National Cancer Institute [2009] Prostate-specific antigen test National Cancer Institute Fact Sheet Available at httpwwwcancergovcancertopicsfactsheetDetectionPSA Date accessed September 2010
Wolf AMD Wender RC Etzioni RB et al [2010] American Cancer Society guideline for the early detection of prostate cancer Update 2010 Available at httpcaonlineamcancersocorgcgicontentfullcaac20066v1 Date accessed September 2010
59
Chobanian AV Bakris GL Black HR Cushman WC Green LA Izzo JL Jr Jones DW Materson BJ Oparil S Wright JT Jr Roccella EJ the National High Blood Pressure Education Program Coordinating Committee [2003] The seventh report of the Joint National Committee [JNC-7] on Prevention Detection Evaluation and Treatment of High Blood Pressure JAMA 2892560ndash2571
Gibbons RJ Balady GJ Bricker JT Chaitman BR Fletcher GF Froelicher VF Mark DB McCallister BD Mooss AN OrsquoReilly MG Winters WL Jr [2002] ACCAHA 2002 guideline update for exercise testing summary article a report of the ACCAHA Task Force on Practice Guidelines (Committee to Update the 1997 Exercise Testing guidelines) J Am Coll Cardiol 401531ndash 1540
Greenland et al [2007] ACCFAHA 2007 Clinical Expert Consensus Document on Coronary Artery Calcium Scoring By Computed Tomography in Global Cardiovascular Risk Assessment and in Evaluation of Patients With Chest Pain A Report of the American College of Cardiology Foundation Clinical Expert Consensus Task Force (ACCFAHA Writing Committee to Update the 2000 Expert Consensus Document on Electron Beam Computed Tomography) J Am Coll Cardiol 49378-402
Kales SN Tsismenakis AJ Zhang C Soteriades ES [2009] Blood pressure in fire fighters police officers and other emergency responders Am J Hypertens 2211-20
Schlant RC Adolph RJ DiMarco JP Dreifus LS Dunn MI Fisch C Garson A Jr Haywood LJ Levine HJ Murray JA Noble RJ Ronan JA Jr [1992] Guidelines for electrocardiography A report of the American College of CardiologyAmerican Heart Association Task Force on Assessment of Diagnostic and Therapeutic Cardiovascular Procedures (Committee on Electrocardiography) Circulation 85(3)1221-1228
Soteriades ES Kales SN Liarokapis D Christiani DC [2003] Prospective surveillance of hypertension in firefighters J Clin Hypertens 5315-320
47
ATTACHMENT F
48
1
Current 1582 (2007) language in reference to pregnancy 43 (4) Report to the fire department physician any medical condition that could interfere with the ability of the individual to safely perform essential job tasks such as illness or injury use of prescription or nonprescription drugs and pregnancy 6112 Category B medical conditions shall include the following (1) Pregnancy for its duration A7792 (e) If HIV prophylaxis is to be given the following tests should be done i CBC ii Glucose renal and hepatic chemical function iii Pregnancy test for females B121 Pregnancy and Reproduction Federal regulations as well as many court decisions including the US Supreme Courtrsquos decision in International Union et al v Johnson Controls Inc [499 US 187 111 S Ct 1196 (1991)] have interpreted the requirements of Title VII with respect to pregnancy and reproduction The AHJ should seek the advice of counsel in resolving specific questions concerning these requirements as well as other requirements that can be imposed by state or local laws C211 (4) Review health status with the individual being evaluated Contraindications for evaluations shall be reviewed addressing any changes in the individualrsquos health status since their last medical evaluation that would warrant deferring the evaluation including (g) Pregnancy Recommendations to language enhancement
A female employee who is assigned to regular fire line duty shall report a pregnancy immediately to their respective Supervisor and the fire department physician The employee will then be given the option of a non-hazardous alternative duty position for the duration of her pregnancy (can we say this or is it even appropriate) Any pregnant employee wishing to remain on regular line duty shall be informed of the possible risks and consequences to herself and her fetus that are associated with continued line fire fighting duty Among those risk factors are exposure to teratogens known to have negative effects on the developing fetus such as smoke diesel fumes hazardous chemicals and extreme heat
49
Page 2
appendix It is recommended that the pregnant employee complete a release of liability form signed by herself and her health care provider utilizing NFPArsquos 13 critical tasks as a reference This will inform the health care provider of specific job-related tasks that will need to be performed in order to continue regular line duty These tasks are basic physical standards that any entry level firefighter would have to be able to complete competently The employeersquos health condition will be kept confidential by the department in accordance with HIPAA standards Employees are allowed to remain on active regular duty until they are no longer able to perform their duties in a reasonable manner andor their protective gear no longer fits correctly It is the responsibility of the health care provider to evaluate the pregnant employee If at any time the health care provider feels the pregnant employee can no longer perform the job related tasks this should be reported to the employer by the employee immediately
50
ATTACHMENT G
51
From GLENN BENARICKTo Sawyer SteveSubject RE RE 7743Date Monday August 30 2010 21633 PM
Yes thats my understanding
Glenn P Benarick 211 Winged Elm CircleAiken SC 29803803-644-7093gbenarprodigynet
--- On Mon 83010 Sawyer Steve ltssawyerNFPAorggt wrote
From Sawyer Steve ltssawyerNFPAorggtSubject RE RE 7743To GLENN BENARICK ltgbenarprodigynetgtDate Monday August 30 2010 212 PM
So it should be ldquoorrdquo instead of ldquoandrdquo for now
Steven F Sawyer
Senior Fire Service Specialist
Executive Secretary IFMAFire Service Section
NFPA
1 Batterymarch Park
Quincy MA 02169
6179847423
Fax 6179847056
ssawyernfpaorg
From GLENN BENARICK [mailtogbenarprodigynet] Sent Monday August 30 2010 1202 PMTo Sawyer SteveSubject Fw RE 7743
52
Steve a couple of our docs agree with April Boyer
Glenn P Benarick 211 Winged Elm Circle
Aiken SC 29803
803-644-7093
gbenarprodigynet
--- On Mon 83010 David Prezant ltprezandfdnynycgovgt wrote
From David Prezant ltprezandfdnynycgovgtSubject RE 7743To Thomas R (CDCNIOSHDSHEFS) Hales lttrh1cdcgovgt GLENNBENARICK ltgbenarprodigynetgtCc Sandy Bogucki ltsandyboguckiyaleedugtDate Monday August 30 2010 1004 AM
agree
we should change this to NHANES III rather than Knudson we should alsomodify this to allow not only for predicted cutoffs but all for use of thelower limit of normal cutoff This is important to prevent false-classificationof spirometry as abnormal in older groups and in taller grps The latter ofparticular import to firefighter occupational health surveillance
thanks
David Prezant MDChief Medical Officer Office of Medical AffairsCo-Director WTC Medical Monitoring amp Treatment ProgramsNew York City Fire Department9 Metrotech Center - Rm 4W-1Brooklyn NY 11201Phone 718-999-2696Fax 718-999-0665
Life is full of twists and turns
53
This email may contain confidential information If you are the unintendedrecipient of this email please send it back and delete from your directory
gtgtgt Hales Thomas R (CDCNIOSHDSHEFS) lttrh1cdcgovgt 8302010955 AM gtgtgt
Glen
This seems like a very reasonable comment and illustrates the importance of having clinicians providefeedback on the std Im not familiar with the software program of the various spirometers (NHANES IIIvs KnudsonATS vs both) Given the large role both Dave Prezant and Sandy Bogucki had for thepulmonary section let me forward to them for clarification
Tom
From GLENN BENARICK [mailtogbenarprodigynet] Sent Sunday August 29 2010 456 PMTo Hales Thomas R (CDCNIOSHDSHEFS)Subject FW 7743
Tom is April Boyer correct
Glenn P Benarick 211 Winged Elm Circle
Aiken SC 29803
803-644-7093
gbenarprodigynet
--- On Thu 82610 Sawyer Steve ltssawyerNFPAorggt wrote
From Sawyer Steve ltssawyerNFPAorggtSubject FW 7743To GLENN BENARICK ltgbenarprodigynetgtDate Thursday August 26 2010 925 PM
FYI Do you have any answer She is write
Steven
54
Steven F Sawyer
Senior Fire Service Specialist
Executive Secretary IFMAFire Service Section
NFPA
1 Batterymarch Park
Quincy MA 02169
6179847423
Fax 6179847056
ssawyernfpaorg
From April Boyer [mailtoaboyerbicclinicorg] Sent Thursday August 26 2010 232 PMTo Sawyer SteveCc RobinMWebbmilstateorusSubject 7743
Steven
The spirometry tests cannot be corrected according to both references as the NFPA states because thereferences are contradictory The first part of 7743 states to follow the ATS guidelines and use theKnudsen (we at Basin Immediate Care use the Nhanes III) The second part states to follow the ACOEMguidelines and use the Nhanes III in the occupational setting if available with your unit (which is availableon ours) 7743 does not use the word OR regarding both requirements it uses the word AND whenreferring to the first and second parts thence making 7743 contradictory I realize the NFPA 1582 hasnot been updated since 2007 unless I have just not received an updated version
Our question to you is which part of 7743 do you want us to follow the first or the second part Anyfacility that has an updated computerized spirometry system (as we do) will not be able to follow bothrequired parts for obvious reasons We can either follow the first part of 7743 and use an oldercorrected version of the Knudson by going into our system and changing out of the Nhanes III conversionOR we can follow the second part of 7743 and use the newer corrected version of Nhanes III which ourunit offers too
If you have any questions you may contact me at anytime and I also have many references in regards toboth parts of 7743 if you would like to see them
55
Thank you~
April
Confidentiality NoticeThis message may contain information that isconfidential or privileged
If you are not the intended recipientPlease advise the sender immediately and delete this message
56
ATTACHMENT H
57
NFPA 1582 771(7) Proposed revisions
Why
Preliminary results of two prospective randomized trials on the PSA test were published in 2009 These studies resulted in medical organizations that previously providing guidance to modify their recommendations
Current language
771 Blood Tests Blood tests shall be performed annually and shall include the following
(7) Prostate specific antigen (PSA) after age 40 for positive family history if African American or if otherwise clinically indicated after age 50 for all other male member
Suggested Revision
771 Blood Tests Blood tests shall be performed annually and shall include the following
(7) Prostate specific antigen (PSA) after age 40 for positive family history if African American or if otherwise clinically indicated after age 50 for all other male member
772 Prostate-Specific Antigen (PSA) test At age 50 fire fighters shall have an opportunity to make an informed decision with either the Fire Department physician or their health care provider concerning the PSA test For fire fighters at increased risk of prostate cancer (African-Americans or those with a first degree relative diagnosed with prostate cancer before age 65) shall have the opportunity for this informed decision at age 40
A772 The PSA as a screening test for prostate cancer in asymptomatic men is controversial controversial for two reasons First there is no consensus that PSA screening actually saves lives For example the PSA test may detect small cancers that would never become life threatening Second it is unclear that the benefits of PSA screening outweigh the risks of follow-up diagnostic tests and cancer treatments For example the prostate biopsy used to diagnose prostate cancer may cause bleeding and infection And prostate cancer treatments such as surgery and radiation therapy may cause incontinence (inability to control urine flow) erectile dysfunction (erections inadequate for intercourse) and other complications For these reasons it is important that the benefits and risks of prostate diagnostic procedures and treatment be taken into account when considering the PSA screening test These considerations can be taken account during discussions with the fire department physician or onersquos health care provider
D211 Cancer Screening
Smith R A C J Mettlin K J Davis and H Eyre 2000 ldquoAmerican Cancer Society guidelines for the early detection of cancerrdquo CA J Clin 50(1)34ndash49
Added references
58
Carroll P Albertsen PC Greene K et al [2010] Prostate-specific antigen best practice statement 2009 update Am Urological Assoc Available at httpwwwauanetorgcontentguidelines-and-quality-careclinical-guidelinesmain-reportspsa09pdf Date accessed September 2010
Ferrini R Woolf SH [2009] Screening for prostate cancer in American men American College of Preventive Medicine Practice Policy Statement Available at httpwwwacpmorgprostatehtm Date accessed September 2010
National Cancer Institute [2009] Prostate-specific antigen test National Cancer Institute Fact Sheet Available at httpwwwcancergovcancertopicsfactsheetDetectionPSA Date accessed September 2010
Wolf AMD Wender RC Etzioni RB et al [2010] American Cancer Society guideline for the early detection of prostate cancer Update 2010 Available at httpcaonlineamcancersocorgcgicontentfullcaac20066v1 Date accessed September 2010
59
ATTACHMENT F
48
1
Current 1582 (2007) language in reference to pregnancy 43 (4) Report to the fire department physician any medical condition that could interfere with the ability of the individual to safely perform essential job tasks such as illness or injury use of prescription or nonprescription drugs and pregnancy 6112 Category B medical conditions shall include the following (1) Pregnancy for its duration A7792 (e) If HIV prophylaxis is to be given the following tests should be done i CBC ii Glucose renal and hepatic chemical function iii Pregnancy test for females B121 Pregnancy and Reproduction Federal regulations as well as many court decisions including the US Supreme Courtrsquos decision in International Union et al v Johnson Controls Inc [499 US 187 111 S Ct 1196 (1991)] have interpreted the requirements of Title VII with respect to pregnancy and reproduction The AHJ should seek the advice of counsel in resolving specific questions concerning these requirements as well as other requirements that can be imposed by state or local laws C211 (4) Review health status with the individual being evaluated Contraindications for evaluations shall be reviewed addressing any changes in the individualrsquos health status since their last medical evaluation that would warrant deferring the evaluation including (g) Pregnancy Recommendations to language enhancement
A female employee who is assigned to regular fire line duty shall report a pregnancy immediately to their respective Supervisor and the fire department physician The employee will then be given the option of a non-hazardous alternative duty position for the duration of her pregnancy (can we say this or is it even appropriate) Any pregnant employee wishing to remain on regular line duty shall be informed of the possible risks and consequences to herself and her fetus that are associated with continued line fire fighting duty Among those risk factors are exposure to teratogens known to have negative effects on the developing fetus such as smoke diesel fumes hazardous chemicals and extreme heat
49
Page 2
appendix It is recommended that the pregnant employee complete a release of liability form signed by herself and her health care provider utilizing NFPArsquos 13 critical tasks as a reference This will inform the health care provider of specific job-related tasks that will need to be performed in order to continue regular line duty These tasks are basic physical standards that any entry level firefighter would have to be able to complete competently The employeersquos health condition will be kept confidential by the department in accordance with HIPAA standards Employees are allowed to remain on active regular duty until they are no longer able to perform their duties in a reasonable manner andor their protective gear no longer fits correctly It is the responsibility of the health care provider to evaluate the pregnant employee If at any time the health care provider feels the pregnant employee can no longer perform the job related tasks this should be reported to the employer by the employee immediately
50
ATTACHMENT G
51
From GLENN BENARICKTo Sawyer SteveSubject RE RE 7743Date Monday August 30 2010 21633 PM
Yes thats my understanding
Glenn P Benarick 211 Winged Elm CircleAiken SC 29803803-644-7093gbenarprodigynet
--- On Mon 83010 Sawyer Steve ltssawyerNFPAorggt wrote
From Sawyer Steve ltssawyerNFPAorggtSubject RE RE 7743To GLENN BENARICK ltgbenarprodigynetgtDate Monday August 30 2010 212 PM
So it should be ldquoorrdquo instead of ldquoandrdquo for now
Steven F Sawyer
Senior Fire Service Specialist
Executive Secretary IFMAFire Service Section
NFPA
1 Batterymarch Park
Quincy MA 02169
6179847423
Fax 6179847056
ssawyernfpaorg
From GLENN BENARICK [mailtogbenarprodigynet] Sent Monday August 30 2010 1202 PMTo Sawyer SteveSubject Fw RE 7743
52
Steve a couple of our docs agree with April Boyer
Glenn P Benarick 211 Winged Elm Circle
Aiken SC 29803
803-644-7093
gbenarprodigynet
--- On Mon 83010 David Prezant ltprezandfdnynycgovgt wrote
From David Prezant ltprezandfdnynycgovgtSubject RE 7743To Thomas R (CDCNIOSHDSHEFS) Hales lttrh1cdcgovgt GLENNBENARICK ltgbenarprodigynetgtCc Sandy Bogucki ltsandyboguckiyaleedugtDate Monday August 30 2010 1004 AM
agree
we should change this to NHANES III rather than Knudson we should alsomodify this to allow not only for predicted cutoffs but all for use of thelower limit of normal cutoff This is important to prevent false-classificationof spirometry as abnormal in older groups and in taller grps The latter ofparticular import to firefighter occupational health surveillance
thanks
David Prezant MDChief Medical Officer Office of Medical AffairsCo-Director WTC Medical Monitoring amp Treatment ProgramsNew York City Fire Department9 Metrotech Center - Rm 4W-1Brooklyn NY 11201Phone 718-999-2696Fax 718-999-0665
Life is full of twists and turns
53
This email may contain confidential information If you are the unintendedrecipient of this email please send it back and delete from your directory
gtgtgt Hales Thomas R (CDCNIOSHDSHEFS) lttrh1cdcgovgt 8302010955 AM gtgtgt
Glen
This seems like a very reasonable comment and illustrates the importance of having clinicians providefeedback on the std Im not familiar with the software program of the various spirometers (NHANES IIIvs KnudsonATS vs both) Given the large role both Dave Prezant and Sandy Bogucki had for thepulmonary section let me forward to them for clarification
Tom
From GLENN BENARICK [mailtogbenarprodigynet] Sent Sunday August 29 2010 456 PMTo Hales Thomas R (CDCNIOSHDSHEFS)Subject FW 7743
Tom is April Boyer correct
Glenn P Benarick 211 Winged Elm Circle
Aiken SC 29803
803-644-7093
gbenarprodigynet
--- On Thu 82610 Sawyer Steve ltssawyerNFPAorggt wrote
From Sawyer Steve ltssawyerNFPAorggtSubject FW 7743To GLENN BENARICK ltgbenarprodigynetgtDate Thursday August 26 2010 925 PM
FYI Do you have any answer She is write
Steven
54
Steven F Sawyer
Senior Fire Service Specialist
Executive Secretary IFMAFire Service Section
NFPA
1 Batterymarch Park
Quincy MA 02169
6179847423
Fax 6179847056
ssawyernfpaorg
From April Boyer [mailtoaboyerbicclinicorg] Sent Thursday August 26 2010 232 PMTo Sawyer SteveCc RobinMWebbmilstateorusSubject 7743
Steven
The spirometry tests cannot be corrected according to both references as the NFPA states because thereferences are contradictory The first part of 7743 states to follow the ATS guidelines and use theKnudsen (we at Basin Immediate Care use the Nhanes III) The second part states to follow the ACOEMguidelines and use the Nhanes III in the occupational setting if available with your unit (which is availableon ours) 7743 does not use the word OR regarding both requirements it uses the word AND whenreferring to the first and second parts thence making 7743 contradictory I realize the NFPA 1582 hasnot been updated since 2007 unless I have just not received an updated version
Our question to you is which part of 7743 do you want us to follow the first or the second part Anyfacility that has an updated computerized spirometry system (as we do) will not be able to follow bothrequired parts for obvious reasons We can either follow the first part of 7743 and use an oldercorrected version of the Knudson by going into our system and changing out of the Nhanes III conversionOR we can follow the second part of 7743 and use the newer corrected version of Nhanes III which ourunit offers too
If you have any questions you may contact me at anytime and I also have many references in regards toboth parts of 7743 if you would like to see them
55
Thank you~
April
Confidentiality NoticeThis message may contain information that isconfidential or privileged
If you are not the intended recipientPlease advise the sender immediately and delete this message
56
ATTACHMENT H
57
NFPA 1582 771(7) Proposed revisions
Why
Preliminary results of two prospective randomized trials on the PSA test were published in 2009 These studies resulted in medical organizations that previously providing guidance to modify their recommendations
Current language
771 Blood Tests Blood tests shall be performed annually and shall include the following
(7) Prostate specific antigen (PSA) after age 40 for positive family history if African American or if otherwise clinically indicated after age 50 for all other male member
Suggested Revision
771 Blood Tests Blood tests shall be performed annually and shall include the following
(7) Prostate specific antigen (PSA) after age 40 for positive family history if African American or if otherwise clinically indicated after age 50 for all other male member
772 Prostate-Specific Antigen (PSA) test At age 50 fire fighters shall have an opportunity to make an informed decision with either the Fire Department physician or their health care provider concerning the PSA test For fire fighters at increased risk of prostate cancer (African-Americans or those with a first degree relative diagnosed with prostate cancer before age 65) shall have the opportunity for this informed decision at age 40
A772 The PSA as a screening test for prostate cancer in asymptomatic men is controversial controversial for two reasons First there is no consensus that PSA screening actually saves lives For example the PSA test may detect small cancers that would never become life threatening Second it is unclear that the benefits of PSA screening outweigh the risks of follow-up diagnostic tests and cancer treatments For example the prostate biopsy used to diagnose prostate cancer may cause bleeding and infection And prostate cancer treatments such as surgery and radiation therapy may cause incontinence (inability to control urine flow) erectile dysfunction (erections inadequate for intercourse) and other complications For these reasons it is important that the benefits and risks of prostate diagnostic procedures and treatment be taken into account when considering the PSA screening test These considerations can be taken account during discussions with the fire department physician or onersquos health care provider
D211 Cancer Screening
Smith R A C J Mettlin K J Davis and H Eyre 2000 ldquoAmerican Cancer Society guidelines for the early detection of cancerrdquo CA J Clin 50(1)34ndash49
Added references
58
Carroll P Albertsen PC Greene K et al [2010] Prostate-specific antigen best practice statement 2009 update Am Urological Assoc Available at httpwwwauanetorgcontentguidelines-and-quality-careclinical-guidelinesmain-reportspsa09pdf Date accessed September 2010
Ferrini R Woolf SH [2009] Screening for prostate cancer in American men American College of Preventive Medicine Practice Policy Statement Available at httpwwwacpmorgprostatehtm Date accessed September 2010
National Cancer Institute [2009] Prostate-specific antigen test National Cancer Institute Fact Sheet Available at httpwwwcancergovcancertopicsfactsheetDetectionPSA Date accessed September 2010
Wolf AMD Wender RC Etzioni RB et al [2010] American Cancer Society guideline for the early detection of prostate cancer Update 2010 Available at httpcaonlineamcancersocorgcgicontentfullcaac20066v1 Date accessed September 2010
59
1
Current 1582 (2007) language in reference to pregnancy 43 (4) Report to the fire department physician any medical condition that could interfere with the ability of the individual to safely perform essential job tasks such as illness or injury use of prescription or nonprescription drugs and pregnancy 6112 Category B medical conditions shall include the following (1) Pregnancy for its duration A7792 (e) If HIV prophylaxis is to be given the following tests should be done i CBC ii Glucose renal and hepatic chemical function iii Pregnancy test for females B121 Pregnancy and Reproduction Federal regulations as well as many court decisions including the US Supreme Courtrsquos decision in International Union et al v Johnson Controls Inc [499 US 187 111 S Ct 1196 (1991)] have interpreted the requirements of Title VII with respect to pregnancy and reproduction The AHJ should seek the advice of counsel in resolving specific questions concerning these requirements as well as other requirements that can be imposed by state or local laws C211 (4) Review health status with the individual being evaluated Contraindications for evaluations shall be reviewed addressing any changes in the individualrsquos health status since their last medical evaluation that would warrant deferring the evaluation including (g) Pregnancy Recommendations to language enhancement
A female employee who is assigned to regular fire line duty shall report a pregnancy immediately to their respective Supervisor and the fire department physician The employee will then be given the option of a non-hazardous alternative duty position for the duration of her pregnancy (can we say this or is it even appropriate) Any pregnant employee wishing to remain on regular line duty shall be informed of the possible risks and consequences to herself and her fetus that are associated with continued line fire fighting duty Among those risk factors are exposure to teratogens known to have negative effects on the developing fetus such as smoke diesel fumes hazardous chemicals and extreme heat
49
Page 2
appendix It is recommended that the pregnant employee complete a release of liability form signed by herself and her health care provider utilizing NFPArsquos 13 critical tasks as a reference This will inform the health care provider of specific job-related tasks that will need to be performed in order to continue regular line duty These tasks are basic physical standards that any entry level firefighter would have to be able to complete competently The employeersquos health condition will be kept confidential by the department in accordance with HIPAA standards Employees are allowed to remain on active regular duty until they are no longer able to perform their duties in a reasonable manner andor their protective gear no longer fits correctly It is the responsibility of the health care provider to evaluate the pregnant employee If at any time the health care provider feels the pregnant employee can no longer perform the job related tasks this should be reported to the employer by the employee immediately
50
ATTACHMENT G
51
From GLENN BENARICKTo Sawyer SteveSubject RE RE 7743Date Monday August 30 2010 21633 PM
Yes thats my understanding
Glenn P Benarick 211 Winged Elm CircleAiken SC 29803803-644-7093gbenarprodigynet
--- On Mon 83010 Sawyer Steve ltssawyerNFPAorggt wrote
From Sawyer Steve ltssawyerNFPAorggtSubject RE RE 7743To GLENN BENARICK ltgbenarprodigynetgtDate Monday August 30 2010 212 PM
So it should be ldquoorrdquo instead of ldquoandrdquo for now
Steven F Sawyer
Senior Fire Service Specialist
Executive Secretary IFMAFire Service Section
NFPA
1 Batterymarch Park
Quincy MA 02169
6179847423
Fax 6179847056
ssawyernfpaorg
From GLENN BENARICK [mailtogbenarprodigynet] Sent Monday August 30 2010 1202 PMTo Sawyer SteveSubject Fw RE 7743
52
Steve a couple of our docs agree with April Boyer
Glenn P Benarick 211 Winged Elm Circle
Aiken SC 29803
803-644-7093
gbenarprodigynet
--- On Mon 83010 David Prezant ltprezandfdnynycgovgt wrote
From David Prezant ltprezandfdnynycgovgtSubject RE 7743To Thomas R (CDCNIOSHDSHEFS) Hales lttrh1cdcgovgt GLENNBENARICK ltgbenarprodigynetgtCc Sandy Bogucki ltsandyboguckiyaleedugtDate Monday August 30 2010 1004 AM
agree
we should change this to NHANES III rather than Knudson we should alsomodify this to allow not only for predicted cutoffs but all for use of thelower limit of normal cutoff This is important to prevent false-classificationof spirometry as abnormal in older groups and in taller grps The latter ofparticular import to firefighter occupational health surveillance
thanks
David Prezant MDChief Medical Officer Office of Medical AffairsCo-Director WTC Medical Monitoring amp Treatment ProgramsNew York City Fire Department9 Metrotech Center - Rm 4W-1Brooklyn NY 11201Phone 718-999-2696Fax 718-999-0665
Life is full of twists and turns
53
This email may contain confidential information If you are the unintendedrecipient of this email please send it back and delete from your directory
gtgtgt Hales Thomas R (CDCNIOSHDSHEFS) lttrh1cdcgovgt 8302010955 AM gtgtgt
Glen
This seems like a very reasonable comment and illustrates the importance of having clinicians providefeedback on the std Im not familiar with the software program of the various spirometers (NHANES IIIvs KnudsonATS vs both) Given the large role both Dave Prezant and Sandy Bogucki had for thepulmonary section let me forward to them for clarification
Tom
From GLENN BENARICK [mailtogbenarprodigynet] Sent Sunday August 29 2010 456 PMTo Hales Thomas R (CDCNIOSHDSHEFS)Subject FW 7743
Tom is April Boyer correct
Glenn P Benarick 211 Winged Elm Circle
Aiken SC 29803
803-644-7093
gbenarprodigynet
--- On Thu 82610 Sawyer Steve ltssawyerNFPAorggt wrote
From Sawyer Steve ltssawyerNFPAorggtSubject FW 7743To GLENN BENARICK ltgbenarprodigynetgtDate Thursday August 26 2010 925 PM
FYI Do you have any answer She is write
Steven
54
Steven F Sawyer
Senior Fire Service Specialist
Executive Secretary IFMAFire Service Section
NFPA
1 Batterymarch Park
Quincy MA 02169
6179847423
Fax 6179847056
ssawyernfpaorg
From April Boyer [mailtoaboyerbicclinicorg] Sent Thursday August 26 2010 232 PMTo Sawyer SteveCc RobinMWebbmilstateorusSubject 7743
Steven
The spirometry tests cannot be corrected according to both references as the NFPA states because thereferences are contradictory The first part of 7743 states to follow the ATS guidelines and use theKnudsen (we at Basin Immediate Care use the Nhanes III) The second part states to follow the ACOEMguidelines and use the Nhanes III in the occupational setting if available with your unit (which is availableon ours) 7743 does not use the word OR regarding both requirements it uses the word AND whenreferring to the first and second parts thence making 7743 contradictory I realize the NFPA 1582 hasnot been updated since 2007 unless I have just not received an updated version
Our question to you is which part of 7743 do you want us to follow the first or the second part Anyfacility that has an updated computerized spirometry system (as we do) will not be able to follow bothrequired parts for obvious reasons We can either follow the first part of 7743 and use an oldercorrected version of the Knudson by going into our system and changing out of the Nhanes III conversionOR we can follow the second part of 7743 and use the newer corrected version of Nhanes III which ourunit offers too
If you have any questions you may contact me at anytime and I also have many references in regards toboth parts of 7743 if you would like to see them
55
Thank you~
April
Confidentiality NoticeThis message may contain information that isconfidential or privileged
If you are not the intended recipientPlease advise the sender immediately and delete this message
56
ATTACHMENT H
57
NFPA 1582 771(7) Proposed revisions
Why
Preliminary results of two prospective randomized trials on the PSA test were published in 2009 These studies resulted in medical organizations that previously providing guidance to modify their recommendations
Current language
771 Blood Tests Blood tests shall be performed annually and shall include the following
(7) Prostate specific antigen (PSA) after age 40 for positive family history if African American or if otherwise clinically indicated after age 50 for all other male member
Suggested Revision
771 Blood Tests Blood tests shall be performed annually and shall include the following
(7) Prostate specific antigen (PSA) after age 40 for positive family history if African American or if otherwise clinically indicated after age 50 for all other male member
772 Prostate-Specific Antigen (PSA) test At age 50 fire fighters shall have an opportunity to make an informed decision with either the Fire Department physician or their health care provider concerning the PSA test For fire fighters at increased risk of prostate cancer (African-Americans or those with a first degree relative diagnosed with prostate cancer before age 65) shall have the opportunity for this informed decision at age 40
A772 The PSA as a screening test for prostate cancer in asymptomatic men is controversial controversial for two reasons First there is no consensus that PSA screening actually saves lives For example the PSA test may detect small cancers that would never become life threatening Second it is unclear that the benefits of PSA screening outweigh the risks of follow-up diagnostic tests and cancer treatments For example the prostate biopsy used to diagnose prostate cancer may cause bleeding and infection And prostate cancer treatments such as surgery and radiation therapy may cause incontinence (inability to control urine flow) erectile dysfunction (erections inadequate for intercourse) and other complications For these reasons it is important that the benefits and risks of prostate diagnostic procedures and treatment be taken into account when considering the PSA screening test These considerations can be taken account during discussions with the fire department physician or onersquos health care provider
D211 Cancer Screening
Smith R A C J Mettlin K J Davis and H Eyre 2000 ldquoAmerican Cancer Society guidelines for the early detection of cancerrdquo CA J Clin 50(1)34ndash49
Added references
58
Carroll P Albertsen PC Greene K et al [2010] Prostate-specific antigen best practice statement 2009 update Am Urological Assoc Available at httpwwwauanetorgcontentguidelines-and-quality-careclinical-guidelinesmain-reportspsa09pdf Date accessed September 2010
Ferrini R Woolf SH [2009] Screening for prostate cancer in American men American College of Preventive Medicine Practice Policy Statement Available at httpwwwacpmorgprostatehtm Date accessed September 2010
National Cancer Institute [2009] Prostate-specific antigen test National Cancer Institute Fact Sheet Available at httpwwwcancergovcancertopicsfactsheetDetectionPSA Date accessed September 2010
Wolf AMD Wender RC Etzioni RB et al [2010] American Cancer Society guideline for the early detection of prostate cancer Update 2010 Available at httpcaonlineamcancersocorgcgicontentfullcaac20066v1 Date accessed September 2010
59
Page 2
appendix It is recommended that the pregnant employee complete a release of liability form signed by herself and her health care provider utilizing NFPArsquos 13 critical tasks as a reference This will inform the health care provider of specific job-related tasks that will need to be performed in order to continue regular line duty These tasks are basic physical standards that any entry level firefighter would have to be able to complete competently The employeersquos health condition will be kept confidential by the department in accordance with HIPAA standards Employees are allowed to remain on active regular duty until they are no longer able to perform their duties in a reasonable manner andor their protective gear no longer fits correctly It is the responsibility of the health care provider to evaluate the pregnant employee If at any time the health care provider feels the pregnant employee can no longer perform the job related tasks this should be reported to the employer by the employee immediately
50
ATTACHMENT G
51
From GLENN BENARICKTo Sawyer SteveSubject RE RE 7743Date Monday August 30 2010 21633 PM
Yes thats my understanding
Glenn P Benarick 211 Winged Elm CircleAiken SC 29803803-644-7093gbenarprodigynet
--- On Mon 83010 Sawyer Steve ltssawyerNFPAorggt wrote
From Sawyer Steve ltssawyerNFPAorggtSubject RE RE 7743To GLENN BENARICK ltgbenarprodigynetgtDate Monday August 30 2010 212 PM
So it should be ldquoorrdquo instead of ldquoandrdquo for now
Steven F Sawyer
Senior Fire Service Specialist
Executive Secretary IFMAFire Service Section
NFPA
1 Batterymarch Park
Quincy MA 02169
6179847423
Fax 6179847056
ssawyernfpaorg
From GLENN BENARICK [mailtogbenarprodigynet] Sent Monday August 30 2010 1202 PMTo Sawyer SteveSubject Fw RE 7743
52
Steve a couple of our docs agree with April Boyer
Glenn P Benarick 211 Winged Elm Circle
Aiken SC 29803
803-644-7093
gbenarprodigynet
--- On Mon 83010 David Prezant ltprezandfdnynycgovgt wrote
From David Prezant ltprezandfdnynycgovgtSubject RE 7743To Thomas R (CDCNIOSHDSHEFS) Hales lttrh1cdcgovgt GLENNBENARICK ltgbenarprodigynetgtCc Sandy Bogucki ltsandyboguckiyaleedugtDate Monday August 30 2010 1004 AM
agree
we should change this to NHANES III rather than Knudson we should alsomodify this to allow not only for predicted cutoffs but all for use of thelower limit of normal cutoff This is important to prevent false-classificationof spirometry as abnormal in older groups and in taller grps The latter ofparticular import to firefighter occupational health surveillance
thanks
David Prezant MDChief Medical Officer Office of Medical AffairsCo-Director WTC Medical Monitoring amp Treatment ProgramsNew York City Fire Department9 Metrotech Center - Rm 4W-1Brooklyn NY 11201Phone 718-999-2696Fax 718-999-0665
Life is full of twists and turns
53
This email may contain confidential information If you are the unintendedrecipient of this email please send it back and delete from your directory
gtgtgt Hales Thomas R (CDCNIOSHDSHEFS) lttrh1cdcgovgt 8302010955 AM gtgtgt
Glen
This seems like a very reasonable comment and illustrates the importance of having clinicians providefeedback on the std Im not familiar with the software program of the various spirometers (NHANES IIIvs KnudsonATS vs both) Given the large role both Dave Prezant and Sandy Bogucki had for thepulmonary section let me forward to them for clarification
Tom
From GLENN BENARICK [mailtogbenarprodigynet] Sent Sunday August 29 2010 456 PMTo Hales Thomas R (CDCNIOSHDSHEFS)Subject FW 7743
Tom is April Boyer correct
Glenn P Benarick 211 Winged Elm Circle
Aiken SC 29803
803-644-7093
gbenarprodigynet
--- On Thu 82610 Sawyer Steve ltssawyerNFPAorggt wrote
From Sawyer Steve ltssawyerNFPAorggtSubject FW 7743To GLENN BENARICK ltgbenarprodigynetgtDate Thursday August 26 2010 925 PM
FYI Do you have any answer She is write
Steven
54
Steven F Sawyer
Senior Fire Service Specialist
Executive Secretary IFMAFire Service Section
NFPA
1 Batterymarch Park
Quincy MA 02169
6179847423
Fax 6179847056
ssawyernfpaorg
From April Boyer [mailtoaboyerbicclinicorg] Sent Thursday August 26 2010 232 PMTo Sawyer SteveCc RobinMWebbmilstateorusSubject 7743
Steven
The spirometry tests cannot be corrected according to both references as the NFPA states because thereferences are contradictory The first part of 7743 states to follow the ATS guidelines and use theKnudsen (we at Basin Immediate Care use the Nhanes III) The second part states to follow the ACOEMguidelines and use the Nhanes III in the occupational setting if available with your unit (which is availableon ours) 7743 does not use the word OR regarding both requirements it uses the word AND whenreferring to the first and second parts thence making 7743 contradictory I realize the NFPA 1582 hasnot been updated since 2007 unless I have just not received an updated version
Our question to you is which part of 7743 do you want us to follow the first or the second part Anyfacility that has an updated computerized spirometry system (as we do) will not be able to follow bothrequired parts for obvious reasons We can either follow the first part of 7743 and use an oldercorrected version of the Knudson by going into our system and changing out of the Nhanes III conversionOR we can follow the second part of 7743 and use the newer corrected version of Nhanes III which ourunit offers too
If you have any questions you may contact me at anytime and I also have many references in regards toboth parts of 7743 if you would like to see them
55
Thank you~
April
Confidentiality NoticeThis message may contain information that isconfidential or privileged
If you are not the intended recipientPlease advise the sender immediately and delete this message
56
ATTACHMENT H
57
NFPA 1582 771(7) Proposed revisions
Why
Preliminary results of two prospective randomized trials on the PSA test were published in 2009 These studies resulted in medical organizations that previously providing guidance to modify their recommendations
Current language
771 Blood Tests Blood tests shall be performed annually and shall include the following
(7) Prostate specific antigen (PSA) after age 40 for positive family history if African American or if otherwise clinically indicated after age 50 for all other male member
Suggested Revision
771 Blood Tests Blood tests shall be performed annually and shall include the following
(7) Prostate specific antigen (PSA) after age 40 for positive family history if African American or if otherwise clinically indicated after age 50 for all other male member
772 Prostate-Specific Antigen (PSA) test At age 50 fire fighters shall have an opportunity to make an informed decision with either the Fire Department physician or their health care provider concerning the PSA test For fire fighters at increased risk of prostate cancer (African-Americans or those with a first degree relative diagnosed with prostate cancer before age 65) shall have the opportunity for this informed decision at age 40
A772 The PSA as a screening test for prostate cancer in asymptomatic men is controversial controversial for two reasons First there is no consensus that PSA screening actually saves lives For example the PSA test may detect small cancers that would never become life threatening Second it is unclear that the benefits of PSA screening outweigh the risks of follow-up diagnostic tests and cancer treatments For example the prostate biopsy used to diagnose prostate cancer may cause bleeding and infection And prostate cancer treatments such as surgery and radiation therapy may cause incontinence (inability to control urine flow) erectile dysfunction (erections inadequate for intercourse) and other complications For these reasons it is important that the benefits and risks of prostate diagnostic procedures and treatment be taken into account when considering the PSA screening test These considerations can be taken account during discussions with the fire department physician or onersquos health care provider
D211 Cancer Screening
Smith R A C J Mettlin K J Davis and H Eyre 2000 ldquoAmerican Cancer Society guidelines for the early detection of cancerrdquo CA J Clin 50(1)34ndash49
Added references
58
Carroll P Albertsen PC Greene K et al [2010] Prostate-specific antigen best practice statement 2009 update Am Urological Assoc Available at httpwwwauanetorgcontentguidelines-and-quality-careclinical-guidelinesmain-reportspsa09pdf Date accessed September 2010
Ferrini R Woolf SH [2009] Screening for prostate cancer in American men American College of Preventive Medicine Practice Policy Statement Available at httpwwwacpmorgprostatehtm Date accessed September 2010
National Cancer Institute [2009] Prostate-specific antigen test National Cancer Institute Fact Sheet Available at httpwwwcancergovcancertopicsfactsheetDetectionPSA Date accessed September 2010
Wolf AMD Wender RC Etzioni RB et al [2010] American Cancer Society guideline for the early detection of prostate cancer Update 2010 Available at httpcaonlineamcancersocorgcgicontentfullcaac20066v1 Date accessed September 2010
59
ATTACHMENT G
51
From GLENN BENARICKTo Sawyer SteveSubject RE RE 7743Date Monday August 30 2010 21633 PM
Yes thats my understanding
Glenn P Benarick 211 Winged Elm CircleAiken SC 29803803-644-7093gbenarprodigynet
--- On Mon 83010 Sawyer Steve ltssawyerNFPAorggt wrote
From Sawyer Steve ltssawyerNFPAorggtSubject RE RE 7743To GLENN BENARICK ltgbenarprodigynetgtDate Monday August 30 2010 212 PM
So it should be ldquoorrdquo instead of ldquoandrdquo for now
Steven F Sawyer
Senior Fire Service Specialist
Executive Secretary IFMAFire Service Section
NFPA
1 Batterymarch Park
Quincy MA 02169
6179847423
Fax 6179847056
ssawyernfpaorg
From GLENN BENARICK [mailtogbenarprodigynet] Sent Monday August 30 2010 1202 PMTo Sawyer SteveSubject Fw RE 7743
52
Steve a couple of our docs agree with April Boyer
Glenn P Benarick 211 Winged Elm Circle
Aiken SC 29803
803-644-7093
gbenarprodigynet
--- On Mon 83010 David Prezant ltprezandfdnynycgovgt wrote
From David Prezant ltprezandfdnynycgovgtSubject RE 7743To Thomas R (CDCNIOSHDSHEFS) Hales lttrh1cdcgovgt GLENNBENARICK ltgbenarprodigynetgtCc Sandy Bogucki ltsandyboguckiyaleedugtDate Monday August 30 2010 1004 AM
agree
we should change this to NHANES III rather than Knudson we should alsomodify this to allow not only for predicted cutoffs but all for use of thelower limit of normal cutoff This is important to prevent false-classificationof spirometry as abnormal in older groups and in taller grps The latter ofparticular import to firefighter occupational health surveillance
thanks
David Prezant MDChief Medical Officer Office of Medical AffairsCo-Director WTC Medical Monitoring amp Treatment ProgramsNew York City Fire Department9 Metrotech Center - Rm 4W-1Brooklyn NY 11201Phone 718-999-2696Fax 718-999-0665
Life is full of twists and turns
53
This email may contain confidential information If you are the unintendedrecipient of this email please send it back and delete from your directory
gtgtgt Hales Thomas R (CDCNIOSHDSHEFS) lttrh1cdcgovgt 8302010955 AM gtgtgt
Glen
This seems like a very reasonable comment and illustrates the importance of having clinicians providefeedback on the std Im not familiar with the software program of the various spirometers (NHANES IIIvs KnudsonATS vs both) Given the large role both Dave Prezant and Sandy Bogucki had for thepulmonary section let me forward to them for clarification
Tom
From GLENN BENARICK [mailtogbenarprodigynet] Sent Sunday August 29 2010 456 PMTo Hales Thomas R (CDCNIOSHDSHEFS)Subject FW 7743
Tom is April Boyer correct
Glenn P Benarick 211 Winged Elm Circle
Aiken SC 29803
803-644-7093
gbenarprodigynet
--- On Thu 82610 Sawyer Steve ltssawyerNFPAorggt wrote
From Sawyer Steve ltssawyerNFPAorggtSubject FW 7743To GLENN BENARICK ltgbenarprodigynetgtDate Thursday August 26 2010 925 PM
FYI Do you have any answer She is write
Steven
54
Steven F Sawyer
Senior Fire Service Specialist
Executive Secretary IFMAFire Service Section
NFPA
1 Batterymarch Park
Quincy MA 02169
6179847423
Fax 6179847056
ssawyernfpaorg
From April Boyer [mailtoaboyerbicclinicorg] Sent Thursday August 26 2010 232 PMTo Sawyer SteveCc RobinMWebbmilstateorusSubject 7743
Steven
The spirometry tests cannot be corrected according to both references as the NFPA states because thereferences are contradictory The first part of 7743 states to follow the ATS guidelines and use theKnudsen (we at Basin Immediate Care use the Nhanes III) The second part states to follow the ACOEMguidelines and use the Nhanes III in the occupational setting if available with your unit (which is availableon ours) 7743 does not use the word OR regarding both requirements it uses the word AND whenreferring to the first and second parts thence making 7743 contradictory I realize the NFPA 1582 hasnot been updated since 2007 unless I have just not received an updated version
Our question to you is which part of 7743 do you want us to follow the first or the second part Anyfacility that has an updated computerized spirometry system (as we do) will not be able to follow bothrequired parts for obvious reasons We can either follow the first part of 7743 and use an oldercorrected version of the Knudson by going into our system and changing out of the Nhanes III conversionOR we can follow the second part of 7743 and use the newer corrected version of Nhanes III which ourunit offers too
If you have any questions you may contact me at anytime and I also have many references in regards toboth parts of 7743 if you would like to see them
55
Thank you~
April
Confidentiality NoticeThis message may contain information that isconfidential or privileged
If you are not the intended recipientPlease advise the sender immediately and delete this message
56
ATTACHMENT H
57
NFPA 1582 771(7) Proposed revisions
Why
Preliminary results of two prospective randomized trials on the PSA test were published in 2009 These studies resulted in medical organizations that previously providing guidance to modify their recommendations
Current language
771 Blood Tests Blood tests shall be performed annually and shall include the following
(7) Prostate specific antigen (PSA) after age 40 for positive family history if African American or if otherwise clinically indicated after age 50 for all other male member
Suggested Revision
771 Blood Tests Blood tests shall be performed annually and shall include the following
(7) Prostate specific antigen (PSA) after age 40 for positive family history if African American or if otherwise clinically indicated after age 50 for all other male member
772 Prostate-Specific Antigen (PSA) test At age 50 fire fighters shall have an opportunity to make an informed decision with either the Fire Department physician or their health care provider concerning the PSA test For fire fighters at increased risk of prostate cancer (African-Americans or those with a first degree relative diagnosed with prostate cancer before age 65) shall have the opportunity for this informed decision at age 40
A772 The PSA as a screening test for prostate cancer in asymptomatic men is controversial controversial for two reasons First there is no consensus that PSA screening actually saves lives For example the PSA test may detect small cancers that would never become life threatening Second it is unclear that the benefits of PSA screening outweigh the risks of follow-up diagnostic tests and cancer treatments For example the prostate biopsy used to diagnose prostate cancer may cause bleeding and infection And prostate cancer treatments such as surgery and radiation therapy may cause incontinence (inability to control urine flow) erectile dysfunction (erections inadequate for intercourse) and other complications For these reasons it is important that the benefits and risks of prostate diagnostic procedures and treatment be taken into account when considering the PSA screening test These considerations can be taken account during discussions with the fire department physician or onersquos health care provider
D211 Cancer Screening
Smith R A C J Mettlin K J Davis and H Eyre 2000 ldquoAmerican Cancer Society guidelines for the early detection of cancerrdquo CA J Clin 50(1)34ndash49
Added references
58
Carroll P Albertsen PC Greene K et al [2010] Prostate-specific antigen best practice statement 2009 update Am Urological Assoc Available at httpwwwauanetorgcontentguidelines-and-quality-careclinical-guidelinesmain-reportspsa09pdf Date accessed September 2010
Ferrini R Woolf SH [2009] Screening for prostate cancer in American men American College of Preventive Medicine Practice Policy Statement Available at httpwwwacpmorgprostatehtm Date accessed September 2010
National Cancer Institute [2009] Prostate-specific antigen test National Cancer Institute Fact Sheet Available at httpwwwcancergovcancertopicsfactsheetDetectionPSA Date accessed September 2010
Wolf AMD Wender RC Etzioni RB et al [2010] American Cancer Society guideline for the early detection of prostate cancer Update 2010 Available at httpcaonlineamcancersocorgcgicontentfullcaac20066v1 Date accessed September 2010
59
From GLENN BENARICKTo Sawyer SteveSubject RE RE 7743Date Monday August 30 2010 21633 PM
Yes thats my understanding
Glenn P Benarick 211 Winged Elm CircleAiken SC 29803803-644-7093gbenarprodigynet
--- On Mon 83010 Sawyer Steve ltssawyerNFPAorggt wrote
From Sawyer Steve ltssawyerNFPAorggtSubject RE RE 7743To GLENN BENARICK ltgbenarprodigynetgtDate Monday August 30 2010 212 PM
So it should be ldquoorrdquo instead of ldquoandrdquo for now
Steven F Sawyer
Senior Fire Service Specialist
Executive Secretary IFMAFire Service Section
NFPA
1 Batterymarch Park
Quincy MA 02169
6179847423
Fax 6179847056
ssawyernfpaorg
From GLENN BENARICK [mailtogbenarprodigynet] Sent Monday August 30 2010 1202 PMTo Sawyer SteveSubject Fw RE 7743
52
Steve a couple of our docs agree with April Boyer
Glenn P Benarick 211 Winged Elm Circle
Aiken SC 29803
803-644-7093
gbenarprodigynet
--- On Mon 83010 David Prezant ltprezandfdnynycgovgt wrote
From David Prezant ltprezandfdnynycgovgtSubject RE 7743To Thomas R (CDCNIOSHDSHEFS) Hales lttrh1cdcgovgt GLENNBENARICK ltgbenarprodigynetgtCc Sandy Bogucki ltsandyboguckiyaleedugtDate Monday August 30 2010 1004 AM
agree
we should change this to NHANES III rather than Knudson we should alsomodify this to allow not only for predicted cutoffs but all for use of thelower limit of normal cutoff This is important to prevent false-classificationof spirometry as abnormal in older groups and in taller grps The latter ofparticular import to firefighter occupational health surveillance
thanks
David Prezant MDChief Medical Officer Office of Medical AffairsCo-Director WTC Medical Monitoring amp Treatment ProgramsNew York City Fire Department9 Metrotech Center - Rm 4W-1Brooklyn NY 11201Phone 718-999-2696Fax 718-999-0665
Life is full of twists and turns
53
This email may contain confidential information If you are the unintendedrecipient of this email please send it back and delete from your directory
gtgtgt Hales Thomas R (CDCNIOSHDSHEFS) lttrh1cdcgovgt 8302010955 AM gtgtgt
Glen
This seems like a very reasonable comment and illustrates the importance of having clinicians providefeedback on the std Im not familiar with the software program of the various spirometers (NHANES IIIvs KnudsonATS vs both) Given the large role both Dave Prezant and Sandy Bogucki had for thepulmonary section let me forward to them for clarification
Tom
From GLENN BENARICK [mailtogbenarprodigynet] Sent Sunday August 29 2010 456 PMTo Hales Thomas R (CDCNIOSHDSHEFS)Subject FW 7743
Tom is April Boyer correct
Glenn P Benarick 211 Winged Elm Circle
Aiken SC 29803
803-644-7093
gbenarprodigynet
--- On Thu 82610 Sawyer Steve ltssawyerNFPAorggt wrote
From Sawyer Steve ltssawyerNFPAorggtSubject FW 7743To GLENN BENARICK ltgbenarprodigynetgtDate Thursday August 26 2010 925 PM
FYI Do you have any answer She is write
Steven
54
Steven F Sawyer
Senior Fire Service Specialist
Executive Secretary IFMAFire Service Section
NFPA
1 Batterymarch Park
Quincy MA 02169
6179847423
Fax 6179847056
ssawyernfpaorg
From April Boyer [mailtoaboyerbicclinicorg] Sent Thursday August 26 2010 232 PMTo Sawyer SteveCc RobinMWebbmilstateorusSubject 7743
Steven
The spirometry tests cannot be corrected according to both references as the NFPA states because thereferences are contradictory The first part of 7743 states to follow the ATS guidelines and use theKnudsen (we at Basin Immediate Care use the Nhanes III) The second part states to follow the ACOEMguidelines and use the Nhanes III in the occupational setting if available with your unit (which is availableon ours) 7743 does not use the word OR regarding both requirements it uses the word AND whenreferring to the first and second parts thence making 7743 contradictory I realize the NFPA 1582 hasnot been updated since 2007 unless I have just not received an updated version
Our question to you is which part of 7743 do you want us to follow the first or the second part Anyfacility that has an updated computerized spirometry system (as we do) will not be able to follow bothrequired parts for obvious reasons We can either follow the first part of 7743 and use an oldercorrected version of the Knudson by going into our system and changing out of the Nhanes III conversionOR we can follow the second part of 7743 and use the newer corrected version of Nhanes III which ourunit offers too
If you have any questions you may contact me at anytime and I also have many references in regards toboth parts of 7743 if you would like to see them
55
Thank you~
April
Confidentiality NoticeThis message may contain information that isconfidential or privileged
If you are not the intended recipientPlease advise the sender immediately and delete this message
56
ATTACHMENT H
57
NFPA 1582 771(7) Proposed revisions
Why
Preliminary results of two prospective randomized trials on the PSA test were published in 2009 These studies resulted in medical organizations that previously providing guidance to modify their recommendations
Current language
771 Blood Tests Blood tests shall be performed annually and shall include the following
(7) Prostate specific antigen (PSA) after age 40 for positive family history if African American or if otherwise clinically indicated after age 50 for all other male member
Suggested Revision
771 Blood Tests Blood tests shall be performed annually and shall include the following
(7) Prostate specific antigen (PSA) after age 40 for positive family history if African American or if otherwise clinically indicated after age 50 for all other male member
772 Prostate-Specific Antigen (PSA) test At age 50 fire fighters shall have an opportunity to make an informed decision with either the Fire Department physician or their health care provider concerning the PSA test For fire fighters at increased risk of prostate cancer (African-Americans or those with a first degree relative diagnosed with prostate cancer before age 65) shall have the opportunity for this informed decision at age 40
A772 The PSA as a screening test for prostate cancer in asymptomatic men is controversial controversial for two reasons First there is no consensus that PSA screening actually saves lives For example the PSA test may detect small cancers that would never become life threatening Second it is unclear that the benefits of PSA screening outweigh the risks of follow-up diagnostic tests and cancer treatments For example the prostate biopsy used to diagnose prostate cancer may cause bleeding and infection And prostate cancer treatments such as surgery and radiation therapy may cause incontinence (inability to control urine flow) erectile dysfunction (erections inadequate for intercourse) and other complications For these reasons it is important that the benefits and risks of prostate diagnostic procedures and treatment be taken into account when considering the PSA screening test These considerations can be taken account during discussions with the fire department physician or onersquos health care provider
D211 Cancer Screening
Smith R A C J Mettlin K J Davis and H Eyre 2000 ldquoAmerican Cancer Society guidelines for the early detection of cancerrdquo CA J Clin 50(1)34ndash49
Added references
58
Carroll P Albertsen PC Greene K et al [2010] Prostate-specific antigen best practice statement 2009 update Am Urological Assoc Available at httpwwwauanetorgcontentguidelines-and-quality-careclinical-guidelinesmain-reportspsa09pdf Date accessed September 2010
Ferrini R Woolf SH [2009] Screening for prostate cancer in American men American College of Preventive Medicine Practice Policy Statement Available at httpwwwacpmorgprostatehtm Date accessed September 2010
National Cancer Institute [2009] Prostate-specific antigen test National Cancer Institute Fact Sheet Available at httpwwwcancergovcancertopicsfactsheetDetectionPSA Date accessed September 2010
Wolf AMD Wender RC Etzioni RB et al [2010] American Cancer Society guideline for the early detection of prostate cancer Update 2010 Available at httpcaonlineamcancersocorgcgicontentfullcaac20066v1 Date accessed September 2010
59
Steve a couple of our docs agree with April Boyer
Glenn P Benarick 211 Winged Elm Circle
Aiken SC 29803
803-644-7093
gbenarprodigynet
--- On Mon 83010 David Prezant ltprezandfdnynycgovgt wrote
From David Prezant ltprezandfdnynycgovgtSubject RE 7743To Thomas R (CDCNIOSHDSHEFS) Hales lttrh1cdcgovgt GLENNBENARICK ltgbenarprodigynetgtCc Sandy Bogucki ltsandyboguckiyaleedugtDate Monday August 30 2010 1004 AM
agree
we should change this to NHANES III rather than Knudson we should alsomodify this to allow not only for predicted cutoffs but all for use of thelower limit of normal cutoff This is important to prevent false-classificationof spirometry as abnormal in older groups and in taller grps The latter ofparticular import to firefighter occupational health surveillance
thanks
David Prezant MDChief Medical Officer Office of Medical AffairsCo-Director WTC Medical Monitoring amp Treatment ProgramsNew York City Fire Department9 Metrotech Center - Rm 4W-1Brooklyn NY 11201Phone 718-999-2696Fax 718-999-0665
Life is full of twists and turns
53
This email may contain confidential information If you are the unintendedrecipient of this email please send it back and delete from your directory
gtgtgt Hales Thomas R (CDCNIOSHDSHEFS) lttrh1cdcgovgt 8302010955 AM gtgtgt
Glen
This seems like a very reasonable comment and illustrates the importance of having clinicians providefeedback on the std Im not familiar with the software program of the various spirometers (NHANES IIIvs KnudsonATS vs both) Given the large role both Dave Prezant and Sandy Bogucki had for thepulmonary section let me forward to them for clarification
Tom
From GLENN BENARICK [mailtogbenarprodigynet] Sent Sunday August 29 2010 456 PMTo Hales Thomas R (CDCNIOSHDSHEFS)Subject FW 7743
Tom is April Boyer correct
Glenn P Benarick 211 Winged Elm Circle
Aiken SC 29803
803-644-7093
gbenarprodigynet
--- On Thu 82610 Sawyer Steve ltssawyerNFPAorggt wrote
From Sawyer Steve ltssawyerNFPAorggtSubject FW 7743To GLENN BENARICK ltgbenarprodigynetgtDate Thursday August 26 2010 925 PM
FYI Do you have any answer She is write
Steven
54
Steven F Sawyer
Senior Fire Service Specialist
Executive Secretary IFMAFire Service Section
NFPA
1 Batterymarch Park
Quincy MA 02169
6179847423
Fax 6179847056
ssawyernfpaorg
From April Boyer [mailtoaboyerbicclinicorg] Sent Thursday August 26 2010 232 PMTo Sawyer SteveCc RobinMWebbmilstateorusSubject 7743
Steven
The spirometry tests cannot be corrected according to both references as the NFPA states because thereferences are contradictory The first part of 7743 states to follow the ATS guidelines and use theKnudsen (we at Basin Immediate Care use the Nhanes III) The second part states to follow the ACOEMguidelines and use the Nhanes III in the occupational setting if available with your unit (which is availableon ours) 7743 does not use the word OR regarding both requirements it uses the word AND whenreferring to the first and second parts thence making 7743 contradictory I realize the NFPA 1582 hasnot been updated since 2007 unless I have just not received an updated version
Our question to you is which part of 7743 do you want us to follow the first or the second part Anyfacility that has an updated computerized spirometry system (as we do) will not be able to follow bothrequired parts for obvious reasons We can either follow the first part of 7743 and use an oldercorrected version of the Knudson by going into our system and changing out of the Nhanes III conversionOR we can follow the second part of 7743 and use the newer corrected version of Nhanes III which ourunit offers too
If you have any questions you may contact me at anytime and I also have many references in regards toboth parts of 7743 if you would like to see them
55
Thank you~
April
Confidentiality NoticeThis message may contain information that isconfidential or privileged
If you are not the intended recipientPlease advise the sender immediately and delete this message
56
ATTACHMENT H
57
NFPA 1582 771(7) Proposed revisions
Why
Preliminary results of two prospective randomized trials on the PSA test were published in 2009 These studies resulted in medical organizations that previously providing guidance to modify their recommendations
Current language
771 Blood Tests Blood tests shall be performed annually and shall include the following
(7) Prostate specific antigen (PSA) after age 40 for positive family history if African American or if otherwise clinically indicated after age 50 for all other male member
Suggested Revision
771 Blood Tests Blood tests shall be performed annually and shall include the following
(7) Prostate specific antigen (PSA) after age 40 for positive family history if African American or if otherwise clinically indicated after age 50 for all other male member
772 Prostate-Specific Antigen (PSA) test At age 50 fire fighters shall have an opportunity to make an informed decision with either the Fire Department physician or their health care provider concerning the PSA test For fire fighters at increased risk of prostate cancer (African-Americans or those with a first degree relative diagnosed with prostate cancer before age 65) shall have the opportunity for this informed decision at age 40
A772 The PSA as a screening test for prostate cancer in asymptomatic men is controversial controversial for two reasons First there is no consensus that PSA screening actually saves lives For example the PSA test may detect small cancers that would never become life threatening Second it is unclear that the benefits of PSA screening outweigh the risks of follow-up diagnostic tests and cancer treatments For example the prostate biopsy used to diagnose prostate cancer may cause bleeding and infection And prostate cancer treatments such as surgery and radiation therapy may cause incontinence (inability to control urine flow) erectile dysfunction (erections inadequate for intercourse) and other complications For these reasons it is important that the benefits and risks of prostate diagnostic procedures and treatment be taken into account when considering the PSA screening test These considerations can be taken account during discussions with the fire department physician or onersquos health care provider
D211 Cancer Screening
Smith R A C J Mettlin K J Davis and H Eyre 2000 ldquoAmerican Cancer Society guidelines for the early detection of cancerrdquo CA J Clin 50(1)34ndash49
Added references
58
Carroll P Albertsen PC Greene K et al [2010] Prostate-specific antigen best practice statement 2009 update Am Urological Assoc Available at httpwwwauanetorgcontentguidelines-and-quality-careclinical-guidelinesmain-reportspsa09pdf Date accessed September 2010
Ferrini R Woolf SH [2009] Screening for prostate cancer in American men American College of Preventive Medicine Practice Policy Statement Available at httpwwwacpmorgprostatehtm Date accessed September 2010
National Cancer Institute [2009] Prostate-specific antigen test National Cancer Institute Fact Sheet Available at httpwwwcancergovcancertopicsfactsheetDetectionPSA Date accessed September 2010
Wolf AMD Wender RC Etzioni RB et al [2010] American Cancer Society guideline for the early detection of prostate cancer Update 2010 Available at httpcaonlineamcancersocorgcgicontentfullcaac20066v1 Date accessed September 2010
59
This email may contain confidential information If you are the unintendedrecipient of this email please send it back and delete from your directory
gtgtgt Hales Thomas R (CDCNIOSHDSHEFS) lttrh1cdcgovgt 8302010955 AM gtgtgt
Glen
This seems like a very reasonable comment and illustrates the importance of having clinicians providefeedback on the std Im not familiar with the software program of the various spirometers (NHANES IIIvs KnudsonATS vs both) Given the large role both Dave Prezant and Sandy Bogucki had for thepulmonary section let me forward to them for clarification
Tom
From GLENN BENARICK [mailtogbenarprodigynet] Sent Sunday August 29 2010 456 PMTo Hales Thomas R (CDCNIOSHDSHEFS)Subject FW 7743
Tom is April Boyer correct
Glenn P Benarick 211 Winged Elm Circle
Aiken SC 29803
803-644-7093
gbenarprodigynet
--- On Thu 82610 Sawyer Steve ltssawyerNFPAorggt wrote
From Sawyer Steve ltssawyerNFPAorggtSubject FW 7743To GLENN BENARICK ltgbenarprodigynetgtDate Thursday August 26 2010 925 PM
FYI Do you have any answer She is write
Steven
54
Steven F Sawyer
Senior Fire Service Specialist
Executive Secretary IFMAFire Service Section
NFPA
1 Batterymarch Park
Quincy MA 02169
6179847423
Fax 6179847056
ssawyernfpaorg
From April Boyer [mailtoaboyerbicclinicorg] Sent Thursday August 26 2010 232 PMTo Sawyer SteveCc RobinMWebbmilstateorusSubject 7743
Steven
The spirometry tests cannot be corrected according to both references as the NFPA states because thereferences are contradictory The first part of 7743 states to follow the ATS guidelines and use theKnudsen (we at Basin Immediate Care use the Nhanes III) The second part states to follow the ACOEMguidelines and use the Nhanes III in the occupational setting if available with your unit (which is availableon ours) 7743 does not use the word OR regarding both requirements it uses the word AND whenreferring to the first and second parts thence making 7743 contradictory I realize the NFPA 1582 hasnot been updated since 2007 unless I have just not received an updated version
Our question to you is which part of 7743 do you want us to follow the first or the second part Anyfacility that has an updated computerized spirometry system (as we do) will not be able to follow bothrequired parts for obvious reasons We can either follow the first part of 7743 and use an oldercorrected version of the Knudson by going into our system and changing out of the Nhanes III conversionOR we can follow the second part of 7743 and use the newer corrected version of Nhanes III which ourunit offers too
If you have any questions you may contact me at anytime and I also have many references in regards toboth parts of 7743 if you would like to see them
55
Thank you~
April
Confidentiality NoticeThis message may contain information that isconfidential or privileged
If you are not the intended recipientPlease advise the sender immediately and delete this message
56
ATTACHMENT H
57
NFPA 1582 771(7) Proposed revisions
Why
Preliminary results of two prospective randomized trials on the PSA test were published in 2009 These studies resulted in medical organizations that previously providing guidance to modify their recommendations
Current language
771 Blood Tests Blood tests shall be performed annually and shall include the following
(7) Prostate specific antigen (PSA) after age 40 for positive family history if African American or if otherwise clinically indicated after age 50 for all other male member
Suggested Revision
771 Blood Tests Blood tests shall be performed annually and shall include the following
(7) Prostate specific antigen (PSA) after age 40 for positive family history if African American or if otherwise clinically indicated after age 50 for all other male member
772 Prostate-Specific Antigen (PSA) test At age 50 fire fighters shall have an opportunity to make an informed decision with either the Fire Department physician or their health care provider concerning the PSA test For fire fighters at increased risk of prostate cancer (African-Americans or those with a first degree relative diagnosed with prostate cancer before age 65) shall have the opportunity for this informed decision at age 40
A772 The PSA as a screening test for prostate cancer in asymptomatic men is controversial controversial for two reasons First there is no consensus that PSA screening actually saves lives For example the PSA test may detect small cancers that would never become life threatening Second it is unclear that the benefits of PSA screening outweigh the risks of follow-up diagnostic tests and cancer treatments For example the prostate biopsy used to diagnose prostate cancer may cause bleeding and infection And prostate cancer treatments such as surgery and radiation therapy may cause incontinence (inability to control urine flow) erectile dysfunction (erections inadequate for intercourse) and other complications For these reasons it is important that the benefits and risks of prostate diagnostic procedures and treatment be taken into account when considering the PSA screening test These considerations can be taken account during discussions with the fire department physician or onersquos health care provider
D211 Cancer Screening
Smith R A C J Mettlin K J Davis and H Eyre 2000 ldquoAmerican Cancer Society guidelines for the early detection of cancerrdquo CA J Clin 50(1)34ndash49
Added references
58
Carroll P Albertsen PC Greene K et al [2010] Prostate-specific antigen best practice statement 2009 update Am Urological Assoc Available at httpwwwauanetorgcontentguidelines-and-quality-careclinical-guidelinesmain-reportspsa09pdf Date accessed September 2010
Ferrini R Woolf SH [2009] Screening for prostate cancer in American men American College of Preventive Medicine Practice Policy Statement Available at httpwwwacpmorgprostatehtm Date accessed September 2010
National Cancer Institute [2009] Prostate-specific antigen test National Cancer Institute Fact Sheet Available at httpwwwcancergovcancertopicsfactsheetDetectionPSA Date accessed September 2010
Wolf AMD Wender RC Etzioni RB et al [2010] American Cancer Society guideline for the early detection of prostate cancer Update 2010 Available at httpcaonlineamcancersocorgcgicontentfullcaac20066v1 Date accessed September 2010
59
Steven F Sawyer
Senior Fire Service Specialist
Executive Secretary IFMAFire Service Section
NFPA
1 Batterymarch Park
Quincy MA 02169
6179847423
Fax 6179847056
ssawyernfpaorg
From April Boyer [mailtoaboyerbicclinicorg] Sent Thursday August 26 2010 232 PMTo Sawyer SteveCc RobinMWebbmilstateorusSubject 7743
Steven
The spirometry tests cannot be corrected according to both references as the NFPA states because thereferences are contradictory The first part of 7743 states to follow the ATS guidelines and use theKnudsen (we at Basin Immediate Care use the Nhanes III) The second part states to follow the ACOEMguidelines and use the Nhanes III in the occupational setting if available with your unit (which is availableon ours) 7743 does not use the word OR regarding both requirements it uses the word AND whenreferring to the first and second parts thence making 7743 contradictory I realize the NFPA 1582 hasnot been updated since 2007 unless I have just not received an updated version
Our question to you is which part of 7743 do you want us to follow the first or the second part Anyfacility that has an updated computerized spirometry system (as we do) will not be able to follow bothrequired parts for obvious reasons We can either follow the first part of 7743 and use an oldercorrected version of the Knudson by going into our system and changing out of the Nhanes III conversionOR we can follow the second part of 7743 and use the newer corrected version of Nhanes III which ourunit offers too
If you have any questions you may contact me at anytime and I also have many references in regards toboth parts of 7743 if you would like to see them
55
Thank you~
April
Confidentiality NoticeThis message may contain information that isconfidential or privileged
If you are not the intended recipientPlease advise the sender immediately and delete this message
56
ATTACHMENT H
57
NFPA 1582 771(7) Proposed revisions
Why
Preliminary results of two prospective randomized trials on the PSA test were published in 2009 These studies resulted in medical organizations that previously providing guidance to modify their recommendations
Current language
771 Blood Tests Blood tests shall be performed annually and shall include the following
(7) Prostate specific antigen (PSA) after age 40 for positive family history if African American or if otherwise clinically indicated after age 50 for all other male member
Suggested Revision
771 Blood Tests Blood tests shall be performed annually and shall include the following
(7) Prostate specific antigen (PSA) after age 40 for positive family history if African American or if otherwise clinically indicated after age 50 for all other male member
772 Prostate-Specific Antigen (PSA) test At age 50 fire fighters shall have an opportunity to make an informed decision with either the Fire Department physician or their health care provider concerning the PSA test For fire fighters at increased risk of prostate cancer (African-Americans or those with a first degree relative diagnosed with prostate cancer before age 65) shall have the opportunity for this informed decision at age 40
A772 The PSA as a screening test for prostate cancer in asymptomatic men is controversial controversial for two reasons First there is no consensus that PSA screening actually saves lives For example the PSA test may detect small cancers that would never become life threatening Second it is unclear that the benefits of PSA screening outweigh the risks of follow-up diagnostic tests and cancer treatments For example the prostate biopsy used to diagnose prostate cancer may cause bleeding and infection And prostate cancer treatments such as surgery and radiation therapy may cause incontinence (inability to control urine flow) erectile dysfunction (erections inadequate for intercourse) and other complications For these reasons it is important that the benefits and risks of prostate diagnostic procedures and treatment be taken into account when considering the PSA screening test These considerations can be taken account during discussions with the fire department physician or onersquos health care provider
D211 Cancer Screening
Smith R A C J Mettlin K J Davis and H Eyre 2000 ldquoAmerican Cancer Society guidelines for the early detection of cancerrdquo CA J Clin 50(1)34ndash49
Added references
58
Carroll P Albertsen PC Greene K et al [2010] Prostate-specific antigen best practice statement 2009 update Am Urological Assoc Available at httpwwwauanetorgcontentguidelines-and-quality-careclinical-guidelinesmain-reportspsa09pdf Date accessed September 2010
Ferrini R Woolf SH [2009] Screening for prostate cancer in American men American College of Preventive Medicine Practice Policy Statement Available at httpwwwacpmorgprostatehtm Date accessed September 2010
National Cancer Institute [2009] Prostate-specific antigen test National Cancer Institute Fact Sheet Available at httpwwwcancergovcancertopicsfactsheetDetectionPSA Date accessed September 2010
Wolf AMD Wender RC Etzioni RB et al [2010] American Cancer Society guideline for the early detection of prostate cancer Update 2010 Available at httpcaonlineamcancersocorgcgicontentfullcaac20066v1 Date accessed September 2010
59
Thank you~
April
Confidentiality NoticeThis message may contain information that isconfidential or privileged
If you are not the intended recipientPlease advise the sender immediately and delete this message
56
ATTACHMENT H
57
NFPA 1582 771(7) Proposed revisions
Why
Preliminary results of two prospective randomized trials on the PSA test were published in 2009 These studies resulted in medical organizations that previously providing guidance to modify their recommendations
Current language
771 Blood Tests Blood tests shall be performed annually and shall include the following
(7) Prostate specific antigen (PSA) after age 40 for positive family history if African American or if otherwise clinically indicated after age 50 for all other male member
Suggested Revision
771 Blood Tests Blood tests shall be performed annually and shall include the following
(7) Prostate specific antigen (PSA) after age 40 for positive family history if African American or if otherwise clinically indicated after age 50 for all other male member
772 Prostate-Specific Antigen (PSA) test At age 50 fire fighters shall have an opportunity to make an informed decision with either the Fire Department physician or their health care provider concerning the PSA test For fire fighters at increased risk of prostate cancer (African-Americans or those with a first degree relative diagnosed with prostate cancer before age 65) shall have the opportunity for this informed decision at age 40
A772 The PSA as a screening test for prostate cancer in asymptomatic men is controversial controversial for two reasons First there is no consensus that PSA screening actually saves lives For example the PSA test may detect small cancers that would never become life threatening Second it is unclear that the benefits of PSA screening outweigh the risks of follow-up diagnostic tests and cancer treatments For example the prostate biopsy used to diagnose prostate cancer may cause bleeding and infection And prostate cancer treatments such as surgery and radiation therapy may cause incontinence (inability to control urine flow) erectile dysfunction (erections inadequate for intercourse) and other complications For these reasons it is important that the benefits and risks of prostate diagnostic procedures and treatment be taken into account when considering the PSA screening test These considerations can be taken account during discussions with the fire department physician or onersquos health care provider
D211 Cancer Screening
Smith R A C J Mettlin K J Davis and H Eyre 2000 ldquoAmerican Cancer Society guidelines for the early detection of cancerrdquo CA J Clin 50(1)34ndash49
Added references
58
Carroll P Albertsen PC Greene K et al [2010] Prostate-specific antigen best practice statement 2009 update Am Urological Assoc Available at httpwwwauanetorgcontentguidelines-and-quality-careclinical-guidelinesmain-reportspsa09pdf Date accessed September 2010
Ferrini R Woolf SH [2009] Screening for prostate cancer in American men American College of Preventive Medicine Practice Policy Statement Available at httpwwwacpmorgprostatehtm Date accessed September 2010
National Cancer Institute [2009] Prostate-specific antigen test National Cancer Institute Fact Sheet Available at httpwwwcancergovcancertopicsfactsheetDetectionPSA Date accessed September 2010
Wolf AMD Wender RC Etzioni RB et al [2010] American Cancer Society guideline for the early detection of prostate cancer Update 2010 Available at httpcaonlineamcancersocorgcgicontentfullcaac20066v1 Date accessed September 2010
59
ATTACHMENT H
57
NFPA 1582 771(7) Proposed revisions
Why
Preliminary results of two prospective randomized trials on the PSA test were published in 2009 These studies resulted in medical organizations that previously providing guidance to modify their recommendations
Current language
771 Blood Tests Blood tests shall be performed annually and shall include the following
(7) Prostate specific antigen (PSA) after age 40 for positive family history if African American or if otherwise clinically indicated after age 50 for all other male member
Suggested Revision
771 Blood Tests Blood tests shall be performed annually and shall include the following
(7) Prostate specific antigen (PSA) after age 40 for positive family history if African American or if otherwise clinically indicated after age 50 for all other male member
772 Prostate-Specific Antigen (PSA) test At age 50 fire fighters shall have an opportunity to make an informed decision with either the Fire Department physician or their health care provider concerning the PSA test For fire fighters at increased risk of prostate cancer (African-Americans or those with a first degree relative diagnosed with prostate cancer before age 65) shall have the opportunity for this informed decision at age 40
A772 The PSA as a screening test for prostate cancer in asymptomatic men is controversial controversial for two reasons First there is no consensus that PSA screening actually saves lives For example the PSA test may detect small cancers that would never become life threatening Second it is unclear that the benefits of PSA screening outweigh the risks of follow-up diagnostic tests and cancer treatments For example the prostate biopsy used to diagnose prostate cancer may cause bleeding and infection And prostate cancer treatments such as surgery and radiation therapy may cause incontinence (inability to control urine flow) erectile dysfunction (erections inadequate for intercourse) and other complications For these reasons it is important that the benefits and risks of prostate diagnostic procedures and treatment be taken into account when considering the PSA screening test These considerations can be taken account during discussions with the fire department physician or onersquos health care provider
D211 Cancer Screening
Smith R A C J Mettlin K J Davis and H Eyre 2000 ldquoAmerican Cancer Society guidelines for the early detection of cancerrdquo CA J Clin 50(1)34ndash49
Added references
58
Carroll P Albertsen PC Greene K et al [2010] Prostate-specific antigen best practice statement 2009 update Am Urological Assoc Available at httpwwwauanetorgcontentguidelines-and-quality-careclinical-guidelinesmain-reportspsa09pdf Date accessed September 2010
Ferrini R Woolf SH [2009] Screening for prostate cancer in American men American College of Preventive Medicine Practice Policy Statement Available at httpwwwacpmorgprostatehtm Date accessed September 2010
National Cancer Institute [2009] Prostate-specific antigen test National Cancer Institute Fact Sheet Available at httpwwwcancergovcancertopicsfactsheetDetectionPSA Date accessed September 2010
Wolf AMD Wender RC Etzioni RB et al [2010] American Cancer Society guideline for the early detection of prostate cancer Update 2010 Available at httpcaonlineamcancersocorgcgicontentfullcaac20066v1 Date accessed September 2010
59
NFPA 1582 771(7) Proposed revisions
Why
Preliminary results of two prospective randomized trials on the PSA test were published in 2009 These studies resulted in medical organizations that previously providing guidance to modify their recommendations
Current language
771 Blood Tests Blood tests shall be performed annually and shall include the following
(7) Prostate specific antigen (PSA) after age 40 for positive family history if African American or if otherwise clinically indicated after age 50 for all other male member
Suggested Revision
771 Blood Tests Blood tests shall be performed annually and shall include the following
(7) Prostate specific antigen (PSA) after age 40 for positive family history if African American or if otherwise clinically indicated after age 50 for all other male member
772 Prostate-Specific Antigen (PSA) test At age 50 fire fighters shall have an opportunity to make an informed decision with either the Fire Department physician or their health care provider concerning the PSA test For fire fighters at increased risk of prostate cancer (African-Americans or those with a first degree relative diagnosed with prostate cancer before age 65) shall have the opportunity for this informed decision at age 40
A772 The PSA as a screening test for prostate cancer in asymptomatic men is controversial controversial for two reasons First there is no consensus that PSA screening actually saves lives For example the PSA test may detect small cancers that would never become life threatening Second it is unclear that the benefits of PSA screening outweigh the risks of follow-up diagnostic tests and cancer treatments For example the prostate biopsy used to diagnose prostate cancer may cause bleeding and infection And prostate cancer treatments such as surgery and radiation therapy may cause incontinence (inability to control urine flow) erectile dysfunction (erections inadequate for intercourse) and other complications For these reasons it is important that the benefits and risks of prostate diagnostic procedures and treatment be taken into account when considering the PSA screening test These considerations can be taken account during discussions with the fire department physician or onersquos health care provider
D211 Cancer Screening
Smith R A C J Mettlin K J Davis and H Eyre 2000 ldquoAmerican Cancer Society guidelines for the early detection of cancerrdquo CA J Clin 50(1)34ndash49
Added references
58
Carroll P Albertsen PC Greene K et al [2010] Prostate-specific antigen best practice statement 2009 update Am Urological Assoc Available at httpwwwauanetorgcontentguidelines-and-quality-careclinical-guidelinesmain-reportspsa09pdf Date accessed September 2010
Ferrini R Woolf SH [2009] Screening for prostate cancer in American men American College of Preventive Medicine Practice Policy Statement Available at httpwwwacpmorgprostatehtm Date accessed September 2010
National Cancer Institute [2009] Prostate-specific antigen test National Cancer Institute Fact Sheet Available at httpwwwcancergovcancertopicsfactsheetDetectionPSA Date accessed September 2010
Wolf AMD Wender RC Etzioni RB et al [2010] American Cancer Society guideline for the early detection of prostate cancer Update 2010 Available at httpcaonlineamcancersocorgcgicontentfullcaac20066v1 Date accessed September 2010
59
Carroll P Albertsen PC Greene K et al [2010] Prostate-specific antigen best practice statement 2009 update Am Urological Assoc Available at httpwwwauanetorgcontentguidelines-and-quality-careclinical-guidelinesmain-reportspsa09pdf Date accessed September 2010
Ferrini R Woolf SH [2009] Screening for prostate cancer in American men American College of Preventive Medicine Practice Policy Statement Available at httpwwwacpmorgprostatehtm Date accessed September 2010
National Cancer Institute [2009] Prostate-specific antigen test National Cancer Institute Fact Sheet Available at httpwwwcancergovcancertopicsfactsheetDetectionPSA Date accessed September 2010
Wolf AMD Wender RC Etzioni RB et al [2010] American Cancer Society guideline for the early detection of prostate cancer Update 2010 Available at httpcaonlineamcancersocorgcgicontentfullcaac20066v1 Date accessed September 2010
