## Transcript

 Estimated 19 min reading time.

Welcome to the USFA Podcast, the official podcast of the U.S. Fire Administration. I'm your host, Teresa Neal. Before we jump into this episode, I want to invite you to join the conversation about fire safety. Please email your questions, stories or podcast ideas to usfapodcast@fema.dhs.gov. Please reach out.

We would like to know what topics or interviews you are most interested in. Okay. On this episode we're discussing firefighter physicals and the new “Provider's Guide to Firefighter Medical Evaluations.” Firefighters are at increased risk for several types of cancer on duty, cardiovascular events, sleep disorders, as well as behavioral health concerns such as depression, suicidal thoughts, anxiety and post-traumatic stress.

Every firefighter needs to take control of their own health care and ensure their providers are aware of the physical and mental health stress common for firefighters. The U.S. Preventative Services Task Force provides recommendations for exams and screenings for the general population.

And while these are good as a baseline, they're not designed for an occupational group with increased risk like firefighting. To help you make your provider aware of the risk, the First Responder Center for Excellence, The International Association of Fire Chiefs, International Association of Firefighters, National Volunteer Fire Council, and the National Fallen Firefighters Foundation designed the “Provider's Guide to Firefighter Medical Evaluations.”PDF

On this episode, we'll be joined by Dr. Sara Jahnke, director and senior scientist with the Center for Fire, Rescue and EMS Health Research at the National Development and Research Institutes, and also Todd LeDuc of Lifespan Wellness, who worked on this project.

Okay, so thank you Todd and Sara for being on this episode with us. You're going to talk to us about how this health care provider's guide started.

Yeah. Let me, let me, uh, take a stab at that. And Teresa, thank you for, for having, uh, Dr. Jahnke and myself both on.

So, kind of the history of the provider's guide started back with the International Association of Fire Chiefs, going back, uh, well probably 6, 7 years. Their safety, health and survival section, which is one of the larger, more active sections of the IAFC recognized through our strategic planning that we needed to do a better job on ensuring not only that firefighters get appropriate annual medical exams, but then also to educate clinicians that care for those firefighters.

And we did that through a number of stakeholder visioning sessions where we invited key stakeholders from all the different walks, both clinically, occupational health, our research partners, our insurance partners, our payer groups, workman's comp, and that was a consistent theme that kind of inside baseball, if you will.
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The provider's guide, I think, has been a labor of love for both of us in ensuring that we get the critical information about firefighter occupational health and risk, and then medical screening into the hands of the nation's medical providers that actually take care of our firefighters.

We all have an understanding of what the current occupational health risk to firefighters are. But when you look at kind of the bigger picture — as an example, my internal medicine provider that I see maybe has 2 firefighters that are in his practice that he cares for. And really, it's a challenge for them to be up to speed on all the great emerging research that's been done.

So, we came up with this idea with a small network — we took that theme — we had a small — I think that FRI, Sara, if I'm not mistaken — a few of us sat down over lunch and kind of sketched out what this might look like. So you know, the thought process was, let's condense into easily digestible information pod, if you will, that can be handed to a health care provider.

So, if you think about your own physicals, you know, and we still need to do a better job with that. I think 2016, the IFC surveyed its members and still showed on the volunteer side, I think, was 40% of departments weren't doing NFPA 1582 physicals. On the career side, it was about 20%. Still had more work to do, but after you have that physical, you're typically managed at the course of your career by a health care provider.

And so, the goal was to — how do we get the right information to the right clinician in making it easily digestible? We — I think when we had our stakeholder meetings, and Sara, correct me if I'm wrong, it's been a few years, but one of the things that we clearly heard was that average patient encounter, and think about it, when you go to your own clinician, it's about 20 minutes.

So, and unfortunately some of that's just driven by insurance and time constraints. And so your provider may have 20 minutes to not only conduct a physical, but uh, listen to any health concerns you have. So, in that small package of time, how do we deliver meaningful information about what we know on occupational risk, and then how do we suggest perhaps what best practices may look like in terms of screening and management of those disease processes?

So, from that small luncheon, we were blessed to uh — we met with some folks at FEMA and started talking about — this is a pretty heavy lift in terms of a national product and the — how we would have the infrastructure in place to actually be successful in producing such a document. And ultimately, we ended applying for FEMA, I believe, Fire Prevention Safety Grant.

Perhaps it might have been under the R and D or it — basically, we were successful in partnering with FEMA to receive grant funding, which is so vital in so many aspects of the fire service to help with these type of initiatives. So out of that, we convened a couple stakeholder meetings.

I happened to be chief of Broward County, Florida, at the time in — we hosted 1 or 2 down in, in Broward County. Well, we invited in folks like Dr. Jahnke and clinicians and fire experts on health and wellness, and started assembling what the science was and then what best practice recommendations would look like.

So, we like to say that's version 1.0 and that was the history. Sara, I think, certainly will talk about some lessons we learned from that, what worked, what needed to maybe be tweaked and fine-tuned, and Sara can shed some light on what we just released — version — I'm calling version 2.0, which is an updated provider's guide.

**But our goal — and what we're so thankful for the U.S. Fire Administration to allow us this forum — is to have this in the hands of every firefighter in the United States, but also every clinical provider, right? So ideally, a firefighter can bring this to their physician, nurse practitioner, P.A., and say, “Hey, I'm a firefighter. You need to look at me a little bit differently.” So that's kinda the background and history.**

Yeah. And I really think — and I also appreciate being brought on to talk about this, because I think it's such an amazing resource that people are not necessarily aware of. And what we kept hearing is that people would take these things, you know, they would go talk to their doctor and they'd be like, “Oh, I'm a firefighter.”

And the doctor would be like, “Yeah, okay. And?” And because they operate off the U.S. Preventative Services Task Force, you know, that's what dictates billing and those types of things. And often, if they're not looking even for symptoms that are beyond — you know, you hear a symptom and it's a cough or something like that.

General population: probably nothing. Firefighters: slightly more likely to have some of these diseases, whether it be, you know, cancer or any, and actually a pretty wide variety of impacts. And so, it's really to just raise the awareness of this is a risk factor that I face similar to like, you know, they ask your smoking status.

That's because if you're a smoker, they consider things differently. They ap different things to the list of differentials. And so, we did. The first one was awesome. We took it out, put it in the hands of a lot of primary care docs and we got a lot of feedback that was “love it, but ...” And so, when we looked at the — what are the buts?

They tended to be things like we have, you know, so 20 minutes is generous; often it's 5 to 7 minutes with someone. So they said, “We really can't. 2 pages is too much.” And it was a struggle because, you know, when we did the brainstorm, we were like, oh, we want to give everyone a book.

No one, no primary care doc's gonna read a book. And so they said, you know, it has to be shorter, it has to be front and back. But then there was also a subset that said, “I'd really love to learn more about this, so could you expand it?” So I'm like, okay, so we're gonna cut it back to a post-it note or we're gonna expand it to, to a dictionary. Got it, totally on it.

The other thing that we got feedback on that was interesting, both from firefighters and from primary care docs is, you know, don't tell us, you have to do this because for some people it's not appropriate. And for some people, even with that respect, or they would do screenings differently.

And so there was some concern around that and there were some things that said we already know this. If we — if this is what we do in general, you know, our initial one was, this is comprehensive, you know? Annual medical with your annual physical with your primary care provider.

They said, if we're already gonna do it, then don't, you know, don't tell us to do it. So, the revised version took into account a lot of that feedback, all that feedback, and looked at how can we provide more resources and more information with less real estate, and so we cut back quite a bit in terms of — words are very succinct. It's now like bullet points.

This, this, this and this. So that was one of the big changes from the last time. The other one is we now have resources online for those who are like, “Oh gosh, I'd really like to know more about that.” So, we have like a dermatologist that's recorded.

So there's now a QR code and a website, a web address that they can go to and get that information and say, “Oh, okay, now I get it.” This is — you know — this is what Dr. Kanlar, who's been working with a lot of firefighters up in the Northeast in particular — here's what she says to look for and how we should be monitoring this, or this is what Denise Smith says about this topic.

So that part I think is helpful. The other thing is we changed it from “do this” to “consider this.” And because it gives room for the providers to say this is not what we wanna do right now, and this is and this is why, because some firefighters were going in and going, “I have to have all this.”

And the docs are like, no, because there is a challenge with this screening piece, right? You don't wanna screen all people for all things all the time because there's sometimes implications and negative you — if you over-screen, the cost is bigger than the benefit. And so, but it's really more for awareness raising.

### Recommended links

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            - USFA health and wellness manuals

It's not — there was 17 days of disagreement on whether this is an NFPA light, and it's not. It's not asking — it's not designed for a primary care doc to release you for duty. This is designed for — even for people that are getting department physicals. To be able to go to their doctor and say, hey, 'cuz those med providers are not your physician; they're the department physician clearing you for duty.

And they're clear on that role. What we found is the fire service is not clear on that role. You know, firefighters are like, “Oh yeah, I saw a doctor,” but it's not your doctor. So if you need, you know, your blood pressure monitored or, you know, your whatever is out of whack — that primary care doc, unless it excludes you from duty, you're either good to go or you're not.

So we need to make sure that people are tying into primary care physicians who get to know them, who understand what they do, those types of things.

And also Sara, I wanted to point out, I think, you know, we'd be remiss to — as this has evolved, we certainly, you know, wanna give credit, because they're a tremendous resource and, you know, for the audience and listeners, the IFC actually, between version 1 and the one that just released, has partnered with the First Responder Center of Excellence.

Which is an offshoot of the National Fallen Firefighters Foundation. And they are doing amazing work looking at cardiac cancer, behavioral health and then physicals. So their leadership and partnership with the IFC has been tremendous in not only the provider's guide, but if you check their website, they have a tremendous amount of research, resources, toolboxes.

And then I think the other thing that was, at least for me, and I know probably Sara as well, is having the — as this has evolved, having just the number of partners that have partnered on this. I think when you'd flip the back of the provider's guide over and you see the, you know, the IFF as a partner in all the different stakeholders, says that, you know, there's a unity of message on this across the fire service, whether you're volunteer or whether you're career IFF.

We're all speaking with 1 voice when it comes to the medical care and evaluation. You know, I think, as Sara pointed out, NFPA does an excellent job speaking to occupational physicals and medical clearance. But when that management is so critical, right? So, when that provider or that firefighter goes to see a provider, we need to make sure that they have that understanding.

And Sara has done a tremendous job taking the lead on trying to figure out that sweet spot where we get them as much information as we can in a format that they'll receive it well and then not supplanting their clinical judgment. Just, you know, opening some windows for dialogue with their patients that may be different than other general population.

So, I heard you mention Dr. Smith and her research she's done on cardiovascular. So can you talk about some better heart cardiac screening recommendations for the firefighters?

Sure, and Sara and I both had the honor of working with Dr. Denise Smith, who's a dear friend to both of us, and working with her in the Better Heart Study.

And I think — and Sara will fact check me on the science — but I think what we would evolve out of that kind of deep dive into cardiac — studying cardiac death and starting cardiac events — is that many of those instances have what's referred to as subclinical cardiac disease. So it may not be overt, but it's lying in wait, if you would.

Things like better control of hypertension, weight loss, better heart study is a great example of folks like Dr. Jahnke and Dr. Smith leading the way on science and research to help policymakers — whether that's fire chiefs or health and safety officers, or even NFPA technical committee members — incorporate the most cutting science that's evidence based in how we evaluate and screen firefighters. So specifically, Dr. Smith's recommendations were to consider at age 40 a 1-time baseline for calcification screening, calcification coronary. Calcification screening. So that's a picture of your calcified plaque within each of your coronary arteries.
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And the other really fascinating piece — and I find it somewhat sad — but is a majority of the (cardiac) deaths have left ventricular hypertrophies. So, an enlargement of the left ventricle, left septum, which easily can be screened for and in many cases, if you find hypertrophy, it can be reversed with early intervention.

Documenting clinical cardiovascular disease, and then also to consider screening with cardiac echo or enlargement of the left ventricle. So again, the — whether we're talking about cancer, behavioral health, and better heart, obviously cardiac. The earlier we find reversible causes prevents tragedy. I mean, that's the bottom line is all too often, unfortunately, we've all seen loved ones in our lives and friends.

And oftentimes by the time symptoms develop, there's already been disease spread. Cancer's another, you know, great example of the time — you have symptomology, often it's past the site of origin and into the lymph nodes and spreads. So I definitely want to give a shout out to Dr. Denise Smith, and she brought together a panel of just rock stars and some of the best minds in the industry and research and medicine.

And those recommendations I think are really a game changer on setting cardiac death and firefighters.

Totally agree. I don't have anything to add to what touches it. No, that's what I think is awesome right now about, like, where we're at is — and you know, this is gonna be 2.0, but there's gonna be 3.0 because we're quickly learning — we're looking pretty aggressively at like screenings and what — and you know, this is outside of what the U.S. Preventative Services Task Force recommends, which is some of the pushback we've had from providers.

But at the same time, I think those are designed for general population. And so then the question is, you know — and also we need to be consistent with messaging that's going on in the fire service that people can take to their providers and say, “Hey, here's what I'm hearing. What does that mean for me?” type stuff. So, there are a couple departments that are like doing amazing things where they're going to their primary or they're going to their insurance companies the department has, and they're saying, “Hey, we want our firefighters to get screened for these things. Let's negotiate that.”

Insurance companies are developing a separate code for a firefighter physical, and they do that, so there's like, I see progress. So much progress. It's such an exciting time to be in this field 'cuz there's so much progress on what's happening and what can happen — what should happen.

So there'll be 3.0. I have no doubt about that — that this is gonna be evolving.

Yeah, I was gonna ask, how do they get around some of these insurance blocks where we don't screen for that because you're not the age or we don't screen for that for whatever reason and how they get the insurance companies to approve it and move it forward?

So that's one thing that I, you know — so some departments have done it where they've just taken it head on. Hey, for insurance, I know Denver did that and they — some of the insurance companies there. I know there have been, and I think that's one conversation that we need to be facilitating for people who've been successful, 'cuz they think it's an awesome idea.

The other way is that a lot of times physicians will ask about symptoms of things that they wouldn't necessarily be looking for, and once they ask, then, you know, you often can get that reimbursed if you're having symptoms, but so often we just don't even know what the symptoms are. So, hey, are you having symptoms of X, Y or Z? Okay, then let's go ahead and get you screened for that.

And then that's covered by — and I'm not saying that like — and it's a way to trick the system, but we're not just, in general, the provider's like, “Hey, you good?” You know, your blood looks good, this looks good. And so many things. I mean, that's what we see with cancer and the difference with early detection.

You know, people just don't know what the signs and symptoms are, you know? And so, when they look for them, then they're like, “Oh, got it. Got it.”

And it's probably advantageous in the long run for the insurance company because if you get it early, it's not the same expense as if it's later on.

I was just gonna add that as well, I think, and I love our insurance friends and folks in the insurance industry to death, but again, they work off of actuarial, you know, dollars and cents, and you're absolutely right. I mean, I think just 1 small example, and it's not really small, but the RAND Corporation did some great economic analysis on the NIOSH study on firefighter cancer, just quantifying what the cost was financially to find a cancer with early screening versus a later stage.

And obviously outcomes, you know, I think always trump dollars. So, I think as Sara said, having that and the insurance industry was at the stakeholder table early. But I think we need to continue that dialogue and educate them on, as you said, not only the better outcomes, but also, the financial return on investment from investing in perhaps different screenings and would be recommended for general public. So that's an ongoing educational piece.

So you said there would probably be, or there will be a 3.0, 4.0. — so what are the next steps? What are the ones that you're looking at now?

I think following the data that we have around screenings is one specifically that will be big and what should be screened and what shouldn't.

I think we'll get some feedback from primary care docs and what they did or didn't like on this. You know, 1 of the things that was interesting — that I found most interesting is, you know, we're giving this about like — here's the physical concerns. Almost to the primary care doc. They said that what they really liked about it was the having behavioral health listed, mental health listed on the page because they said it gives me permission to bring it up.

And so I think that probably looking at how can we, you know — is it just bringing it up on the page or do they want some sort of screening, something like that, so I can see that being an area of growth. I think we're seeing some work in the reproductive health and we're really, actually, we're working with FRCE to design like a version for OBGYNs.

What do you need to be aware of? We're seeing documentation of fertility issues in both men and women. What should we tell someone who is either a firefighter's trying to get pregnant, or either that woman is the firefighter or her husband's a firefighter, 'cuz we're seeing fertility issues of men, and then once a woman is pregnant, then what?

And we're seeing with that some like, increased risks of miscarriage and preterm labor. So, what does that mean? What are the implications and what are the job tasks? You know, like when you talk to a firefighter and they wanna be on the truck and you say, “What do you do?” They say they drive, you know, like, drive up on fires and do it, put it on it, you know, but it — and I get it, I get it.

And there are a lot of like, complications in terms of when people go offline or go on light duty or — but we, you know, I think as we learn more about that, I know Jeff Burgess and his team are doing a lot of work. And we're helping him out on some of it, but I gotta give him the credit for being the mastermind looking at AMH and women, and we know that being in the fire service, he's measuring and will be measuring people pre- and post-fire exposure and looking at women pre- and post-fire exposure in recruit school and looking at the — basically being in the fire service ages your reproductive health faster than if you were just, you know, doing my job sitting behind a desk.

Yeah. I was gonna say, are you focusing on women? Because I know, for myself, years ago I had breast cancer. Nobody in my family had ever had breast cancer and didn't understand why I, you know — at that time we were still thinking that it was something that your mother has or somebody, your aunt?

No one in either side of my family had it. And so I was doing some research and, I mean, I don't want to get bad letters, but you know, there was a thing that said women who served in the military are 25% more likely to have breast cancer than women who did not serve in the military. That might not be absolutely true, but that's what I read.

And so I wasn't in a job that was around nuclear or radiation or things like that, but it's just the different way that you used your body at that time. I suppose, I don't know, but now it's something that anytime one of my friends from my military days, you know — I tell them, get screened.

Get screened. Cause I was 42, you know, it wasn't a time frame when I really thought that cancer was gonna be, you know, an issue in my life. And so I know we're getting it younger and younger and there's all different types of reasons. I am not saying my time in the military had anything to do with it, because I loved my time in the military. But it is a consideration.

Right, and a lot of, you know — because there's also been the other side of it. People are like, “Oh my gosh, are we pushing people out of the fire service because they're gonna be scared? They're gonna be whatever?” I think I understand where that's coming from.

I think there's so much that we can do to mitigate it, and like, was your time in the military tied to it? I don't know. We'd have to look at the original studies and see, you know, what that link was, and are — likely you were exposed to things that you didn't realize at the time. I mean — and everything from like, shift work has now been classified as a probable carcinogen by the World Health Organization.

Like even some of those, like behavioral and environmental pieces, like those can play an often-significant role in the how cancer develops in people. So, I'm not saying that it was, but I'm also not saying it wasn't, you know? It's an empirical question.

Absolutely. And you know, I think, you mentioned version 3.0 and 4.0 and beyond, and even the dialogue that we're having right now, I really have to give credit. I know Sara is humble and won't say it, but you know, she mentioned Dr. Jeff Burgess, but we, relatively, have a very small community of occupational health researchers for the fire service. And we're blessed to have not only a tight-knit community, but ones that are so passionate and dedicate their time and talent.

So it's really — I mean, we could do probably a weeklong plus show just on the evolving, emerging research we just published with Denise Smith on borderline testosterone in cardiovascular risk in firefighters, and pick an area.

And, the science is evolving so quickly, but none of that would be possible without the talent of the Dr. Jahnkes, the Dr. Smiths, the Dr. Burgess, and I don't know, I'm missing many, but as a whole, the fire service is blessed to have such researchers and talent that are allowing us to evolve to a healthier and a safer workforce.

And ultimately, we'll never be able to manage inherently a hundred percent of the risks, but shame on us if we don't manage preventable risk. And that's the key with this. So, I want to give a shout out to our research community. I wanna shamelessly plug as well.

They're woefully underfunded, and whenever I have a microphone and a platform, thank God we have the R and D grants from FEMA, but, you know, really, we're just scratching the surface on firefighter health. And you know, we talked about women's health issues in the fire service. I mean, it's just starting to shine a light on some of these issues.

Funding is always critical. So for our legislators out there and our lobbyists that are listening, I just wanna put that plug in because it is making a difference. It's saving firefighters' lives.

So, is there anything else you would like to discuss or tell me about this tool that is now available? How can they find it if they don't know about it?

It's currently on the — I believe it's on the First Responder Center of Excellence website. The other website that it's on is our Science Alliance website, and so it's www.science-alliance.org and we have that up. It's a network that we're building to really facilitate conversations between the scientists and the people who actually need the information.

Because on the science side of stuff, we've not been great at that. So I know that's there under resources, and you can click on “Provider's Guide,” and it has both the provider's guide that you can print, and that's where the QR code goes to all the references and the list of people who reviewed it and the videos and all those types of things.

Okay. So is there anything else you'd like to add?

I don't think so. Thanks so much for amplifying this work.

It's very important.

It is, and it just has to be. We have to hit this on all ends, you know? If we really wanna make an impact, it's not — there's no one and done.

So it's, yeah — it takes partnership. It takes this, it takes you going, “Hey, we need to talk about this and get it out there and get it out on a podcast to make it happen.”

Yeah. Thanks Teresa. We really appreciate the forum, and for our listeners, a tremendous resource, not just for yourself, but as Dr. Jenkins said, help us spread the message right throughout your department, throughout your local — in your community. So it does take a village on this. It's a big, heavy lift — never ceases to amaze me. I still go to Health and Safety Conferences and ask, “Has anyone seen the Provider's Guide?”

And, you know, out of a room of a hundred, maybe 20 hands go up. So we, as the fire service, need to do a better job at communicating these resources. So thank you for helping us do that, and want to give a plug to our U.S. fire administrator, Dr. Lori Moore-Merrell, and for her support. Again, this is an issue of not only critical importance for the service, but actually rubber meets the road, right? We're talking about the lives of our nation's first responders and their families.

Well, thank you so much.

Thank you. Have a great day.

Thanks, you too.

Have a great one. Stay safe.

Thank you for listening to the USFA Podcast and thank you to Dr. Sara Jahnke and Todd LeDuc for joining us today. Remember, if your department has medical evaluations to clear you for duty, that's great. However, occupational medicine and department exams are focused on clearing you for duty for your department.

Your primary care provider is focused on managing your health, so help them understand your special risk. As mentioned in the beginning of the episode, you can join the conversation about fire safety by emailing your questions and sharing your stories to fema-usfapodcast@fema.dhs.gov.

 Don’t forget to subscribe to our show on Apple or YouTube Podcasts.

We share our new episodes every third Thursday of the month. You can visit us at usfa.fema.gov or on social media by searching “usfire.” Until next month, stay safe.