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Running head: ANNUAL MEDICAL EVALUATIONS AT THE ABERDEEN FIRE 1

Annual Medical Evaluations at the Aberdeen Fire Department - Reducing the Risk of Heart

Attack

Thomas D. Hubbard

Aberdeen Fire Department

Aberdeen, Washington

ANNUAL MEDICAL EVALUATIONS AT THE ABERDEEN FIRE 2

CERTIFICATION STATEMENT

I hereby certify that this paper constitutes my own product, that where the language of others is

set forth, quotation marks so indicate, and that appropriate credit is given where I have used the

language, ideas, expressions, or writings of another.

Signed: ______________________________

Thomas D. Hubbard


Abstract

The number one cause of firefighter line of duty death each year is heart attack and has been so

for the past twenty years. The problem was the Aberdeen Fire Department (AFD) did not have a

system in place that indentified or monitored firefighters at increased risk for cardiovascular

disease. The purpose of this research was to identify viable methods by which the AFD and

local fire departments could reduce the incidence of heart attack by identifying and reducing

cardiac risk factors among firefighters. Descriptive research utilizing internal and external

questionnaires and personal interviews was used to answer the research questions to (a)

determine if the firefighters included in the research had taken steps to indentify and reduce their

risk of heart attack; (b) identify the personal and organizational barriers preventing firefighters

from improving their cardiovascular health; (c) identify cardiac screening programs that would

result in cardiac risk reduction for firefighters, and (d) assess if physical fitness was an

organizational priority for the fire departments included in this research.

The results indicated that none of the fire departments required incumbent firefighters to

undergo annual medical evaluations; that nearly half of the firefighters surveyed could be at

increased risk of heart attack due to undiagnosed and untreated cardiac risk factors, and that

financial costs, staffing issues, lack of organizational prioritization, and personal choice were the

primary barriers preventing firefighters from obtaining medical evaluations and improving their

overall physical fitness.

It was recommended that the fire departments utilize NFPA 1582, The Fire Service Joint

Labor Management Wellness-Fitness Initiative, and the Health and Wellness Guide for the

Volunteer Fire and Emergency Services to develop mandatory cardiac screening programs

designed to identify and treat firefighters with elevated cardiac risk factors.


Table of Contents

Abstract…………………………………………………………………………….............page 3

Table of Contents………………………………………………………………………..…page 4

Introduction……………………………………………………………………………..….page 5

Background and Significance………………………………………………………….…...page 6

Literature Review……………………………………………………………………….….page 10

Procedures………………………………………………………………………………….page 18

Results……………………………………………………………………………………...page 29

Discussion………………………………………………………………………………….page 43

Recommendations……………………………………………………………………….…page 48

Reference List……………………………………………………………………………....page 51

Appendices

Appendix A……………………………………………………………………………...…page 55

Appendix B………………………………………………………………………………...page 56

Appendix C…………………………………………………………………………….......page 57

Appendix D………………………………………………………………………………...page 59

Appendix E………………………………………………………………………………....page 60

Appendix F………………………………………………………………………………....page 62

Appendix G………………………………………………………………………………...page 63

Appendix H………………………………………………………………………………...page 66

Appendix I……………………………………………………………………………...…..page 69

Appendix J……………………………………………………………………………….…page 71


Introduction

In its annual report titled Firefighter Fatalities in the United States in 2008, the United

States Fire Administration reported that 45 firefighters died in 2008 from heart attacks and that

“firefighting is extremely strenuous physical work and is likely one of the most physically

demanding activities the human body performs” (United States Fire Administration [USFA],

2009a, p. 22). Basri and Bergman (2009a) note that with the exception of September 11, 2001,

over the past 20 years the number one cause of firefighter line of duty deaths was attributed to

heart attacks, with 50% of all line of duty firefighter deaths resulting from cardiovascular

disease. The authors note that during the same time period heart attacks accounted for 22% of

the line of duty deaths of police officers and that the occupational national average was 15%.

Because firefighter’s death from cardiovascular disease is well documented, the National

Institute for Occupational Safety and Health is one of several agencies that recommend that fire

departments “provide mandatory annual medical evaluations to ensure members are capable of

performing job tasks with minimal risk of sudden incapacitation” (National Institute for

Occupational Health and Safety [NIOSH], 2007, p. 16).

The problem addressed by this research is that the Aberdeen Fire Department (AFD) does

not have a system in place to assess or monitor the cardiovascular fitness of its incumbent

firefighters which places the mission of the fire department and the health of the individual

firefighter at risk for heart attack. The purpose of this research is to identify methods for

assessing and improving the cardiovascular fitness of firefighters at the AFD. Descriptive

research utilizing internal and external questionnaires and personal interviews were used to

address the following research questions: (a) Have the fire departments and firefighters included

in this research taken steps to identify and reduce the risk of heart attack, (b) what are the


barriers preventing firefighters from improving their cardiovascular health, (c) what are the

options available to the AFD for providing annual medical evaluations, and (d) is physical fitness

an organizational priority for the fire departments included in this research.

Background and Significance

Cardiovascular disease is not just isolated to the fire service but rather afflicts a

significant cross section of the adult population of the United States. Data released by the

American Heart Association (AHA) in their Heart Disease and Stroke Statistics 2010 Update

indicate that in 2006 one out of every six deaths was from coronary artery disease and that an

estimated 785,000 people will have a new coronary attack in 2010 (Lloyd-Jones et al., 2009, p.

e2). According to data from the Centers for Disease Control and Prevention “heart disease is the

leading cause of death in the United States and is a major cause of disability. The most common

heart disease in the United States is coronary heart disease, which often appears as a heart

attack.” (Centers for Disease Control and Prevention [CDC], 2010, para. 1). This correlates with

the results of a ten year retrospective study of firefighter deaths from 1990 to 2000 by the

TriData Corporation that found “heart attacks were the leading cause of firefighter deaths,

accounting for 44% of the total cause of firefighter deaths” (USFA, 2002, p. 23).

The AFD is a municipal fire department staffed by 33 career firefighters who provide fire

protection and ALS and BLS ambulance transport to a population of 25,000 people. The AFD

operates with an eight man minimum that staff one ladder truck, one engine, one ambulance, and

one command unit per 24 hour shift. The AFD operates on a 24 hour on-duty 48 hour off-duty

schedule with overtime call back of personnel for greater alarm structure fires and for inter-

facility transport of patients to definitive care hospitals. To gain employment with the AFD,

candidates must pass a pre-employment medical evaluation that is compliant with the criteria


contained in NFPA 1582 (see Appendix A). Once hired however, firefighters are not required to

undergo medical evaluations to maintain their position with the department. There are two

exceptions and they are: (a) when an employee is absent from work for more than one week due

to medical reasons they must present a signed physician release prior to returning to work; or (b)

if they miss 90 days or more of work they may be required to submit to a fit for duty examination

prior to resuming their duties (Aberdeen Fire Department [AFD], 2010).

The issue of health and fitness for the members of the AFD has been addressed through

policies; however, the policies primarily delineate the steps a firefighter must take to return to

work after an illness or injury occurs. Section 1.0 of the Health and Wellness section of the fire

department’s Safety and Accident Prevention Program states “the Aberdeen Fire Department

shall ensure that members with fit for duty job requirements are fit for duty” (Aberdeen Fire

Department [AFD], 2004, p. 1) and defines fit for duty as “the state of physical conditioning,

mental and medical health that allows the member to safely perform the essential functions of the

job. Fit for Duty is determined by the City of Aberdeen’s physician or licensed health care

provider” (AFD, 2004, p. 2). The City of Aberdeen’s Personnel Policies, Section 9.10 Health

and Fitness state:

Each Employee is expected to maintain physical and mental health fitness necessary to

effectively and efficiently perform the duties of his or her position. When the health of

an employee becomes a hazard to other persons or property, or prevents the employee

from effectively performing the duties of the assigned position, the employee may be

required by the department head to undergo a health examination. When so required, the

employee will be paid for the time required for the examination and for the cost of the

examination itself if it exceeds insurance benefits. Correction or treatment of conditions


diagnosed during this health examination will be the responsibility of the employee (City

of Aberdeen, 2003, p. 33).

Additionally, the State of Washington mandates through the Washington Administrative

Code (WAC) 296-305, Safety Standards for Firefighters, Section 296-305-01509, Management’s

Responsibility, that “the employer shall assure that employees who are expecting to do interior

structural firefighting are physically capable of performing duties that may be assigned to them

during emergencies” (Washington State Safety Standards for Firefighters, 1997).

A challenge that must be addressed by the AFD is the financial impact of implementing

any new program. The City of Aberdeen has been faced with significant financial hardship. The

county’s unemployment rate of 14.9%, economic stagnation and rising employee costs are all

negatively impacting the general budget. According to the Finance Director for the City of

Aberdeen the general budget is derived primarily from sales tax revenue which has declined 20%

since 2006. This revenue decrease is further impacted by a 21% increase in employee benefit

costs and a 5% increase in salaries since 2007. Even capital improvements to city facilities and

infrastructure have been non-existent in recent years unless they can be funded by state or federal

grants (K. Skolrood, personal communication, March 15, 2010). In discussing budgetary

concerns with the fire chief of the AFD, he reported that employee costs accounted for 90% of

the fire department’s budget with the remainder allocated to supplies, operating costs, vehicle

maintenance and mandated training. Programs such as fire prevention in the schools and

hazardous material teams have been eliminated due to lack of funding (D. Carlberg, personal

communication, January 11, 2010).

The significance of this applied research paper is that the AFD needs to develop a

medical screening program that would improve the health of its firefighters by identifying


and addressing health issues before they result in a disability or a line of duty death. Two goals

of this research paper are to educate firefighters about the significant risk of cardiovascular

disease in the fire service and to identify medical screening programs that would be effective,

economically feasible, and acceptable to both the firefighters and management. The lack of a

health screening program at the AFD was brought to the forefront when a 39 year-old member of

the fire department suffered a heart attack in 2009. The impact this event had on the fire

department was a catalyst for choosing this topic for the applied research project. To protect his

privacy, the firefighter will be referred to as FF#1 and his personal observations will be cited as

anonymous.

The topic addressed by this research project supports the USFA operational objective of

improving the fire and emergency services’ capability for response to and recovery from all

hazards, specifically, Objective 3.2 which advocates a culture of health, fitness, and behavior that

enhances emergency responder safety and survival (USFA Strategic Plan-Fiscal Years 2009-

2013, p. 9). This topic also reflects upon curriculum contained within the Executive

Development course at the National Fire Academy. Two of the objectives contained within Unit

7, Organizational Culture and Change are: (a) “recognize the indicators that point to a legitimate

need for an organization’s culture to change”, and (b) “recognize that the Executive Fire Officer

should be an agent of cultural organizational change” (Federal Emergency Management Agency

[FEMA], 2006, p. SM 7-1). The implementation of annual medical evaluations would be

an adaptive challenge for management as well as the firefighters at the AFD. Heifetz and Linsky

(2002) suggest that adaptive challenges require a change of culture, attitudes, values and beliefs

and that such challenges cannot be made by implementation of policy alone but require

acceptance and endorsement by the entire organization.


Literature Review

Because heart disease is not only the leading cause of line of duty death in the fire service

but is also the leading cause of death among the general U.S. adult population, significant

research has been directed towards reducing its impact (CDC, 2010). The AHA has identified

nine risk factors that contribute to coronary heart disease, six of which have been determined to

be modifiable through lifestyle changes and medical treatment. The modifiable risk factors

include tobacco use, high blood cholesterol, high blood pressure, physical inactivity, obesity and

diabetes mellitus (American Heart Association [AHA], 2008). The AHA lists the three non-

modifiable risk factors as increasing age, gender, with males being at higher risk, and heredity

and makes clear that those with a strong family history of heart disease are especially at risk

(AHA, 2008). The prevalence of hypertension, high cholesterol and obesity in the U.S. are

addressed by the CDC in a series of data briefs utilizing data from the National Health and

Nutrition Examination Survey (National Health and Nutrition Examination Survey [NHANES]

n.d.). In 2008 the National Center for Health Statistics released its findings regarding

hypertension utilizing data from the 2005-2006 survey. It was found that 29% of the U.S. adult

population ≥ 18 years of age had hypertension defined as systolic blood pressure ≥ 140 mmHg

and that 28% had pre-hypertension defined as systolic blood pressure ranging from 120 –

130mmHg (Ostchega, Yoon, Hughes, & Louis, 2008). A separate NHANES study found that

16% of the U.S. adult population ≥ 20 years old had total serum cholesterol levels of ≥ 240 mg/dl

placing them at significant risk for heart disease (Schober, Carroll, Lacher, & Hirsch, 2007).

Data obtained from the NHANES study for the years 2005-2006 was not encouraging when

assessing obesity in the U.S. with over one-third of the population registering as obese. For the

study, obesity was defined as anyone with a body mass index (BMI) ≥ 30.0 and was calculated


by dividing a person’s weight in kilograms by their height in meters squared. In comparing

obesity data from 1980 to 2007 it was noted that the adult population of the U.S. was becoming

heavier (Ogden, Carroll, McDowell, & Flegal, 2007).

As a group, firefighters must understand that they are included in these worrisome

statistics and that they in fact face a significantly higher risk of cardiovascular disease due to

their occupation. Referring again to the ten year retrospective study of firefighter deaths from

1990 to 2000 by the TriData Corporation, heart attacks were the number one cause of line of

duty firefighter deaths in the United States (USFA, 2002).

According to Scanlon and Ablah (2008) the modifiable risk factors, if not managed, are

associated with a high degree of morbidity and mortality and recommend firefighters control

them through proper diet, exercise, lifestyle changes, and physician intervention. In their study

of heart disease among firefighters Kales, Soteriades, Christophi, and Christiani (2007) indicated

that firefighters were at the greatest risk of heart attack during fire suppression activities because

many have undiagnosed coronary heart disease that has not been treated. The study further

revealed that this problem is exacerbated by the fact that nearly 75% of all United States fire

departments do not have programs designed to address the health and fitness issues affecting

firefighters. The study also concluded that responding to emergency alarms and physical

training in the form of physical fitness, live fire training and search and rescue drills, because of

the associated increases in cardiac demand, accounted for the next highest incidence of heart

attack in firefighters. In another study of firefighter deaths Kales, Soteriades, Christoudias, and

Christiani (2003) reported that heart attacks were the result of several work related stressors.

The stressors included periods of inactivity followed by heavy physical demands, working at or

near maximal heart rates for extended periods of time, reacting immediately to alarms, which


resulted in increased heart rates, and exposure to heat stress and dehydration which all placed a

strain on the cardiovascular system. The study examined 52 firefighter deaths and found that

over 25% of the firefighters had pre-existing arterial disease and that high blood pressure and

high cholesterol levels were common among the group. It was also determined that the majority

had not had an adequate medical evaluation during the two years preceding their death. Kales et

al. (2003) concluded that since the firefighter deaths were predominantly linked to pre-existing

cardiovascular conditions, improving the fire service’s attention to fitness and implementing

medical screening would greatly reduce the incidences of premature death from cardiovascular

disease. A study conducted in California that spanned 17 years and involved 71 male firefighters

from a career fire department concluded that as a whole, the group had better physical fitness

than a comparable male reference group (Davis, Jankovitz, & Rein, 2002). Importantly,

however, the study also documented that as part of the normal aging process both groups

experienced an increase in their cardiac risk factors in the form of increased total serum

cholesterol, increased BMI, and elevated blood pressures which reinforced their recommendation

that firefighters should be obtaining medical evaluations to manage those changes in a proactive

and preventative manner.

In a series of articles written to focus firefighter’s attention on their risk of heart attacks,

Basri and Bergman (2009b, 2009c, 2010) discussed the implementation of medical evaluations

as a way to identify firefighters with elevated cardiac risk factors. The authors stated that

firefighters who have unidentified and untreated cardiac risk factors are at the greatest risk of

dying on the job. They recommended that annual medical examinations be mandatory for

firefighters and that the examinations include screening for high blood pressure, high cholesterol,

diabetes, signs of cardiovascular disease, and BMI analysis. They also recommended that at the


time of the examination, physicians should be counseling firefighters about ways to reduce their

cardiac risk factors through lifestyle changes which included improving dietary intake and the

importance of obtaining 30 minutes of aerobic exercise four times per week. Loy (2001a) in

discussing cardiac risk factors reported that people are classified as being at moderate risk for

heart disease if they are male over the age of 45 or female over the age of 55 and have two or

more cardiac risk factors.

Published by the National Fire Protection Association, NFPA 1582 titled Standard on

Comprehensive Occupational Medical Program for Fire Departments specifically addresses the

requirements for annual medical evaluations for firefighters. It must be noted that since NFPA is

not a government agency, fire departments are not required to abide by the recommendations

unless the state or jurisdiction they are in adopts the standard as law. First published in 1992, the

standard was developed to address the medical requirements for firefighters and its most recent

edition in 2007 continues to promote health in the fire service. Within the standard, fire

departments and physicians will find the recommended criteria to be included in firefighter

medical evaluations as well as criteria that would preclude a firefighter from continuing in the

fire service (National Fire Protection Association, [NFPA], 2007). It is this exclusionary criteria

listed within the standard that may be the largest stumbling block preventing some fire

departments from adopting NFPA 1582. According to Basri and Bergman (2010) both career

and volunteer firefighters may view medical screening programs as a direct threat to their ability

to remain in the fire service. In answer to this the authors stated that fire departments should

make it clear that the purpose of the medical screening programs are to improve the firefighter’s

total overall health throughout their career and to ultimately prevent them from dying on the job.

NFPA 1582 addresses this topic by stating that firefighters should be considered the most


important resource at a fire department and that the implementation of NFPA 1582 should be

done in such a way that it improves firefighter health and wellness (NFPA, 2007).

The Fire Service Joint Labor Management Wellness-Fitness Initiative created by the

International Association of Fire Chiefs and the International Association of Firefighters define

the role union firefighters should take with respect to health and wellness. In the introduction to

the initiative it states that union leadership must work with management to ensure that the health

and safety of its members is an organizational priority and that fire departments should ensure

that each member is physically, mentally and spiritually capable of performing their duties to the

best of their ability (International Association of Firefighters, 2008). The initiative also states

that the program should be positive in nature and non-punitive with the improvement of the

individual’s health as the ultimate goal. Likewise, the USFA along with the National Volunteer

Fire Council (NVFC) has published guidelines for the volunteer fire and emergency services

(United States Fire Administration, 2009b). One of the goals of the publication is to provide a

foundation upon which volunteer fire departments can build their own health and wellness

programs. In 2003, 16 volunteer fire departments were identified that had viable health and

wellness programs and those programs were followed to determine what worked and what did

not work. Three common roadblocks were identified and they were funding issues, lack of well

defined program elements, and the difficulty in keeping the firefighters motivated to sustain the

programs (USFA, 2009b).

Of particular interest to this research was an article describing the preliminary results of a

2008 study conducted on 300 firefighters from the Gwinnett County (GA) Fire and Emergency

Services (Ward, 2009). During the initial medical screening process to identify cardiovascular

risk factors in firefighters, three members of the fire department were identified as requiring


immediate surgical intervention to save their lives. The author unequivocally stated that three

firefighter deaths were prevented that day by the timely medical evaluations. Preliminary results

from that research indicated that firefighters are at a 300% greater risk of developing

cardiovascular disease than the average citizen and that the increased risk is due to the inherent

physiological and emotional stressors of the job. The study also indicated that those stressors

coupled with poor dietary intake and lack of physical conditioning resulted in otherwise healthy

firefighters displaying increased risk for heart attack. The author concluded his article with this

advice, “Take care of yourself. Start with a checkup. Eat healthy and work out a little. That’s

not asking too much” (Ward, 2009, p. 84).

As referenced previously, a member of the AFD suffered a heart attack in 2009. The

heart attack occurred twenty-one hours after getting off work from what would be described as a

typical shift of responding to emergency medical calls, daily training, apparatus maintenance,

and station up-keep. Upon interviewing FF#1 regarding his cardiac risk factors it was

determined that he had a family history of cardiovascular disease, was being treated for

borderline hypertension and had a BMI > 30.0. He had also been treated in the past for elevated

cholesterol levels. He stated that his lifestyle would not have been classified as sedentary but

that he was not obtaining 30 minutes of aerobic exercise four times per week. FF#1 stated that

during his emergent cardiac angioplasty it was discovered that two of his coronary arteries were

severely occluded by cholesterol plaque. He conceded that the occlusions did not occur

overnight and that in retrospect he had experienced vague warning signs in the form of increased

fatigue and unexplained transient back pain brought on by exertion. FF#1 was candid in stating

that the two months he spent off work undergoing cardiac rehabilitation following his coronary

angioplasty was an extremely stressful time for both he and his family. He also stressed that


firefighters must pay attention to the signs and symptoms they are experiencing and to not

discount them as trivial. As of March 2010, his medical bills had totaled one hundred thousand

dollars and the determination as to whether his heart attack would be covered as a work related

presumptive cardiac illness under Washington State Labor and Industries Law was still pending.

His message to firefighters is very straightforward; he realizes he has been given a second

chance to continue working in the profession he loves and he wanted other firefighter to realize

that heart attacks can happen to them and that the identification and reduction of cardiac risk

factors should be the goal of every firefighter (Anonymous, personal communication, March 21,

2010). FF #1 missed two months of work due to his heart attack and AFD payroll records

obtained from the Administrative Assistant to the fire chief indicated that the fire department

spent $7,200 dollars in overtime costs to fill his vacancy in order to maintain a minimum staffing

level of eight firefighters. Had his absence from work occurred during the summer months,

when the fire department routinely operates at an eight man minimum due to scheduled

vacations, the overtime cost could have reached as high as $17,500 dollars (S. Johnson, personal

communication, March, 2010).

A portion of this research paper must focus on the benefits of physical exercise since it is

inherently linked to cardiovascular fitness. Heiden, Testa, and Musolf (2008) succinctly

described the benefits of regular aerobic exercise as training the lungs to breathe more effectively

and improving the hearts ability to pump blood throughout the body. The authors claim that

regular aerobic exercise results in thinner blood which improves oxygen transport to the cells,

helps keep the arteries clear of blockages, and results in a more efficient vascular system. The

overall effect is a reduction in blood pressure, lower cholesterol levels, and a reduction in cardiac

diseases including coronary artery disease and congestive heart failure. To measure a person’s


fitness level, Heiden et al. (2008) described the benefits of usingVO2 max testing as a tool to

indicate how efficiently a person’s heart, lungs, and blood are delivering oxygen to working

muscles. VO2 max is a measurement used to assesses an individual’s cardio-respiratory system

and ultimately their fitness level. Loy (2001b) reported that the Los Angeles Fire Department

uses a submaximal bench step test to obtain the VO2 max measurement of its firefighters on an

annual basis. The author reports that the fire department uses the bench step test because it is

easily administered at each fire station. An alternative VO2 max test referred to by the author, as

well as endorsed by The Joint Labor Management Wellness-Fitness Initiative, is a submaximal

treadmill test which utilizes the Gerkin Test Protocol. According to Loy (2001b) obtaining an

actual VO2 max value would require that firefighters be tested at an exercise physiology

laboratory but that the submaximal tests available, such as the bench step test or the treadmill test

are logistically more realistic for firefighters and fire departments. Loy (2001b) stated that at a

minimum, firefighters should be able to obtain VO2 max scores between 45 and 49 ml/kg/min

during the testing procedure. In assessing VO2 max scores the higher the value the more

physically fit someone is considered to be. Loy (2001b) adds that to become physically fit a

person must exercise at more than 70% of their age predicted maximum heart rate as part of a

regular exercise regimen.

In summary, the literature review indicated that firefighters are needlessly dying from

heart attacks at an alarming rate. The number of line of duty deaths from heart attacks has

remained at or near 50% per year for the past 20 years (Basri & Bergman, 2009a). There has

been medical research, legislation, and standards developed to address the issue but to date there

has not been a widespread cultural change in how fire departments operate or how firefighters

themselves view the issue. There are some bright spots however, with programs such as The


Joint Labor Management Fitness-Wellness Initiative and the Health and Wellness Guide

sponsored by the USFA and the National Volunteer Fire Council which have proven effective in

improving the health and wellness of firefighters. However, with only 25% of the U.S. fire

departments reporting that they have some form of health and wellness program in place,

undiagnosed cardiovascular disease will continue to threaten the lives of firefighters.

Improving firefighter physical fitness is also of paramount importance if the fire service

is to reduce the incidence of line of duty deaths from heart attacks. Basri (2005) is of the opinion

that firefighters must view themselves as occupational athletes and train their minds and bodies

accordingly. He stated that firefighters work at maximum physical and emotional extremes that

place a severe strain on the body and if they are not physically prepared the end result could be

their death.

The impact of the literature review on this research paper was significant. The reason

why firefighters should be obtaining annual medical evaluations became readily apparent early

on in the research process. This author realized that if this project was to have significance

within his own organization and the surrounding fire departments, this paper would need to

identify and present solutions to the barriers that were preventing local fire departments from

developing effective cardiac screening programs that identified and reduced cardiac risk factors.

Procedures

Descriptive research utilizing questionnaires was used to determine if the fire

departments and firefighters included in this research had taken steps to identify and reduce the

effects of cardiovascular disease in their organizations, assess perceived barriers preventing

firefighters from improving their health, and had the firefighters rate their overall physical

fitness. Three questionnaires were developed to obtain information specific to each target


population. The questions were developed by this author and reviewed for clarity and content by

the assistant chief and the training officer of the AFD. The external firefighter questionnaire was

developed to assess the firefighters of three surrounding mutual aid fire departments. The fire

chiefs of each of these departments and the AFD were also given a questionnaire to assess their

views on cardiovascular disease and physical fitness within their departments and to compare the

chiefs’ responses with the firefighters they supervise. A third questionnaire was developed to

solicit information from the members of the AFD. The three questionnaires are discussed in the

following sections.

External Firefighter Questionnaire

The three fire departments that participated in this research were selected because they

provide mutual aid response to the AFD for greater alarm fires and medical calls and therefore

work closely with the AFD at emergency incidents. The departments surveyed consist of two

that are staffed by a combination of career and volunteer firefighters and one that is staffed

exclusively by career firefighters. The career firefighters of the three departments are

represented by the IAFF for contractual items that address wages, hours and working conditions

and the volunteer firefighters are represented by their respective volunteer associations. Prior to

delivering the questionnaires the fire chief of each department and the union president of each

local bargaining unit were contacted by this author to determine if they would agree to

participate in the research project. All parties contacted expressed interest in participating in the

research. A cover letter (see Appendix B) was included with each external questionnaire which

explained the purpose of the questionnaire and the goal of the research. The letter also stated

that all information gathered would remain anonymous with respect to respondent identity and

that completion of the questionnaire was on a voluntary basis.


The external firefighter questionnaires (see appendix C) were delivered to the

participating fire departments on January 15, 2010 and retrieved on February 5, 2010, which

allowed the respondents 22 days to complete the questions. During the initial telephone contact

with the fire chief of each department it was determined that there were a total of 116 firefighters

in the external firefighter population. A total of 62 completed questionnaires were returned

resulting in a 53.4% return rate.

The following section provides an overview of the questions contained within

the external firefighter questionnaire along with the rationale for their inclusion. Question

number one of the questionnaire was used to determine the demographics of age, number of

years served in the fire service and the respondent’s career or volunteer status. Age and number

of years in the fire service were considered important data to collect as the literature review

indicated that as age and length of time in the fire service increased, so did the firefighters

inherent risk of cardiovascular disease. The respondent’s employment status of career or

volunteer was collected in order to compare response commonalities and differences between the

career and volunteer firefighters. Questions two and three assessed the respondent’s knowledge

of their organization’s current practice of providing pre-employment and incumbent firefighter

medical evaluations. If the respondent indicated that their organization provided annual medical

evaluations they were directed to skip to question number six, but if their organization did not

provide annual medical evaluations they were directed to continue on to question four. Question

four had the respondent indicate whether they obtained annual medical evaluations on their own

initiative. If the respondent answered no, question five provided selections for the respondent to

indicate why they did not obtain annual medical evaluations. The four answers provided were

identified during the literature review as being the most common reasons firefighters were not


obtaining annual medical evaluations. The respondent was also given the opportunity to list their

own reason for not obtaining annual medical evaluations should the four prepared responses not

accurately reflect their opinion. Question six asked that the respondent indicate whether they felt

that annual medical evaluations should be mandatory, voluntary or allowed them to provide their

own answer with explanation. Information gained from the literature review recommended that

medical evaluations should be a mandatory requirement for firefighters in order to identify and

treat life threatening conditions before they resulted in career ending disability or line of duty

death. Question seven was used to assess if the respondent was aware that heart attacks had been

the leading cause of firefighter line of duty deaths for the past five years. This question was

asked to determine if the heart attack line of duty death statistics and case studies published by

organizations such as the USFA, IAFF, IAFC and NIOSH were being reviewed by the

firefighters included in this research. This question was important because if firefighters are not

aware of the information contained in these reports they are not adequately informed about the

risk of cardiovascular disease in the fire service. Question eight was used to determine if the

respondent’s department had a policy in place regarding firefighter physical fitness and question

nine asked the respondent to indicate how often they exercised to improve their cardiovascular

fitness level. Both of these questions were used to ascertain if physical fitness was an

organizational and personal priority since increasing physical activity is one of the six modifiable

risk factors identified by the AHA. Question ten and eleven were used to determine the

respondent’s self-reported fitness level and required the respondent to indicate how they

determined their fitness level. The three responses available to the respondent were

medical/physical testing, comparison to others, or that they rated their cardiovascular fitness

subjectively. Question eleven was written to emphasize that without quantitative measurable


data in the form of lab work and medical screening, the respondent’s self assessment was purely

subjective and could result in undiagnosed and untreated cardiovascular disease. Questions

twelve and thirteen were used to assess the organizational culture of the respondent’s fire

department. The questions asked if the respondent felt that physical fitness was a priority for

their organization and then asked the respondent to select from a list of barriers they felt may be

preventing firefighters in their organization from maintaining a physically fit state.

The following limitations are noted for the external firefighter survey. First, prior to

dissemination to the research group, the questionnaire was not tested on a sample population to

screen for ambiguous questions. Therefore, some of the questions may have allowed for

individual interpretation not intended by this author. Specifically, questions nine through twelve

of the questionnaire allowed for subjective interpretation and therefore the results, although

informative, should not be used to rate the firefighters as fit or not fit. It is, however, a

contention of this research paper that unless firefighters undergo medical and physical testing

they are not able to accurately determine their cardiovascular fitness level. This concept is

emphasized by question number eleven which asked the respondent to rate their cardiovascular

fitness level. It is this author’s contention that only the respondents who had undergone

medical/physical testing could accurately answer this question. The second identified limitation

was an error contained in the cover letter attached to the questionnaire. The definition for

medical evaluation, line f. cardiovascular/aerobic testing, should have listed spirometry as the

diagnostic procedure to be used and not treadmill/Stairmaster. This author does not believe that

this error had a negative impact on the results of the questionnaire but is noted here for

clarification. The last identified limitation is that this author did not contact the leadership of

each volunteer association prior to delivery of the questionnaire as was done with the fire chiefs


and union presidents. This failure to adequately inform the volunteer leadership as to the

purpose of the research may have accounted for the 36.6% return rate from the volunteer

firefighters as compared to the 94.1% return rate from the career firefighters.

Fire Chief Questionnaire

The fire chiefs of the three external fire departments included in this research project as

well as the fire chief of the AFD were provided with an explanatory cover letter and

questionnaire during the same 22 day period as the firefighters (see Appendices D and E). All

four questionnaires were returned for a 100% return rate. The purpose of these questionnaires

was to determine management’s stance on annual medical evaluations, gain insight into the

organizational culture of each organization regarding medical and physical fitness testing, and to

compare the fire chiefs’ responses with the responses given by their firefighters. Included with

the questionnaire were pages 1582-16 to 1582-17 of NFPA 1582 which lists the required

elements of a firefighter medical evaluation.

The following section provides an overview of the questions contained within the fire

chief questionnaire along with the rationale for their inclusion. Question number one was used

to determine if the fire departments the fire chiefs represented required a candidate firefighter to

successfully pass a medical evaluation prior to employment. Question number two was used to

determine if their fire department required its incumbent firefighters to undergo annual medical

evaluations. Both questions listed NFPA 1582 as the required medical evaluation standard and

both questions applied to career and volunteer firefighters. Question number three asked if their

fire department had developed essential job tasks as described in NFPA 1582 for each position in

the fire department. Essential job tasks are a key component of NFPA 1582 when determining

firefighter fitness for duty issues. Question number four was used to ascertain whether the


employee’s medical health plan would cover the financial cost of providing annual medical

evaluations for the department’s firefighters regardless of their career or volunteers status. This

question was important as the financial burden, whether born by the organization or by the

individual firefighter, could be a significant barrier to implementing annual medical evaluations.

Question number five was used to determine if in the past five years a member of their fire

department had lost time from work due to a cardiovascular condition. The term cardiovascular

condition was defined as cardiac arrest, myocardial infarction, coronary artery disease, angina

pectoris, cardiac arrhythmia and hypertension. This question was used to determine if there was

a history of cardiovascular disease among the fire department’s members that had impacted their

fire department. Questions six and seven were used to determine if the fire departments had

policies in place that delineated medical and physical fitness standards, whether their firefighters

were compliant with the existing policies, and if the organizational culture of their fire

department promoted physical fitness as a priority. Question number eight requested that the fire

chiefs list the three most significant barriers they felt would inhibit them from implementing

annual medical evaluations for their firefighters. This question was important because, without

identifying those barriers, developing solutions would not be possible.

A limitation of the fire chief’s questionnaire was that it was only distributed to four fire

chiefs and therefore did not represent widespread management input as opposed to the 93

questionnaires received from the combined firefighter group. Another limitation was that the

questionnaire did not seek to determine if the fire chiefs had identified solutions to the barriers

they identified in question number eight regarding the implementation of annual medical

evaluations in their organizations. The solutions they proposed would have been a key

component to this research and was an oversight by this author.


Aberdeen Firefighter Questionnaire

An explanatory cover letter and questionnaire (see Appendices F and G) were delivered

to the firefighters of the AFD on January 26, 2010 and retrieved on February 10th, 2010 which

allowed the firefighters 16 days to complete the questionnaires. Prior to dispersing the

questionnaires this author met with the fire chief of the AFD and the union president to address

any questions they may have had and to gain their support for the project. A total of 33

questionnaires were distributed and 31 completed questionnaires were returned resulting in

in a return rate of 93.9%. The questions were formulated based on information gained from the

literature review and from this author’s personal observations as a member of the AFD for 15

years. Because of this personal knowledge, questions regarding the existence of pre-employment

medical evaluations, annual medical evaluations, and physical fitness programs were eliminated

from the questionnaire. The focus of the questionnaire was directed towards assessing individual

firefighter’s cardiac risk factors and determining their level of participation in health and fitness

programs currently available to them. The questionnaire was also used to determine if the

firefighters were in favor of implementing an annual medical evaluation program.

The following section provides an overview of the questions along with rationale for their

inclusion in the questionnaire. Question number one asked that the respondent indicate their age

and number of years in the fire service. As with the external firefighter questionnaire this

information was important to collect since studies have shown a corresponding increase in

cardiac risk factors due to increasing age and length of time in the fire service. Question number

two had the respondent indicate when their last medical evaluation occurred that met the criteria

listed in NFPA 1582. The purpose of this question was to determine how many respondents

were currently obtaining medical evaluations on their own initiative. Question number three


asked if the respondent had a primary physician and attempted to determine how often they saw

their physician and for what purpose. This question was used to determine if there were

firefighters at the AFD who did not have a primary physician they could go to on an annual basis

for medical evaluations. Question number four asked if the respondent participated in the City of

Aberdeen’s Wellness Program or if they were aware that it even existed. The Wellness program

is managed by the City of Aberdeen’s Human Resource Director. Annual health screening

which includes cholesterol testing, diabetes screening and identification of cardiac risk factors is

offered to all city employees free of charge. Question number five addressed the six modifiable

cardiac risk factors identified by the AHA. This question was considered a key component of

this research because it has been shown that an annual medical evaluation that is designed to

identify and treat the six modifiable cardiac risk factors is the most effective way for firefighters

to decrease their risk of cardiovascular disease. A body mass index table was included with each

questionnaire that enabled the respondent to calculate their BMI and body classification type.

The body classification types consisted of the following: a BMI of 19 to 25 was classified as

normal, 26 to 30 was classified as overweight, 31 to 39 was classified as obese, and 40 to 54 was

classified as extreme obesity. Question number six was used to determine if the firefighters at

the AFD were aware that annual medical evaluations were recommended by both The Fire

Service Joint Labor Management Wellness-Fitness Initiative and NFPA 1582. This question was

used to ascertain the current level of awareness of these two documents in order to determine a

starting point for educating the members as to the benefits of medical evaluations. Question

number seven asked the respondent to indicate whether they were in favor of the AFD

implementing a mandatory annual medical evaluation program. This question was used to assess

whether there would be opposition to implementing a medical evaluation program as well as


document the concerns of the firefighters. Question number eight was used to determine how

many firefighters currently employed by the AFD participated in a voluntary cardiac stress test

offered by the Grays Harbor County Medical Program Director, Dr. Daniel Canfield, during the

first quarter of 2007. Dr. Canfield, a retired paramedic/firefighter from the AFD, offered this

service to the AFD as a result of a line of duty death of a firefighter in March of 2006. The

firefighter, who was employed by another municipality within our county, was taking part in surf

rescue training when he died from cardiac arrest secondary to hypothermia and exhaustion. In

speaking with Dr. Canfield, he stated that he was motivated to offer this test in order to provide a

proactive tool for members of the AFD to identify and treat cardiovascular disease before it

resulted in a catastrophic event (D. Canfield, personal communication, January 15, 2010). This

question also had those firefighters who had declined to participate in the cardiac stress test

document their reasons for abstaining. This question was considered important to include

because, as with the Health and Wellness program provided by the City of Aberdeen, there is no

financial cost to the firefighter and determining why some members chose to not participate in

the stress test could help to identify personal barriers. Question number nine was directed

towards firefighters at the AFD who were not obtaining annual medical evaluations from their

own physicians. This question was included as an additional attempt to identify personal barriers

that would have to be overcome if the AFD were to implement an annual medical evaluation

program. Questions ten and eleven were identical to questions ten and eleven of the external

firefighter questionnaire. Question ten had the respondent rate their cardiovascular fitness level

ranging from excellent to poor and question number eleven had them indicate how they had

determined their answer to question number ten. Again, the purpose of these two questions was

to highlight that without quantifiable data obtained from a medical evaluation, determining one’s


cardiovascular fitness level is not possible. Question number twelve had the respondent indicate

if they regularly exercised to determine the current fitness culture at the AFD and question

number thirteen was used to determine if the respondent was aware that heart attacks were the

leading cause of firefighter deaths for the past five years. Question fourteen addressed the topic

of physical fitness at the AFD and asked the respondent to indicate if they felt there were barriers

preventing them from maintaining a physically fit state. The answers available to the respondent

were identified from the literature review as being the most common reasons firefighters had

given for not maintaining their fitness. Question fourteen also asked the respondent to indicate if

they currently exercised while on-duty. As with question number twelve, this question was used

to determine the current fitness culture at the AFD. Question fifteen asked the respondent to

indicate whether they would be in favor of implementing annual physical fitness assessments as

described in NFPA 1583 and The Joint Labor Management Wellness-Fitness Initiative. The tests

described in this question consist of an aerobic capacity test utilizing a treadmill, body

composition analysis, muscular strength and flexibility measurement and that the program would

be designed to be non-punitive in nature. Although this question was not directly related to the

purpose of this research paper, the information obtained was directed towards determining the

current fitness culture at the AFD.

The following limitations for this questionnaire are noted. As with the external

firefighter questionnaire, the AFD firefighter questionnaire was not administered to a test

population prior to dissemination to the research group to determine if the questions were

optimally phrased to obtain the desired information. It should also be noted that the author, who

is a member of the AFD, included the answers from his own questionnaire in the results. This is

not believed to have impacted the results in a negative manner. A limitation applicable to all of


the questionnaires used in this research was that the data received was all self-reported and not

verified by this author. It is believed, however, that the provision of organizational anonymity

for the external fire departments and personal anonymity for all the firefighters involved allowed

for candid and insightful responses.

Telephone interviews were held with the City of Aberdeen’s medical insurance

representative, the City of Aberdeen’s Human Resources Director, the EMS Medical Program

Director and local medical professionals in order to determine what options were available to

local fire departments should they choose to implement medical screening programs. The

conversations were informal and unscripted on the part of this researcher. The one limitation

noted for these interviews was the interview with the medical insurance representative. She

stated that she was not in a position to document in writing the opinions she had expressed but

felt that the insurance carrier would most likely share her conclusions. The information collected

from these interviews is contained within the Results section of this research.

Results

The data collected from the questionnaires was entered into a Microsoft Excel

spreadsheet and is presented here in narrative format. The complete results are displayed in

Appendix H for the AFD questionnaire, Appendix I for the external firefighter questionnaire

(EFQ), and Appendix J for the fire chief questionnaire. The results for the EFQ and the AFD

firefighters are presented separately where appropriate to facilitate comparison between the two

groups. The EFQ cohort consisted of 62 firefighters of which 32 were career firefighters and 30

were volunteer firefighters. The AFD cohort was comprised of 31 career firefighters. Data

collected indicated an average age of 38.5 for the EFQ and 36.1 for the AFD. The average

length of time in the fire service was 12.4 years for the EFQ respondents and 13.9 years for AFD


respondents. In order to gain further insight into the demographics of each cohort the

respondents were separated into one of four age groups. The results are displayed in Table 1.

Table 1

Age Group Comparison of the AFD and EFQ Respondents

______________________________________________________________________________

Age group AFD respondents

18 to 30 years old 29% 33%

EFQ respondents

31 to 40 years old 42% 18%

41 to 50 years old 19% 31%

51 to 60 years old 10% 18%

______________________________________________________________________________

Examination of the age group data indicated that 29% of the AFD respondents and 49%

of the EFQ respondents are nearing or have achieved an age that has been identified as having an

increased risk for cardiovascular disease, that being 45 for males and 55 for females.

In order to determine if the fire departments and firefighters were taking steps to reduce

the risk of heart attack the following information was collected. The external fire departments

and the AFD all required candidates for employment to undergo pre-employment physical

evaluations. This was confirmed by data collected from the fire chief questionnaires. The fire

chiefs who supervised volunteer firefighters also reported that their volunteer firefighters were

given pre-employment medical evaluations that met the medical requirements set forth by the

Washington State Bureau of Volunteer Firefighters. The fire chiefs indicated, however, that this

medical evaluation was slightly less inclusive than the criteria contained in NFPA 1582. For

career firefighters, the pre-employment physicals were compliant with NFPA 1582. For the EFQ


respondents, 91.9% were aware that their department required pre-employment physicals, 4.8%

did not think physicals were required and 3.2% did not know if they were required.

All of the departments surveyed indicated they do not require firefighters, whether they

are career or volunteer, to undergo annual medical evaluations once they are employed. In

determining whether the firefighters obtained annual medical evaluations on their own initiative,

50% of the EFQ respondents reported they did not, 43.5% indicated that they did and 6.5% did

not answer the question. For the firefighters at the AFD, a range of years was provided for them

to indicate when they had last undergone a medical evaluation that met the criteria outlined in

NFPA 1582. For 22.6% of the AFD respondents five years or longer had elapsed since they had

undergone a physical and 16.1% indicated they had never had a physical evaluation that met the

requirements. The data also indicated that 6.5% of the firefighters had physicals within the past

three years, 16.1% within the past two years, and 38.7% within the past year. The high

percentage of firefighters receiving physicals within the past year is explained by the fact that

50% of those firefighters received them as part of their pre-employment hiring process.

Examination of this data indicated that 50% of the EFQ respondents and 45.2% of the

AFD respondents could be at increased risk for cardiovascular disease due to the length of time

since their last medical evaluation. It was an encouraging finding, however, that all four

departments surveyed provided thorough pre-employment medical evaluations for their

firefighters.

The members of the AFD were asked to indicate whether they had their own primary

care physician and to indicate if they saw their physician annually or just on an as needed basis.

The results showed that 94% of the AFD firefighters did have a primary physician but that

only 32% went to their doctor annually and that 65% went only when they were sick.


The members of the AFD were asked to perform a self assessment to determine if they

had any of the six modifiable cardiac risk factors that could place them at increased risk for

cardiovascular disease and those results are displayed in Table 2.

Table 2

Assessment of Modifiable Cardiac Risk Factors for AFD Respondents

______________________________________________________________________________

Cardiac risk factors

Smoking 97% No 3% Yes

AFD respondents

Knowledge of cholesterol level 52% No 45% Yes

Medical history of hypertension 90% No 10% Yes

Aerobic exercise: 120 min/week 55% No 45% Yes

Body mass index category 26% Normal 55% Overweight 19% Obese

History of diabetes 100% No

______________________________________________________________________________

Examination of the data included in Table 2 indicated that some respondents at the AFD

may be at an increased risk of cardiovascular disease. The AFD respondents considered at

increased risk would be those that were not aware of their cholesterol level, were not obtaining

adequate aerobic exercise or were categorized as either overweight or obese.

The AFD respondents were asked to indicate if they participated in the Wellness Program

sponsored by the Association of Washington Cites and the Human Resources Department. Only

26% of the respondents indicated that they participated in the program, 74% indicated that they

did not and of those 74%, 13% were not aware that the program existed. This data indicated

that the health resources currently available to the AFD respondents are being underutilized.


The AFD respondents were also queried regarding their familiarity with The Fire Service

Joint Labor Management Wellness-Fitness Initiative. Specifically, they were asked to indicate if

they were aware that both the Wellness-Fitness Initiative and NFPA 1582 required firefighters to

undergo annual medical evaluations. The results indicate that 38% of the respondents were

aware of the requirement, 39% were not aware it and 22% indicated they were only vaguely

aware of the requirement. These results indicated that widespread knowledge is lacking among

this group regarding the elements contained within the initiative or NFPA 1582.

The firefighters from both cohorts were asked to indicate whether they would support the

implementation of mandatory annual medical evaluations at their fire departments or

if they felt that the program should only require voluntary participation. The results for this

question are displayed in Table 3.

Table 3

Implementation of Mandatory vs. Voluntary Medical Evaluations

______________________________________________________________________________

AFD response

Support mandatory evaluations 87% 60%

EFQ response

Support voluntary evaluations 3% 37%

Undecided 10% 3%

______________________________________________________________________________

One EFQ respondent commented that annual medical evaluations should be a mandatory

requirement for career firefighters but should be a voluntary requirement for the volunteer

firefighters. The results indicated that the majority of respondents supported the implementation

of mandatory medical evaluations at their fire departments which was not an expected result


considering that mandatory programs of any kind are often viewed with trepidation in the fire

service.

To assess the level of awareness the firefighters had regarding the risk of heart disease in

the fire service the firefighters were asked to indicate if they knew that heart attacks had been the

leading cause of line of duty deaths for the past five years. For the EFQ firefighters, 77%

indicated they were aware of the risk, 16% were not aware and 5% reported that they were

vaguely aware. In response to the same question 97% of the AFD firefighters knew that heart

attacks had been the leading cause of line of duty deaths and 3% percent did not. This data was

encouraging since firefighters who are aware of the increased risk of heart attack in the fire

service may be more likely to participate in programs designed to reduce cardiac risk factors.

In an attempt to identify barriers that would inhibit the implementation of programs

designed to improve the health of firefighters the following data was collected. The four fire

chiefs surveyed were asked to list the three most significant barriers they felt they would face if

they attempted to implement annual medical evaluations at their fire departments. Three of the

fire chiefs indicated that the financial burden of such a program would be a major obstacle given

their current budgetary constraints. Other barriers identified by the fire chiefs included

negotiating with the labor unions, promoting participation among the firefighters, designing the

program so that it promoted health and was not punitive, and addressing the concerns of the

firefighters who may feel that annual medical evaluations would be a threat to their job security.

The fire chiefs were asked if annual medical evaluations would be a procedure covered

by their department’s medical insurance plan. For the career firefighters, two of the departments

did have medical plans that included medical evaluations as a covered service but two

departments reported that their insurance plan would not. It was also reported that annual


medical evaluations for the volunteer firefighters included in this research would not be

covered by their fire department’s medical insurance plan.

The fire chiefs were asked to indicate whether their departments had policies in place

that delineated medical and physical fitness standards for their firefighters. The three fire chiefs

of the external fire departments indicated that they did not have policies in place that addressed

either the medical or physical fitness criteria of their employees. The fire chief of the AFD

indicated that a policy for medical fitness did exist but that there was not a policy in place

regarding the physical fitness criteria of firefighters.

The four fire chiefs were asked to indicate if their fire departments had developed an

essential job task analysis as described in NFPA 1582. The three external fire chiefs reported

that their fire departments had not developed a job task analysis but the fire chief of the AFD

reported that a job task analysis had been developed several years ago to assist physicians in

determining what duties firefighters could perform while on light duty.

In summary, the data collected from the fire chiefs indicated that the financial cost of

implementing annual medical evaluations would be the primary obstacle they would have to

address. The financial cost could be a significant barrier for the two fire departments with

medical insurance plans that do not include medical evaluations as a covered service for their

career firefighters. This barrier also exists for the two departments that have volunteer

firefighters since they are not eligible to receive medical evaluations covered by their fire

department’s medical insurance. Only one fire department had developed an essential job task

analysis for firefighters. This document is a requirement under NFPA 1582 and is used by

physicians to determine if a firefighter is capable of performing fire ground operations based on

specific tasks. Finally, none of the fire departments surveyed indicated that they have a policy in


place that described a physical fitness standard their firefighters must meet, and only one fire

department had a policy in place that described the medical standard a firefighter must meet

to be considered fit for duty. Results from the fire chief questionnaire also indicated that the

AFD was the only organization included in the research that had a member experience a heart

attack. In fact, the other fire departments reported no documented employee time loss due to

cardiovascular disease over the past five years.

To assess why some firefighters were not obtaining annual medical evaluations on their

own initiative the respondents were asked to indicate what personal barriers they felt existed.

The questionnaire provided four responses from which the respondents were instructed to choose

all that applied and the results are displayed in Table 4.

Table 4

Personal Barriers Preventing Firefighters from Obtaining Annual Medical Evaluations

______________________________________________________________________________

AFD response EFQ response

Organization’s responsibility 13% 21%

Cost is financially prohibitive 16% 10%

Physically fit: Don’t need one 13% 10%

Could result in job loss 3% 6%

______________________________________________________________________________

Additional comments received in response to this question were that some of the

firefighters had not previously considered getting annual medical evaluations and for others

medical evaluations were not a high priority. Table 4 indicates that a large percentage of

the firefighters are not obtaining medical evaluations because they felt it was the fire


department’s responsibility to provide them and also that the financial cost was prohibitive. The

data also indicated that some firefighters did not feel they needed medical evaluations because

they considered themselves physically fit. It was interesting to note that the fear that medical

evaluations could result in job loss was not a significant factor.

The respondents from both cohorts were asked to indicate what organizational barriers

they felt existed that were preventing firefighters within their departments from maintaining a

physically fit state. The questionnaire provided eight responses from which the respondents

were instructed to choose all that applied and the results are shown in Table 5.

Table 5

Firefighters Perceived Organizational Barriers to Physical Fitness

_____________________________________________________________________________

Barrier identified AFD response EFQ response

No barriers identified 10% 24%

Call volume vs. staffing 74% 32%

Budget constraints 48% 29%

Not an organizational priority 45% 58%

Lack of awareness of the issue 13% 32%

Poor equipment 26% 32%

Union/Management issue 3% 16%

Individual laziness 52% 66%

_____________________________________________________________________________

Examination of the data in Table 5 indicates that for the AFD respondents the high call

volume run by the department was the primary obstacle to obtaining physical fitness. Both


cohorts also cited budget constraints, individual laziness and their organization’s culture as

significant barriers that must be addressed in order to improve firefighter fitness.

In an effort to provide fire departments with viable options that would address the

financial and logistical barriers identified by this research, three alternatives were identified that

have the potential to reduce the incidence of cardiovascular disease. First, during an interview

with the Human Resource Director for the City of Aberdeen it was reported that the City of

Aberdeen Wellness Committee, in conjunction with the Human Resources Department and the

Association of Washington Cities, provides free annual health screening to all city employees

and their spouses. Although the screening elements are not specifically designed for firefighters,

they do assess an individual’s cardiac risk factors. The tests include screening values for height,

weight, blood pressure, total cholesterol, and glucose. The results are reviewed with the

employee by a health professional and the entire process lasts approximately 15 minutes (L.

Hein, personal communication, March 14, 2010). As previously noted in this research only 26%

of the AFD firefighters currently participate in this program. The second option identified was

cardiac screening offered by a consortium of local physicians associated with Grays Harbor

Cardiovascular Imaging. The Managing Director of Operations stated that his clinic could

provide in-depth cardiac screening which included evaluation of stroke risks, 12 lead EKG

analysis, body mass index analysis, assessment of peripheral artery disease and blood analysis

including cholesterol levels, glucose monitoring and liver function tests (K. Sprouffske, personal

communication, January 27, 2010). At the time of this report the cost of this service was $90.00

dollars. He also stated that his organization could provide 12-lead treadmill testing and

pulmonary function tests designed to specifically meet the needs of firefighters. The third option

identified was that each firefighter could obtain annual medical evaluations with their own


physicians that met the requirements of NFPA 1582. The members of the AFD have medical

insurance through the Association of Washington Cities Regence BlueShield and are covered

under the PPO Medical Plan-2010. Under this plan preventative care in the form of physical

examinations is considered a covered service, subject to a co-pay of $10.00 dollars. The medical

screening elements contained within NFPA 1582 were sent to the insurance representative at

Regence BlueShield and it was confirmed that medical evaluations would be a covered service

under the current medical plan. A question pertinent to this research was determining if the

insurance plan would cover an annual physical evaluation that was part of a mandatory health

screening program. This question was posed to the service representative at Regence

BlueShield. The representative stated that the service would be covered minus the $10.00 dollar

co-pay as long as the mandatory health screening program was designed to promote health and

wellness and was not a condition of employment (M. Vess, personal communication, February

16, 2010). This information differs from the information contained within the PPO Medical

Program Guide which stated that physical examinations that are used to obtain or continue

employment are excluded from insurance coverage. At the time of this report this researcher was

unable to obtain documentation from the insurance carrier stating that mandatory medical

evaluations would be a covered service. This issue would require communication between the

City of Aberdeen’s Human Resource Director and Regence BlueShield. The three medical

screening options identified have the potential to reduce the financial burden placed on the fire

departments while providing effective cardiac screening for firefighters.

The last problem addressed was determining if physical fitness was an organizational

priority for the fire departments included in this research. This question was asked of the four

fire chiefs and their responses were varied. Two of the chiefs reported they felt that their


organizations supported physical fitness as a priority and one chief reported that philosophically

fitness was a priority but that lack of funding did not support the philosophy. The fourth chief

emphatically stated that physical fitness was not a priority for his organization.

In comparison, Table 5 indicates that 45% of the AFD respondents and 58% of the EFQ

respondents felt that physical fitness was not a priority for their organizations.

In order to gauge what priority the firefighters at the AFD placed on fitness they were

asked to indicate if they participated in a voluntary cardiac treadmill stress test that was offered

free of charge to the fire department during March 2007. Only one half of the firefighters

employed during that time period participated in the testing. Some of the reasons given by those

that chose not to participate included that they were too busy, did not think they needed it and,

one respondent felt that it could lead to mandatory testing.

The respondents from both cohorts were asked to indicate if they exercised regularly to

improve their cardiovascular fitness level and those results are contained in Table 6.

Table 6

Self-Reported Exercise Frequency

_____________________________________________________________________________

Exercise frequency AFD respondents

Exercise regularly 52% 58%

EFQ respondents

Do not exercise regularly 0% 15%

Inconsistent exercise regimen 48% 27%

_____________________________________________________________________________

It is noted that a limitation of this question was that the term regular exercise was not

defined and therefore allowed for individual interpretation by the respondents. The data does


indicate, however, that a significant number of respondents from both cohorts are not obtaining

regular exercise to improve their cardiovascular fitness. The AFD respondents were asked to

indicate if they exercised while they were on-duty and 65% responded that they did and 35%

responded that they did not. The fact that the majority of firefighters are exercising while on

duty was an encouraging finding.

The respondents from both cohorts were also asked to rate their current cardiovascular

fitness level. The respondents were provided answers ranging from excellent to poor and the

results are displayed in Table 7

Table 7

Self- Reported Cardiovascular Fitness Levels

_____________________________________________________________________________

Fitness level AFD respondent

Excellent 10% 10%

EFQ respondent

Very good 32% 23%

Good 26% 40%

Average 29% 24%

Poor 3% 2%

_____________________________________________________________________________

Again the limitation noted for this question was that each fitness level was not clearly

defined which allowed for individual interpretation by each respondent. It is noted that the

majority of respondents placed themselves in the very good to average range with very few

rating themselves as excellent and an even smaller percentage choosing the poor fitness category.

The respondents were asked to indicate how they determined their fitness level by


selecting from the three answers provided and those results are displayed in Table 8.

Table 8

Determination of Self-Reported Fitness Level

_____________________________________________________________________________

Determination criteria AFD respondents

Medical/physical testing 35% 32%

EFQ respondents

As compared to others 71% 53%

Just picked a category 10% 16%

_____________________________________________________________________________

The results indicate that approximately one third of each cohort could rate their

cardiovascular fitness level based on quantifiable data obtained from medical and physical

testing. The majority of the respondents based their fitness level on how they compared to their

peer group. A small percentage of respondents indicated they just picked a category without

having a basis for doing so.

The EFQ respondents were asked if their fire department had a policy in place regarding

firefighter physical fitness. The answers to this question were compared to the answers from the

external fire chiefs who had previously reported that no policies existed. The EFQ respondent

answers indicated that 79% of them were aware that no policy existed, 2% thought there were

policies in place and 16% indicated they did not know if there was a policy or not.

The final question posed to the AFD respondents was used to determine if there would

be interest in developing an annual fitness assessment as outlined in NFPA 1583 and The Fire

Service Joint Labor Management Wellness-Fitness Initiative. The testing listed in the

questionnaire included a treadmill test, body composition analysis, muscular strength, muscular


endurance, and flexibility. The question also indicated that the programs described in the two

publications are to be non-punitive. The results indicated that 97% of the department was in

favor of implementing this program while 3% were against it.

Discussion

For the fire departments included in this research, one could apply the English idiom that

the elephant sitting in the corner of the apparatus bay is named “heart attack” and that no one

wants to acknowledge him. It is an indisputable fact, however, that heart attack is the number

one cause of line of duty firefighter death and has been so for the last twenty years (Basri &

Bergman, 2009a; USFA, 2002). There has been progress made on a national level to address this

issue with standards such as NFPA 1582 and The Fire Service Joint Labor Management

Wellness-Fitness Initiative but information gained from this research indicated that locally the

fire departments and firefighters have not formally addressed the issue. Only one of the fire

departments included in this research had developed a medically fit for duty policy and none of

the fire departments had developed a physical fitness standard. The fact that only one of the four

departments included in this research had past experience with a member having a heart attack

may account for the lack of attention to this issue. It was determined, however, that 97% of the

AFD respondents and 77% of the EFQ respondents were aware that heart attacks were the

number one cause of firefighter line of duty deaths.

The AHA has developed a list of nine cardiac risk factors used by physicians to assess

an individual’s risk of cardiovascular disease (AHA, 2008). It was determined from this research

that 29% of the AFD and 49% of the EFQ respondents were at or nearing an age associated with

increased cardiac risk, that being 45 for males and 55 for females as reported by Loy (2001a).

This research attempted to assess the cardiac risk factors of the AFD respondents and the data


indicated that the department’s personnel were not effectively managing their modifiable cardiac

risk factors, with 74% of the respondents either overweight or obese, 52% indicating that they

were not aware of their cholesterol level, and 55% reporting they were not obtaining sufficient

aerobic exercise. According to Loy (2001a) people who had achieved an age identified as being

at increased risk and who also had two or more elevated cardiac risk factors were classified as

being at moderate risk for heart disease.

On a positive note, all the fire departments surveyed did provide pre-employment

medical evaluations that were compliant with NFPA 1582 for the career firefighters and the

Washington State Bureau of Volunteer Firefighter medical evaluation for the volunteer

firefighters. It was determined; however, that none of the fire departments required that their

firefighters undergo annual medical evaluations once they are employed. This practice could be

placing firefighters at risk for heart attack because, as Scanlon and Ablah (2008) reported,

firefighters who have untreated or undiagnosed cardiac risk factors are at the greatest risk of

dying. This is further supported by Kales et al. (2003) who reported that 25% of the 52

firefighter deaths from heart attack he examined had pre-existing arterial disease, high

cholesterol levels, or hypertension and had not had a medical evaluation in the two years

preceding their deaths. The results of this research project indicated that 45.2% of the AFD and

50% of the EFQ respondents were at increased risk because they were not obtaining annual

medical evaluations on their own initiative and therefore may have undiagnosed cardiovascular

disease. Kales et al. (2003) reached the conclusion that since the firefighter deaths reviewed in

his study were predominantly linked to pre-existing cardiac conditions the fire service must

improve its attention to fitness and move towards implementing annual medical screening. He

contends that this would greatly reduce the incidence of premature death from cardiovascular


disease in the fire service. Kales et al. (2007) in another study of cardiovascular disease and its

effect on firefighters reported that because of the physical and psychological stressors associated

with the job of fire fighting, undiagnosed cardiovascular disease is particularly deadly to

firefighters.

Firefighters must be made to understand that their occupation places them at increased

risk of death from cardiovascular disease. According to the CDC (2010) cardiovascular disease

is the number one cause of death in the adult U.S. population and firefighters need to be aware

that as a group they are included in these statistics. Data from a series of surveys under the

auspices of the NHANES data base indicated that 29% of the U.S. adult population has

hypertension, 16% have elevated cholesterol levels and 33% are considered obese (NHANES,

n.d.). The findings of Davis et al. (2002) support this since the firefighters included in their

multi-year study all experienced age-related increases in their cardiac risk factors, which

included increased cholesterol levels, weight gain, and hypertension.

According to the USFA only 25% of U.S fire departments have a health and wellness

program in place designed to protect firefighters from illness or injury (USFA, 2009b). This is

consistent with the findings of this research that found that none of the four departments

surveyed had a formal health and wellness program. Both NFPA 1582 and The Fire Service

Joint Labor Management Wellness-Fitness Initiative recommend that fire departments

implement wellness programs that have mandatory medical evaluations as a component of the

program (NIOSH, 2007; IAFF, 2008). A positive finding from this research was that 87%

of the AFD respondents and 60% of the EFQ respondents indicated that they would support the

implementation of mandatory medical evaluations at their fire departments. The support of the

firefighters would be instrumental in the development of any new program designed to identify


and reduce the incidence of cardiovascular disease.

Common barriers to improving firefighter health were identified in the literature review

and consisted primarily of funding issues, program design, and motivating firefighters to stay

engaged with the program (USFA, 2009a). This research project identified similar barriers with

funding being the primary concern expressed by the fire chiefs and the firefighters in each

cohort. This obstacle cannot be underestimated given the current financial hardship facing all

the departments included in this study. Other significant barriers identified included the impact

of high call volume on the firefighter’s ability to maintain fitness and the perception that fitness

was not an organizational priority. It was interesting to note that a large percentage of each

cohort cited individual laziness as a personal barrier preventing firefighters from achieving a

physically fit state. A formal program endorsed by each organization could go a long way

towards improving group participation through the use of peer support and peer pressure.

NFPA 1582 recommends that fire departments appoint dedicated department physicians

that are specifically trained in occupational medicine to manage health screening programs for

firefighters (NIOSH, 2007). The standard does recognize the financial burden associated with

this type of program and offers as an alternative that each firefighter could obtain medical

evaluations from their own private physicians using the criteria contained in NFPA 1582.

Besides the full implementation of NFPA 1582, three viable alternatives were identified during

this research. Each has the benefit of identifying the firefighter’s cardiac risks while placing

minimal financial burden on the fire departments. It was identified that the members of the AFD

have access to the City of Aberdeen Wellness Program that offers free annual medical

screening that would be effective in identifying cardiac risk factors as well as provide access to

counseling on general wellness issues. Unfortunately it was determined that only 26% of the


AFD respondents are currently taking advantage of this program. It was not determined from

this research if comparable programs existed for the external fire departments. The cardiac

screening capabilities of a local cardiovascular clinic were also identified as being an excellent

resource that local fire departments could utilize. The fee for this service was nominal and they

indicated that they were willing to develop a program that specifically meets the needs of

firefighters. Finally, depending on an individual’s medical insurance plan, firefighters could

obtain annual medical evaluations on their own if their insurance included medical evaluations as

a covered service.

A part of this research included documentation of each respondent’s current exercise

regimen and the data indicated that only one half of all the respondents currently obtain aerobic

exercise on a regular basis. The firefighters who do not routinely perform aerobic conditioning

are placing themselves at risk for a heart attack. According to Basri and Bergman (2010)

firefighters need to obtain at least 30 minutes of aerobic exercise four times per week and Loy

(2001b) indicated that for aerobic training to be beneficial a person must exercise at more than

70% of their age predicted maximum heart rate.

The implications of this research for the fire departments involved and specifically the

AFD are literally a matter of life and death. The AFD has already had a member experience a

heart attack and at the time of this report that incident has not resulted in widespread operational

or cultural changes that would promote the reduction of heart disease among its members.

Reducing the incidence of heart attacks among firefighters will require a multifaceted

approach. There must be education provided so that firefighters understand that the inherent

stressors of the job place them at risk for developing cardiovascular disease. They must be made

aware of the existence of their modifiable risk factors so that they can take steps to mitigate them


and fire departments must find ways to promote a culture of health and fitness for the firefighters

which will ultimately lead to a more productive work force that is better equipped to meet the

challenges of today’s fire service.

Recommendations

The finding that the majority of firefighters who took part in this research were aware

that heart attack was the leading cause of firefighter deaths was encouraging since awareness of

the issue should provide incentive for firefighters and their organizations to address heart disease

in a proactive and positive manner. What was not encouraging was that based on the data

obtained from this research a number of respondents could be considered at moderate risk for

heart disease. This combined with the fact that none of the fire departments surveyed provided

or mandated annual medical evaluations could result in a firefighter having a heart attack from

undiagnosed and untreated cardiovascular disease. With only half of the respondents indicating

they obtained medical evaluations on their own initiative, a significant number of respondents

may not even be aware they have elevated cardiac risk factors.

Another encouraging finding was a majority of the respondents indicated that they would

support the implementation of mandatory medical evaluation programs. It is this author’s

recommendation that each fire department included in this research should utilize this support to

implement a mandatory medical evaluation program designed to identify and manage their

firefighter’s cardiac risk factors. This research identified four options available that would meet

this need. The adoption of NFPA 1582 while being the most inclusive program would also be

the most expensive program for a fire department to implement due to its stringent requirements.

The second option applies to the firefighters at the AFD and that is to promote greater

participation in the Wellness Program managed by the City of Aberdeen Wellness Committee.


This program would provide the most expedient solution as well as result in no cost to the fire

department or its employees. This was not identified as an option for the external fire

departments included in this research and it is recommended that those fire departments

determine if similar programs exist in their jurisdictions. The third option available to all the

firefighters included in this research was the service offered by Grays Harbor Cardiovascular

Imaging. The quoted fee was nominal considering the in-depth cardiovascular screening and this

option had the added benefit that the program could be specifically designed to meet the needs of

firefighters. The fourth option applies to those firefighters who have medical insurance plans

that include medical evaluations as a covered service. Those firefighters could obtain annual

medical evaluations using the criteria contained in NFPA 1582. What was clear from the

literature was the recommendation that any program implemented should require mandatory

participation by firefighters to ensure that all firefighters are reducing their cardiac risk factors.

It is recommended that each fire department form a joint labor/management wellness

committee that should utilize the information contained in The Fire Service Joint Labor

Management Wellness-Fitness Initiative, the Health and Wellness Guide for the Volunteer Fire

and Emergency Services, and NFPA 1582 to develop mandatory medical evaluation programs

within their departments that promote cardiovascular health. For the AFD, official

communication between the City of Aberdeen Human Resource Department and its medical

insurance carrier Regence BlueShield must take place to determine if mandatory medical

evaluations would be a covered service under the current medical plan.

Each fire department should also task its labor/management wellness committee with

identifying solutions to the personal and organizational barriers unique to their department that

are preventing firefighters from improving their overall fitness. A challenge that these


committees must face is the current organizational culture of their fire departments. The goal of

the wellness committee should be to promote a culture that actively supports the health and

wellness of its firefighters in a non-punitive manner.

It is further recommended that an inter-agency wellness committee be formed by all the

departments included in this survey. Formation of this committee would facilitate the sharing of

ideas and solutions and foster improved cooperation among the involved agencies which would

lead to an overall improvement in the health of local fire service personnel. Participation by

multiple agencies in one cardiac screening program could also result in a discounted price being

offered to the entire group.

The cost of doing nothing is too high. It is a fact that firefighter lives will be saved by

implementing cardiac screening programs and this should motivate both firefighters and their fire

departments to act expeditiously to address this issue.


References

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Prevention Program. Aberdeen, WA.

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Procedures. Aberdeen, WA.

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23, 2010, from http://www.americanheart.org/presenter.jhtml?identifier=500

Basri, R. (2005, August). The key to reducing firefighter deaths. Firehouse, 30(8), 82.

Basri, R., & Bergman, E. (2009a, April). Cardiovascular disease in firefighters: Defining the

problem firefighters are at higher risk of cardiac death than the public. Firehouse, 34(4),

48-51.

Basri, R., & Bergman, E. (2009b, May). Cardiovascular disease in firefighters: who is at risk-

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physical exams-the importance of identifying and managing cardiac risk factors.

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Basri, R., & Bergman, E. (2010, March). Preventing cardiovascular disease- a comprehensive

medical program includes lifestyle modification. Firehouse, 35(3), 116-118.

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Website: http://www.cdc.gov/dhdsp/announcements/american_heart_month.htm

City of Aberdeen. (2003, December 17). City of Aberdeen - Personnel Policies. Aberdeen, WA.


Davis, S. C., Jankovitz, K. Z., & Rein, S. (2002, September). Physical fitness and cardiac risk

factors of professional firefighters across the career span. Research Quarterly for

Exercise and Sport, 73(3), 363-370.

Federal Emergency Management Agency. (2006). Executive Development-Student Manual (3rd

ed., 2nd Printing).

Heiden, E., Testa, M., & Musolf, D. (2008). Faster better stronger. New York, NY:

HarperCollins.

Heifetz, M., & Linsky, R. (2002). Leadership on the Line. Cambridge, MA: Harvard University

Press.

International Association of Firefighters, International Association of Fire Chiefs. (2008). The

fire service joint labor management wellness-fitness initiative (3 ed.).

Kales, S. N., Soteriades, E. S., Christophi, C. A., & Christiani, D. C. (2007, March 22).

Emergency duties and death from heart disease among firefighters in the United States.

The New England Journal of Medicine, 356(12), 1207-1215.

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Lloyd-Jones, D., Adams, R. J., Brown, T. M., Carnethon, M., Dai, S., De Simone, G., Ferguson,

T. B., ... Wylie-Rosett, J. (2009, December 17). Heart Disease and Stroke Statistics 2010

Update. A Report from the American Heart Association. Circulation: Journal of the

American Heart Association, e1 - e170. doi: 10.1161/CIRCULATIONAHA.109.192667

Loy, S. (2001a, March). I am firefighter, I am immortal no, you’re not. Fire Chief, 45(3), 29-30.


Loy, S. (2001b, April). Play by the numbers to measure department fitness. Fire Chief, 45(4), 14-

15.

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http://www.cdc.gov/nchs/data/databriefs/db03.pdf

Scanlon, P., & Ablah, E. (2008). Self-reported cardiac risks and interest in risk modification

among volunteer firefighters: A survey based study. Journal of the American Osteopathic

Association, 108(12), 694-698.

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Appendix A

ABERDEEN FIRE DEPARTMENT

PRE-EMPLOYMENT PHYSICAL

EXAMINATION

EXAMINATION REQUIREMENTS UNDER NFPA 1582

1. Physical Exam & Summary Review

2. Respiratory Questionnaire and Review

3. Pulmonary Function Test (Spirometry)

4. Blood Work: CMP

CBC

Lipid Panel

Liver Panel

5. Audiometry

6. Visual Acuity – Snellen

7. Chest X-Ray with Interpretation

8. 12 Lead EKG with Interpretation

Ancillary Test:

Urinalysis with Toxicology Screen

Revised: 6/11/2009


Appendix B

EXTERNAL FIREFIGHTER QUESTIONNAIRE COVER LETTER

January 19, 2010 TO: Questionnaire Participant FROM: Battalion Chief Tom Hubbard The purpose of this questionnaire is to obtain information to assist me in preparing an applied research project for the Executive Fire Officer Program at the National Fire Academy. My goal is to identify barriers, whether personal or organizational, preventing firefighters from obtaining annual medical physicals designed to identify cardiovascular disease. It is well documented that the leading cause of firefighter fatalities is heart attacks. The secondary focus of this questionnaire is to determine what priority the individual firefighters and their organizations place on physical fitness in order to maintain a “firefighting fit” state of readiness.

Completion of this questionnaire is voluntary and all information obtained will remain confidential as to organization and individual respondent.

For the purpose of this questionnaire the term medical evaluation shall encompass at the very minimum the following tests/procedures as detailed in NFPA 1582.

a. Thorough physical examination b. Analysis to determine BMI. (Fat vs. Lean body mass) c. Blood analysis including cholesterol screening d. 12 Lead EKG e. Age/gender specific cancer screening f. Aerobic/cardiovascular evaluation (Treadmill/Stairmaster)


Appendix C

EXTERNAL FIREFIGHTER QUESTIONNAIRE

1. What is your age? ____ Status: Career □ Volunteer □ Number of Years in the Fire Service _______ 2. Does your organization require candidate firefighters to undergo medical evaluations as part of the pre-employment screening process. (Applies to volunteer firefighter applicants as well) Yes □ No □ Don’t Know □ 3. Does your organization provide annual medical evaluations for incumbent firefighters? Yes □ No □ If you answered yes above proceed to question #6 If you answered no above proceed to question #4 4. On your own initiative do you obtain an annual medical evaluation? Yes □ No □ If you answered yes above proceed to question #6 If you answered No proceed to question #5. 5. Select the answer(s) that most accurately reflect why you do not obtain an annual medical Evaluation (choose all that apply)

a. I feel it is my organization’s responsibility to provide them □ b. The cost of obtaining an evaluation is financially prohibitive □

c. I don’t think I need one because I am physically fit □ d. I am concerned that a physical could reveal a problem which might result in my separation from my organization □ e. Other: Please explain below □


6. Should annual medical evaluations be mandatory or voluntary? Mandatory □ Voluntary □ Other □ (Explain below) 7. Are you aware that the United States Fire Administration has listed heart attacks as the number one cause of firefighter Line of Duty Deaths for the years 2005 to 2009? Yes □ No □ Somewhat Aware □ 8. Does your organization currently have a policy regarding firefighter physical fitness? Yes □ No □ Don’t Know □ 9. Do you regularly exercise to improve your cardiovascular fitness level? Yes □ No □ I Am Inconsistent □ 10. How would you rate your current cardiovascular physical fitness level?

Excellent □ Very Good □ Good □ Average □ Poor □ 11. How did you determine your answer to question #10? (Choose all that apply) Medical/Physical Testing □ Compared Myself to Others □ I Just Picked One □ 12. Do you feel that maintaining physically fit firefighters is a high priority for your organization? Yes □ No □ 13. In your opinion, what barriers exist in your organization that are preventing firefighters from maintaining a physically fit state? (Choose all that apply) There are no barriers □ Call Volume vs. Staffing □ Budget Constraints □ Not an Organizational Priority □ Lack of Awareness on the Issue □ Poor equipment □ Union/Management issue □ Individual Laziness □ Other □ (Please list below)


Appendix D

FIRE CHIEF COVER LETTER

January 19, 2010

TO: Fire Chief XXXXX FROM: Battalion Chief Tom Hubbard The purpose of this questionnaire is to obtain information to assist me in preparing an applied research project for the Executive Fire Officer Program at the National Fire Academy. My goal is to identify barriers, whether personal or organizational, preventing firefighters from obtaining annual medical physicals designed to identify cardiovascular disease. It is well documented that the leading cause of firefighter fatalities is heart attacks. The secondary focus of this questionnaire is to determine what priority the individual firefighters and their organization place on physical fitness in order to maintain a “firefighting fit” state of readiness.

Completion of this questionnaire is voluntary and all information obtained will remain confidential as to organization and individual respondent.

I have included material from NFPA 1582 to assist you in answering the questions contained in the questionnaire. If you have questions or concerns regarding this questionnaire please contact me. Thank you for taking the time to respond to my questions and for allowing me to utilize the personnel within your organization to formulate my research. Upon the conclusion of my paper I would be more than happy to discuss my findings with you. Battalion Chief Tom Hubbard Aberdeen Fire Department


Appendix E

FIRE CHIEF QUESTIONNAIRE 1. Does your organization currently require candidates to undergo a medical evaluation prior to employment that fulfills the requirements set forth in NFPA 1582 Standard on Comprehensive Occupational Medical Programs for Fire Departments (2007)?

Yes □ No □ Additional comments: 2. Does your organization currently require incumbent members to undergo an annual medical evaluation that fulfills the requirements set forth in NFPA 1582 Standard on Comprehensive Occupational Medical Programs for Fire Departments (2007)? Yes □ No □ Additional comments: 3. Does your organization have in place an Essential Job Task Analysis described in NFPA 1582 (2007)? Yes □ No □ Additional comments: 4. Does your organization’s current health plan cover the cost of annual medical evaluations for its career members? Yes □ No □ For it volunteer members? Additional comments: Yes □ No □


5. Has a member of your organization lost time from work due to a cardiovascular condition in the past 5 years? For the purpose of this questionnaire, cardiovascular condition shall be defined as: Cardiac arrest, Myocardial Infarction, Coronary Artery Disease, Angina Pectoris, Cardiac arrhythmia or Hypertension. Yes □ No □ Additional comments: 6. Does your organization currently have policies in place regarding fitness for duty qualifications that include medical and physical fitness standards? Medical: Yes □ No □ Physical Fitness: Yes □ No □ Additional comments: 6a. If you answered yes to Physical Fitness in question #6, are your members compliant with the policy regarding physical fitness? Yes □ No □ Additional comments: 7. In your opinion, does the organizational culture of your organization support physical fitness as a priority among its members? If not, why do you think that is? Please comment: 8. What do you feel would be the three most significant barriers to implementing annual medical evaluations for your organization? Please comment:


Appendix F

FIREFIGHTER FITNESS COVER LETTER ABERDEEN FIRE DEPARTMENT

January 26, 2010 TO: Questionnaire Participant FROM: Battalion Chief Tom Hubbard The purpose of this questionnaire is to obtain information to assist me in preparing an applied research project for the Executive Fire Officer Program at the National Fire Academy. My goal is to identify barriers, whether personal or organizational, preventing firefighters from obtaining annual medical physicals designed to identify cardiovascular disease. It is well documented that the leading cause of firefighter fatalities is heart attacks. The secondary focus of this questionnaire is to determine what priority the individual firefighters and their organizations place on physical fitness in order to maintain a “firefighting fit” state of readiness.

Completion of this questionnaire is voluntary and all information obtained will remain confidential as to individual respondent.

For the purpose of this questionnaire the term medical evaluation shall encompass at the very minimum the following tests/procedures as detailed in NFPA 1582.

a. Thorough physical examination b. Blood analysis including cholesterol screening c. 12 Lead EKG d. Age/gender specific cancer screening e. Spirometry (Forced Vital Capacity, Forced Expiratory Capacity) f. Chest x-ray

The Body Mass Index Table on the reverse side of this letter is to be used to answer question number 5e. The categories range from normal to extremely obese with the corresponding BMI number directly below. It is well documented that BMI tables can be misleading for individuals who have large muscle mass; however, for the purpose of this questionnaire the information obtained will be representative of the group as a whole and not specific to individual members. Battalion Chief Tom Hubbard


Appendix G

FIREFIGHTER QUESTIONNAIRE ABERDEEN FIRE DEPRTMENT

1. What is your age? _____ Numbers of Years in the Fire Service: ______ Status: Career ■ Volunteer □ 2. When was the last time you had a medical evaluation that met all or part of the criteria outlined in the attached cover letter? 1 Year □ 2 Years □ 3 Years □ 4 Years □ 5 Years or Greater □ Never □ Was this your pre-employment physical? Yes □ No □ Please list the test(s) that were not part of your physical examination: 3. Do you have a primary physician? Yes □ No □ Do you see them on an annual basis? Yes □ No □ N/A □ Do you primarily see them just when you are sick? Yes □ No □ N/A □ 4. Do you participate in the City of Aberdeen’s Health and Wellness Program offered through the Association of Washington Cities and Aberdeen’s Human Resources Department? Yes □ No □ Did not know it existed □ 5. The American Heart Association has identified several risk factors associated with the increased risk of coronary heart disease and heart attack. The risk factors that can’t be changed by the individual are: Increasing age, gender (males have a greater risk), and heredity (including race). The risk factors that can be changed by the individual are: Tobacco smoke, high cholesterol levels, high blood pressure, physical inactivity, obesity, and diabetes mellitus. a. Do you smoke: Yes □ No □ b. Do you know what your current blood cholesterol levels are? Yes □ No □ c. Do you have high blood pressure? HBP is considered > 140/90 untreated, or currently taking antihypertensive medication. Yes □ No □ d. The American College of Sports Medicine recommends that adults perform 30 minutes of moderate intensity physical exercise five days each week: Do you currently meet this standard? Yes □ No □ e. Using the BMI table provided, indicate your Category:__________ & Number: _____ f. Do you have Type I or Type II diabetes? Yes □ No □


6. Are you aware that the IAFF and the IAFC have produced The Fire Service Joint Labor Management Wellness-Fitness Initiative which parallels NFPA 1582 in requiring firefighters to undergo annual medical evaluations? Yes □ No □ Vaguely Aware it Exists □ 7. Would you support the implementation of mandatory annual medical evaluations for members of the Aberdeen Fire Department? Yes □ No □ Undecided □ If you answered no or undecided please write down your reason(s) below. 8. A voluntary Cardiac Stress test was offered by Dr. Canfield in January – March 2007. Were you employed by the AFD during this period? Yes □ No □ If you answered yes above, did you participate in the testing? Yes □ No □ If you chose not to take the stress test, please explain briefly why you chose not to participate. 9. If you currently receive annual medical evaluations go to question 10. If you do not obtain annual medical evaluations please select the answer(s) that most accurately reflect why you do not. (choose all that apply)

a. I feel it is my organization’s responsibility to provide them □ b. The cost of obtaining an evaluation is financially prohibitive □

c. I don’t think I need one because I am physically fit □ d. I am concerned that a physical could reveal a problem which might result in my separation from the fire service □ e. Other: Please explain below □ 10. How would you rate your current cardiovascular physical fitness level? Excellent □ Very Good □ Good □ Average □ Poor □ 11. How did you determine your answer to question #10? (Choose all that apply) Medical/Physical Testing □ Compared Myself to Others □ I Just Picked One □


12. Do you exercise regularly to improve your cardiovascular fitness level? Yes □ No □ I am inconsistent □ 13. Did you know that the United States Fire Administration has listed heart attacks as the number one cause of firefighter deaths for the years 2005 to 2009? Yes □ No □ Vaguely Aware □ 14. In your opinion, what barriers exist at the Aberdeen Fire Department that are preventing firefighters from maintaining a physically fit state? (Choose all that apply) There are no barriers □ Call Volume vs. Staffing □ Budget Constraints □ Not an Organizational Priority □ Lack of Awareness on the Issue □ Poor equipment □ Union/Management issue □ Individual Laziness □ Other □ (Please list below) 15. Do you currently exercise while on-duty? Yes □ No □ 16. NFPA 1583 and the IAFF/IAFC Wellness-Fitness Initiative require annual fitness assessments that measure the following: aerobic capacity (treadmill test), body composition, muscular strength, muscular endurance and flexibility. The program is designed to be non-punitive and is administered by a department Health Fitness Coordinator and Peer Fitness Trainers. Would you be in favor of implementing this program at the Aberdeen Fire Department? Yes □ No □


Appendix H

ABERDEEN FIRE DEPRTMENT FIREFIGHTER QUESTIONNAIRE DATA (n = 31)

1. What is your age? (Avg. 36.2) Numbers of Years in the Fire Service: (Avg. 13.9) Status: Career ■ (31) Volunteer □ (0) 2. When was the last time you had a medical evaluation that met all or part of the criteria outlined in the attached cover letter?

1 Year (38.7%) 2 Years (16.1%) 3 Years (6.5%) 4 Years (0%) 5 Years or Greater (22.6) Never (16.1%)

Was this your pre-employment physical? Yes (45%) No (42%) Please list the test(s) that were not part of your physical examination: The data indicated that 35% did not receive cancer screening, 23% did not receive spirometry testing, 23% did not receive a chest X-Ray, and 10% did not receive a 12 lead EKG. 3. Do you have a primary physician? Yes (94%) No (6%) Do you see them on an annual basis? Yes (32%) No (68%) N/A □ Do you primarily see them just when you are sick? Yes (65%) No (35%) N/A □ 4. Do you participate in the City of Aberdeen’s Health and Wellness Program offered through the Association of Washington Cities and Aberdeen’s Human Resources Department? Yes (26%) No (61%) Did not know it existed (13%) 5. The American Heart Association has identified several risk factors associated with the increased risk of coronary heart disease and heart attack. The risk factors that can’t be changed by the individual are: Increasing age, gender (males have a greater risk), and heredity (including race). The risk factors that can be changed by the individual are: Tobacco smoke, high cholesterol levels, high blood pressure, physical inactivity, obesity, and diabetes mellitus. a. Do you smoke: Yes (3%) No (97%) b. Do you know what your current blood cholesterol levels are? Yes (45%) No (52%) c. Do you have high blood pressure? HBP is considered > 140/90 untreated, or currently taking antihypertensive medication. Yes (10%) No (90%) d. The American College of Sports Medicine recommends that adults perform 30 minutes of moderate intensity physical exercise five days each week: Do you currently meet this standard? Yes (45%) No (55%) Normal Wt. (26%) e. Using the BMI table provided, indicate your Category: Overweight (55%) Obese (19%) f. Do you have Type I or Type II diabetes? Yes (0%) No (100%)


6. Are you aware that the IAFF and the IAFC have produced The Fire Service Joint Labor Management Wellness-Fitness Initiative which parallels NFPA 1582 in requiring firefighters to undergo annual medical evaluations? Yes (38%) No (39%) Vaguely Aware it Exists (23%) 7. Would you support the implementation of mandatory annual medical evaluations for members of the Aberdeen Fire Department? Yes (87%) No (3%) Undecided (10%) If you answered no or undecided please write down your reason(s) below. Answers included: “Only if done on duty” “If fitness and nutrition added to daily Training” “As long as it was not punitive” “Poor medical evaluation = loss of job?” “Don’t like the sound of anything mandatory” 8. A voluntary Cardiac Stress test was offered by Dr. Canfield in January – March 2007. Were you employed by the AFD during this period? Yes (71%) No (29%) If you answered yes above, did you participate in the testing? Yes (35%) No (35%) If you chose not to take the stress test, please explain briefly why you chose not to participate. Answers included: “Too busy” “Lazy” “On vacation” “On disability leave” “Already get one from my doctor” “I felt it could lead to a mandatory thing” “Did not think I needed one because of my age” 9. If you currently receive annual medical evaluations go to question 10. If you do not obtain annual medical evaluations please select the answer(s) that most accurately reflect why you do not. (choose all that apply)

a. I feel it is my organization’s responsibility to provide them (13%) b. The cost of obtaining an evaluation is financially prohibitive (16%)

c. I don’t think I need one because I am physically fit (13%) d. I am concerned that a physical could reveal a problem which might result in my separation from the fire service (3%) e. Other: Please explain below (35%) 10. How would you rate your current cardiovascular physical fitness level? Excellent (10%) Very Good (32%) Good (26%) Average (29%) Poor (3%) 11. How did you determine your answer to question #10? (Choose all that apply) Medical/Physical Testing (35%) Compared Myself to Others (71%) I Just Picked One (10%)


12. Do you exercise regularly to improve your cardiovascular fitness level? Yes (52%) No ()%) I am inconsistent (48%) 13. Did you know that the United States Fire Administration has listed heart attacks as the number one cause of firefighter deaths for the years 2005 to 2009? Yes (97%) No (3%) Vaguely Aware (0%) 14. In your opinion, what barriers exist at the Aberdeen Fire Department that are preventing firefighters from maintaining a physically fit state? (Choose all that apply) There are no barriers (10%) Call Volume vs. Staffing (47%) Budget Constraints (48%) Not an Organizational Priority (45%) Lack of Awareness on the Issue (13%) Poor equipment (26%) Union/Management issue (3%) Individual Laziness (52%) Other (19%) Answers included: “Complacency” “People think they are immune to to this, but because of their job they are a ticking time bomb” “Insufficient workout facility” “Other training and duties take priority over physical fitness” “When you are assigned to the ambulance, working out is almost impossible” “Not enough equipment, go look at the police department” 15. Do you currently exercise while on-duty? Yes (65%) No (35%) 16. NFPA 1583 and the IAFF/IAFC Wellness-Fitness Initiative require annual fitness assessments that measure the following: aerobic capacity (treadmill test), body composition, muscular strength, muscular endurance and flexibility. The program is designed to be non-punitive and is administered by a department Health Fitness Coordinator and Peer Fitness Trainers. Would you be in favor of implementing this program at the Aberdeen Fire Department? Yes (97%) No (3%)


Appendix I

EXTERNAL FIREFIGHTER QUESTIONNAIRE DATA (n = 62)

1. What is your age? (Avg. 38.5) Status: Career (52%) Volunteer (48%) Number of Years in the Fire Service (Avg. 12.3) 2. Does your organization require candidate firefighters to undergo medical evaluations as part of the pre-employment screening process. (Applies to volunteer firefighter applicants as well) Yes (91.9%) No (4.8%) Don’t Know (3.2%) 3. Does your organization provide annual medical evaluations for incumbent firefighters? Yes (3%) No (97%) If you answered yes above proceed to question #6 If you answered no above proceed to question #4 4. On your own initiative do you obtain an annual medical evaluation? Yes (44%) No (50%) If you answered yes above proceed to question #6 If you answered No proceed to question #5. 5. Select the answer(s) that most accurately reflect why you do not obtain an annual medical Evaluation (choose all that apply)

a. I feel it is my organization’s responsibility to provide them (21%) b. The cost of obtaining an evaluation is financially prohibitive (10%)

c. I don’t think I need one because I am physically fit (10%) d. I am concerned that a physical could reveal a problem which might result in my separation from my organization (6%) e. Other: Please explain below (23%) Answers included: “Should but don’t” “Don’t think about it” “As a volunteer, I have a very physical and demanding job” “I get a ‘physical’ every other year for commercial drivers license, but not very thorough” “Laziness” “Is it really necessary?” “I know my issues, don’t need a MD to tell me to lose weight, eat better, lower my BP, and get more exercise”


6. Should annual medical evaluations be mandatory or voluntary? Mandatory (60%) Voluntary (37%) Other (3%) (Explain below) Answers included: “Mandatory for career, voluntary for volunteers” “Only if the employer is financially responsible” “The evaluations should be done bi-annually” 7. Are you aware that the United States Fire Administration has listed heart attacks as the number one cause of firefighter Line of Duty Deaths for the years 2005 to 2009? Yes (77%) No (16%) Somewhat Aware (6%) 8. Does your organization currently have a policy regarding firefighter physical fitness? Yes (2%) No (79%) Don’t Know (16%) 9. Do you regularly exercise to improve your cardiovascular fitness level? Yes (58%) No (15%) I Am Inconsistent (27%) 10. How would you rate your current cardiovascular physical fitness level? Excellent (10%) Very Good (23%) Good (40%) Average (40%) Poor (2%) 11. How did you determine your answer to question #10? (Choose all that apply) Medical/Physical Testing (32%) Compared Myself to Others (53%) I Just Picked One (16%) 12. Do you feel that maintaining physically fit firefighters is a high priority for your organization? Yes (32%) No (68%) 13. In your opinion, what barriers exist in your organization that are preventing firefighters from maintaining a physically fit state? (Choose all that apply) There are no barriers (24%) Call Volume vs. Staffing (32%) Budget Constraints (29%) Not an Organizational Priority (58%) Lack of Awareness on the Issue (32%) Poor equipment (32%) Union/Management issue (16%) Individual Laziness (66%) Other (11%) (Please list below) Answers included: “Department not willing to invest in equipment” “Not allowed to work out during day time hours” “Fear of the unknown” “Should city pay for gym membership?” “There is no equipment at station” “There is no expectation of fitness” “No equipment at station and not allowed to access local gym while on duty”


Appendix J

FIRE CHIEF QUESTIONNAIRE DATA (n = 4)

1. Does your organization currently require candidates to undergo a medical evaluation prior to employment that fulfills the requirements set forth in NFPA 1582 Standard on Comprehensive Occupational Medical Programs for Fire Departments (2007)?

Yes (The four fire chiefs all responded yes) No (0%) Additional comments: “Volunteer firefighters must meet the Washington State Bureau of Volunteer Firefighters which are not as inclusive as NFPA.” 2. Does your organization currently require incumbent members to undergo an annual medical evaluation that fulfills the requirements set forth in NFPA 1582 Standard on Comprehensive Occupational Medical Programs for Fire Departments (2007)? Yes (0%) No (The four fire chiefs all responded no) Additional comments: “Budgetary constraints do not allow the city to enforce this standard.” 3. Does your organization have in place an Essential Job Task Analysis described in NFPA 1582 (2007)? Yes (1 fire chief responded yes) No (3 fire chiefs responded no) Additional comments: “Developed to establish standards for what firefighters can do while on light duty.” 4. Does your organization’s current health plan cover the cost of annual medical evaluations for its career members? Yes (2 fire chiefs responded yes) No (2 fire chiefs responded no) For it volunteer members? Additional comments: Yes (0%) No (For the 2 fire departments with volunteer fire fighters the fire chiefs responded no and the 2 fire chiefs without volunteers indicated N/A).


5. Has a member of your organization lost time from work due to a cardiovascular condition in the past 5 years? For the purpose of this questionnaire, cardiovascular condition shall be defined as: Cardiac arrest, Myocardial Infarction, Coronary Artery Disease, Angina Pectoris, Cardiac arrhythmia or Hypertension. Yes (1 fire chief responded yes) No (3 fire chiefs responded no) Additional comments: 6. Does your organization currently have policies in place regarding fitness for duty qualifications that include medical and physical fitness standards? Medical: Yes (1 fire chief responded yes) No (3 fire chiefs responded no)

Physical Fitness: Yes (0%) No (4 fire chiefs responded no)

Additional comments: 6a. If you answered yes to Physical Fitness in question #6, are your members compliant with the policy regarding physical fitness? Yes (N/A) No (N/A) Additional comments: 7. In your opinion, does the organizational culture of your organization support physical fitness as a priority among its members? If not, why do you think that is? Please comment: The four answers were: 1. “Yes!” 2. “Philosophically wellness and physical fitness are supported, however, the funding is not available to support the philosophy.” 3. “No, not at all” 4. “I feel the current organization values fitness as a whole. May not be 100%, but definitely is the majority” 8. What do you feel would be the three most significant barriers to implementing annual medical evaluations for your organization? Please comment: Answers included: “Job security, Privacy, Some members not wanting to take the time involved, The perception that they would be punished if they received a poor evaluation, Cost, Getting members to participate and follow through, Funding, Labor contract, Monitoring and accountability, Fire District Commissioner support, and What ifs”

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