Letters to the Editor
To the Editor:
In their article, Leffer and Grizzell1 have mistakenly claimed that “In 2007, the National Fire Protection Association (NFPA) began recommending yearly screening for firefighters to include a 12-MET minimum Stage 4 Bruce Protocol Stress Test.”2 This statement is not consistent with the content or intent of NFPA, Standard of Comprehensive Occupational Medicine Program for Fire Departments 1582. Chapter 7 of NFPA 1582 is titled “Occupational Medical Evaluation of Members,” and section 22.214.171.124, states: “Stress EKG with or without echocardiogram or radionuclide scanning shall be performed as clinically indicated by history or symptoms [emphasis added].” The appendix to this section provides suggestions as to when this testing might occur. There is no reference to an MET level requirement in this section of the document.
Chapter 8 of NFPA 1582 is titled “Annual Occupational Fitness Evaluation of Members.” This is a mandatory, nonpunitive program to “establish an individual's baseline [and is] measured against the individual's previous assessments and not against any standard or norm.” There is no mention of any MET requirement either in the standard or the appendix related to chapter 8.
The only reference to MET levels is in chapter 9, section 126.96.36.199. This section addresses the Fire Fighter (FF) with coronary artery disease (CAD) and states that physicians should report limitations for FF's with CAD if they have certain findings present. One of these findings is maximal exercise tolerance of <12 METS and a second is “Exercise induced ischemia or ventricular arrhythmias observed by radionuclide stress test during an evaluation reaching at least 12-METS workload.” The purpose of section 188.8.131.52 is evaluation for ongoing CAD, the risk of sudden incapacitation, and ensuring normal cardiac function while performing essential job tasks.
In addition to pointing out this error, we have a number of questions about the categorization of independent variables, the measurement of outcome variables, and whether the conclusions can be supported from the presented data. For example:
- It is unclear why established body mass index (BMI) criteria for normal, overweight, and obese individuals were not used. Reanalysis of the data using the established BMI ranges for these categories would be useful.
- Why were costs and lost days projected for the injuries in the intervention period as opposed to reporting the actual costs and lost days?
- There is no information about how the injury information was collected, its severity [commonly measured in lost or restricted workdays] or type of injury during any of the time periods. Thus, the assumption that the costs and time lost would be the same for each injury in the intervention periods because it was in the baseline period that cannot be demonstrated.
- The discussion mentions that strength and flexibility measurements were done, but neither these data nor any change of these parameters over the intervention period were reported. The article also mentions that compliance with the physician organized wellness regime was not monitored. Given that none of the parameters measured (BMI, BP, lipids) changed during the intervention, we wonder if the authors considered that it is entirely possible that there was poor compliance for all components of the wellness regime.
- The data reported suggests that the counseling had no clinically important impact on any measure of FF wellness or behavior. Yet the authors conclude that the intervention caused the injury reduction. Did the authors consider that some other factors, not measured, were responsible for the injury reduction? We would appreciate an explanation of how the research data presented supports the authors' conclusions.
Daniel G. Samo, MD
Department of Emergency Medicine Northwestern University Feinberg School of Medicine Chicago, Ill
Sandy Bogucki, MD, PhD
Department of Emergency Medicine Yale University School of Medicine New Haven, Conn
Thomas Hales, MD, MPH
National Institute for Occupational Safety and Health Cincinnati, Ohio
Stanley Haimes, MD, MPH
ACOEM Public Safety Medicine Section Center for Occupational and Environmental Health Orlando, Fla
Fabrice Czarnecki, MD, MA, MPH
Department of Emergency Medicine St. Joseph Medical Center Towson, Md
David Louis, MD, MS
ACOEM Public Safety Medicine Section Dayton, Ohio
1. Leffer M, Grizzell T.. Implementation of a Physician-Oriented Wellness Regime (POWR) enforcing the 2007 NFPA Standard 1582: injury rate reduction and associated cost savings. J Occup Environ Med. 2010;52:336–339.
2. NFPA. NFPA 1582: Standard on Comprehensive Occupational Medical Program for Fire Departments. Quincy, MA: NFPA; 2007.