In October 2014, the American College of Occupational and Environmental Medicine (ACOEM) convened a Task Force of medical practitioners, corporate medical directors, university professors, and fire chiefs having a working knowledge of US oil and gas and petrochemical industries to develop fitness-for-duty guidance for industrial firefighters and address the lack of standards and guidance specific to this population. This lack of a standardized approach could result in firefighters being improperly assessed for their capability to safely perform industrial firefighting duties and puts the firefighter, his/her coworkers, the workplace, and the community at risk. This increased risk has the potential for increased liability to business entities employing industrial firefighters.
In addition to recommending best practices for the determination of an industrial firefighter's fitness-for-duty, an important part of the Task Force's charge was to characterize where possible, the demographic make-up of the industrial firefighter. Such knowledge is essential to differentiate industrial from municipal firefighters particularly as it may relate to cardiovascular disease, the most common cause of work-related mortality among municipal firefighters. As an additional benefit, this information has the potential for conducting directed studies that will advance the health and safety of the industrial firefighter population.
Task Force members identified a list of questions (identified under the section on Topics Reviewed) for which the systematic literature review would seek to document the current state of affairs. Literature searches utilized Medline, PubMed and PubMed Central, and National Library of Medicine databases to identify and characterize the relevant literature for industrial and municipal firefighters, identify gaps that exist for the industrial firefighters, and advance recommendations to address literature gaps.
The Task Force then designed a questionnaire (Appendix 1) for industrial firefighters to identify the following information:
- level and frequency of firefighting duties
- patterns and frequency of training
- variations in the medical clearance process
- access to and involvement in employer-directed regular fitness activities
- risk factors for cardiovascular disease
The questionnaire was reviewed by the University of Pennsylvania Institutional Review Board (IRB), which concluded the project did not meet the criteria to be considered human research and was thus exempt from further IRB oversight. The Task Force engaged ORCHSE Strategies, LLC, a health, safety, and environmental control network that sponsors a cross-industry forum for purposes of benchmarking and sharing best practices, to host the online questionnaire. ORCHSE member companies reached out to their firefighters to complete the questionnaire. No identifiers were included in the questionnaire and data collected were anonymous and confidential. The Task Force members received only aggregate responses to the questionnaire for analysis.
The Task Force identified five questions for systematic literature review to document the current state of affairs in each area:
- What are the differences in job duties for municipal versus industrial firefighters?
- How can cardiovascular fitness for duty be best determined for industrial firefighters?
- Are tools currently used to determine fitness for duty useful?
- What preventive interventions are available and how effective are they?
- How do US laws impact fitness-for-work decisions?
DIFFERENCES IN JOB DUTIES—MUNICIPAL VERSUS INDUSTRIAL FIREFIGHTERS
As previously noted, fitness-for-duty standards and guidance specific to the industrial firefighter population is lacking. The National Fire Protection Association Standard on Comprehensive Occupational Medical Program for Fire Departments (NFPA 1582), does not include industrial fire brigades in its medical assessment standard.1 The NFPA 600 Standard on Facility Fire Brigades contains only minimal reference to the medical clearance process.2 This lack of guidance has contributed to the presence of multiple, differing firefighter assessment methodologies across various industries.
NFPA 600 classifies facility fire brigades as either incipient stage firefighting, advanced exterior firefighting, or interior structural firefighting.2 The incipient stage involves fighting a fire in normal clothing using extinguishers or smaller hand lines (125 gpm). It also requires no evasive actions (eg, crawling to escape heat or smoke), and does not necessitate the use of bunker gear or self-contained breathing apparatus (SCBA).2 Advanced exterior or interior firefighting involves full gear, teams in warm and hot zones utilizing SCBA, attack teams of two or more, established communication systems, experienced members overseeing those less experienced, and the requirement of annual live fire drills. NFPA 600 states that facility fire brigades are exposed to the same degree of hazard as community firefighters, but these hazards do not extend beyond the private facility where they work.2
NFPA statistics from 1996 to 2000 have found that the risk of death in commercial fires exceeds residential fires by more than 60%.3 Calls to industrial fire departments number less than 100 annually compared with several thousand calls for community fire fighters.4 For both groups, the vast majority of the calls are not for fires, but rather for emergency medical services.
To understand industrial firefighter job duties, the Task Force interviewed industrial fire chiefs, fire school faculty, fire team medical directors, and industrial firefighters. In general, there are many similarities between industrial and community (volunteer, municipal, woodland) firefighters. Industrial firefighters are exposed to many of the same physical hazards—including impaired heat exchange from gear, sun, wind, rain, snow, extreme temperature fluctuations, humidity, wetness, mud, skin contact with oil and grease, bloodborne pathogens, noxious odors, and respiratory irritants. Mental health stressors include crucial decision-making, aspects of sustained work, unpleasant situations, and shiftwork and related fatigue.
Many physical demands are also similar including the need for explosive strength (running, jumping, rapid pulling, advance hose line), manual dexterity (assemble machinery, operate hand tools, tie knots on hose, use a wrench), climbing, vision (acuity, depth perception, night vision, color-coding), smell (leaking and burning), and speech and hearing. Municipal firefighting equipment and hoses tends to be smaller, whereas industrial fire equipment and hoses tends to be more heavy duty. This means the industrial firefighter is often handling heavier loads. The physical demands on municipal firefighters emphasize upper body and overhead work (“overhaul”). Industrial fire brigades tend to require less upper body strength but the heavier nature of the equipment may put industrial firefighters at increased risk for back injuries.
Industrial firefighting is also significantly different from community firefighting in that the knowledge required is more specific for the local setting (eg, explosive, chemical, or marine situations). Municipal and industrial firefighters wear standard structural firefighting clothing whereas industrial firefighters’ clothing may include high temperature protective and chemical protective clothing.5 Resulting dehydration and hyperthermia are often a greater issue for industrial firefighters particularly in those with poor cardiovascular conditioning and chronic disease. In the survey developed by this Task Force, the majority of industrial firefighters who have been community firefighters feel the physical work is similar, but the mental demands and danger are greater per episode of industrial firefighting.
In larger cities, municipal/structural firefighters are generally full-time paid positions, whereas industrial fire brigades and smaller city municipal fire departments are part-time, volunteers called to duty only when needed. Most industrial fire brigade members are plant operators or have some other full time job in the facility where they work. Often, full-time paid municipal firefighters engage in an exercise regimen as part of their regular work duties. Municipal firefighters may also plan and prepare food at fire stations. Occasionally, there are also firefighter wellness and health offerings. Industrial firefighters rarely have dedicated work time for exercise, meals, or wellness activities specifically related to the fire team. Consequently, while strength and health maintenance activities may be encouraged for industrial fire teams, these activities may need to be performed outside of work hours.
Typically, municipal firefighters work 24 hours on and 48 hours off (24/48) shifts or 48/96 shifts.6,7 Industrial fire brigades on the other hand usually work 8 to 12 hours, often with rotating shiftwork for 24-hour plant operations. As shiftworkers have increased health risks for obesity, diabetes mellitus, and hypertension, firefighters of all types may also have shift-work-related health risks.
There are also tactical differences in the way fires are approached.8 Industrial fires tend to be larger petroleum-based or pressurized gas fires where the emphasis is on pipe and tank firefighting and isolating and removing the source. Structural fires are more contained, but people can be trapped inside the structure, thus requiring coordinated search and rescue techniques. Additionally, the materials used to fight fires differ. Municipal firefighters primarily use water to fight Class A fires (wood/paper), whereas the primary tool for industrial firefighters is foam which is used to fight class B and C fires (flammables/electrical).
Municipal firefighters have a broader scope of job duties. As job duties are more narrow for industrialized firefighters, there may be more opportunity for accommodation of various medical conditions.6 There is a different skill set as well between the two.8 Municipal firefighters are trained in rapid intervention and team concepts, accountability systems, and search procedures. Industrial firefighters deal more with confined space rescue and must have knowledge of the properties of pressurized gas fires and large scale flammable liquids. Additionally, industrial firefighters are frequently trained in high-angle rescue. Table 1 describes other differences that may exist.
The literature review, completed survey, and interviews, found industrial fire brigades to be as diverse as the companies for which they work. While the scope of duty may be limited to handling fire extinguishers—with anything larger requiring a municipal fire department response—more typically, industrial fire brigades are highly structured with command and control personnel, officers, and front-line firefighters. As the fire chief is usually not actively engaged in fighting the fire, he/she is not subject to the same physical demands—not classifying the chief as a firefighter violates the closely-knit nature of the firefighting team. However, for purpose of classifying physical demands, we use the term “firefighters” for those actively and offensively engaged in the isolation and removal of the fire source.
HOW CAN CARDIOVASCULAR FITNESS FOR DUTY BE BEST DETERMINED FOR INDUSTRIAL FIREFIGHTERS?
In 2007, a National Institute for Occupational Safety and Health (NIOSH) alert, addressed the risks of firefighters dying from preventable cardiovascular disease (CVD).9 Later research supported NIOSH's findings.10–16 A 2014 study found 45% of on-duty firefighter deaths were caused by CVD.17 Nearly all firefighter cardiac deaths involve coronary risk factors—predictors include previous coronary heart disease (CHD), hypertension, and smoking.10,18,19 Metabolic syndrome, psychological stress, noise, sleep disorders, smoke, carbon monoxide, cyanide, and thermoregulatory stress are also associated with cardiovascular risk/fitness in firefighters.20–24 Studies have demonstrated that more than 40% of firefighters exceed low CHD risk.18 Volunteer firefighters have the highest risk for cardiac fatality and CHD.25,26
Industrial firefighting statistics and smaller industrial fires are frequently not public knowledge.27 Firefighting statistics include deaths attributed to fire response that may occur days after the events, and it is even more doubtful such information is made available related to industrial fire response. In the absence of complete data, industrial firefighters may have similar demographic and cardiovascular risks as volunteer community firefighters. The survey conducted by the Task Force assessed health risks of male industrial firefighters who self-reported their height, weight, and waist circumference. Based upon a National Institute of Health risk table,28 90% were found to have increased, high, very high, or extremely high risk for type 2 diabetes, hypertension, and CHD.
Recent biomonitoring of industrial firefighters has demonstrated high peak aerobic demands in industrial live fire simulations (Glencross PM, Turner D. Physiologic Demands of Industrial Firefighting Simulations; 2016. Unpublished manuscript). Firefighting tasks require similar burst and sustained aerobic demands as required in residential firefighting.29–31 In the clinical setting, aerobic capacity can be determined using the gold standard of metabolic testing or estimated using treadmill testing using conversion tables. Aerobic capacity and fitness are also good predictors of cardiac abnormalities and risk.32–35 Maximal treadmill tests (to voluntary exhaustion) should be used to estimate peak aerobic fitness. Submaximal stress tests in firefighters, such as the Gerkin (WFI treadmill protocol) have been shown to overestimate VO2 max and thus underestimate potential cardiac risk and aerobic fitness.36–39 Maximal heart rate formulas and steady-state assumptions used to calculate VO2 max tables contribute to inaccurate estimates with submaximal testing. For example, if 40 mL/kg/min (11 METS) is used as a fitness threshold for firefighters, submaximal stress testing leads to dangerous and erroneous results by suggesting that 17% to 30% of unfit firefighters are aerobically fit.37,39
Elevated body mass index (BMI) was thought to be due to many firefighters’ higher muscle mass.40 However, this has been disproven.41-43 While in other populations, obesity and body composition do not correlate with exercise tolerance, there is evidence it does in firefighters.44,45 Furthermore, in firefighters, an elevated BMI limits the benefits of exercise.32
Autopsy studies have linked cardiomegaly and left ventricular hypertrophy (LVH) to sudden cardiac death in firefighters. As a result, there have been calls for increased early detection by echocardiogram because ECG alone is a specific test, but lacks sensitivity.46–50 Smoking, CHD, hypertension, and obesity are all linked to LVH in firefighters.51
Besides clinic-based testing, industrial fire teams can also develop other tests to demonstrate aerobic fitness. Several studies have demonstrated success in matching timed performance in the field, (running, running with weights) with measured VO2 max in the laboratory, thereby constructing simple to administer field tests.31,52–54 Some of these studies used absolute VO2 max cut-offs. When the measured task requires the carriage of body weight, use of a relative VO2 max goal should be considered. In other words, the same firefighting task may have higher aerobic demands in an individual having a higher body weight and wearing a larger size of wet clothing. Fitness training programs are strongly recommended for firefighters although few industrial fire teams participate in formal programs.4,32,55,56
IS PSYCHOLOGICAL STRESS DIFFERENT FOR STRUCTURAL VERSUS INDUSTRIAL FIREFIGHTERS?
There is extensive literature addressing the psychological stressors of firefighting especially in first responders; however, the literature is devoid of specific studies in industrial firefighters. The Task Force's survey identified a cohort of industrial firefighters who had also served as community firefighters. The perception of this cohort was that the stress of industrial firefighting was greater than what they had experienced as community firefighters (Turner D, Cathcart D, Glencross PM. ORCHSE Survey of Industrial Firefighters; 2016. Unpublished manuscript). Psychological stress in the industrial firefighter is a recognized gap in the literature, and as such represents an opportunity for research to assess the extent and impact it may have on the health and safety of these individuals.
ARE TOOLS CURRENTLY USED TO DETERMINE FITNESS FOR DUTY USEFUL?
Firefighters are universally subject to a high level of physical and mental stresses during their jobs. Industrial firefighters, like their municipal counterparts, share similar demanding environmental factors, but as has been suggested, fatality rates are likely much higher in the setting of industrial fires.57 Proper tools to assess fitness-for-duty are therefore important to ensure firefighters are properly equipped to handle the dangers of the job while minimizing casualties. While studies regarding firefighter fitness exist, very few focus on industrial departments.
Prospective firefighters must pass physical assessments prior to service. Several different methods currently assess fitness, but there are no universally accepted standards across all organizations. NFPA publishes several codes and standards by which many groups abide. (NFPA 1583 provides fitness guidelines that incorporate measures of aerobic capacity, flexibility, muscular and endurance, and body composition testing as part of a regular fitness regimen.58) The Candidate Physical Ability Test (CPAT) is widely used simulation test for which contains eight firefighting tasks that mimic real-life scenarios: (1) stair climb; (2) hose drag; (3) equipment carry; (4) ladder raise and extension; (5) forcible entry; (6) search; (7) rescue; and (8) ceiling breach and pull.59
Industrial fire brigades may have their own internal guidelines for fitness-for-duty measurements. Royal Dutch Shell's global requirements specify minimum fitness and health indicators for firefighters and rescue teams. These include testing of visual acuity, blood pressure, the cardiovascular system, and breathing apparatus usage.60 Occupational Safety and Health Administration (OSHA) standards require passing a trade test, determined by local jurisdictions, which varies by specific roles, but may include elements found in the CPAT such as ladder climb, victim rescue, and equipment carry.61
Bhojani developed a cumulative fitness score ranging from 0 to 140 based on seven parameters of fitness to determine overall industrial firefighter fitness-for-duty evaluation.62 These factors included: (1) resting heart rate; (2) diastolic blood pressure; (3) aerobic capacity; (4) body fat percentage; (5) muscular strength; (6) muscular endurance; and (7) flexibility. All seven components correlated significantly with the total fitness score even after controlling for age and experience.
Assessments such as CPAT are geared toward all firefighters across industries, as the exercises are applicable in many types of situations. OSHA 1910.156(c)(2) lists national training and educational programs specifically for the oil refinery industry, such as those at Texas A&M University and Lamar University, after which all similar programs should be modeled.63 NFPA has standards that describe general job performance requirements for industrial firefighters.64 It is unclear whether additional established tools are necessary specifically for industrial firefighters. A study comparing industrial firefighters to municipal firefighters in California found that “despite programmatic differences, these departments demonstrated similar, relatively high degrees of physical fitness and similar blood lipid concentrations, blood pressure levels, and cardiac risk factors.”4 However, the industrial firefighter sample was small (n = 17). Additional studies examining physiological characteristics of industrial firefighters based on NFPA standards would help determine if it would be beneficial to implement additional tools specific to industrial firefighting.
WHAT PREVENTIVE INTERVENTIONS ARE AVAILABLE AND HOW EFFECTIVE ARE THEY?
Recognizing that cardiovascular disease and sudden cardiac death represent the single most frequent cause of duty-related fatalities in firefighters, an important question to be considered as part of this review is, “What preventive interventions are available and how effective are they in reducing cardiovascular risk?” As with other research questions there is a gap in the literature specifically addressing industrial firefighters. Therefore, this review addresses the effectiveness of wellness/fitness programs to reduce risk factors for cardiovascular disease and to improve cardiovascular capacity in the workforce in general and in municipal firefighters specifically as a potential surrogate for industrial firefighters.
There is abundant evidence in the literature to support the beneficial effects of diet and exercise to prevent cardiovascular disease. The landmark RAND study of US employers validated the effectiveness of workplace wellness programs to influence beneficial changes in behavioral risk factors for cardiovascular disease.65 The study reported statistically significant and clinically meaningful improvements among participants of wellness programs in exercise frequency, smoking behavior, and weight control.
A 2013 study sampled fire departments that had implemented medical and fitness programs comparable to those recommended in the Fire Service Joint Labor Management Wellness Fitness Initiative (WFI).66 WFI recommendations included:
- NFPA 1582 compliant annual medical physical examinations to all fire service personnel
- A designated health/fitness coordinator
- Peer fitness trainers
- Time for physical training/working out while on duty for all fire service personnel
The researchers identified 10 fire departments generally meeting the WFI recommendations and a closely matched number of fire departments that did not meet the criteria. There were 1002 male firefighters in the study; 522 in fire departments aligned with WFI recommendations, and 480 not meeting recommended criteria. The study found that firefighters in departments meeting WFI criteria were less likely to be obese (adjusted odds ratio [AOR] = 0.58; 95% confidence interval [CI] = 0.41 to 0.82), more likely to meet endurance capacity standards for firefighting (AOR = 5.19; 95% CI = 2.49 to 10.83), and have higher estimated VO2 max (40.7 ± 0.6 vs 37.5 ± 1.3 for firefighters in standard departments; P = 0.001). However, studies have found that fewer than 20% of US municipal fire departments routinely engage in fitness programs and periodic fitness-testing.32
Delisle et al36 proposed the potential of a peer-mentor intervention to modify fitness outcomes in firefighters designated as high risk for cardiovascular disease via a 3-month, high-intensity, pilot study. The small cohort firefighters (n = 29) demonstrated the effectiveness of this social cognitive theory approach to increase VO2 max and decrease body fat percentage versus a control group. This difference persisted at 1-year follow-up. The significance of this pilot study could be that is shows the importance of involving firefighters in the planning, implementation, and evaluation process—although, intervention costs were not considered.
The only long-term, randomized, prospective trial in municipal firefighters that was identified in the literature review was the PHLAME (Promoting Healthy Lifestyles: Alternative Models’ Effects) Firefighter Study.67 This trial focused on nutrition, physical activity, and the maintenance of a healthy bodyweight. A team-centric intervention group, an individual-focused motivational interviewing intervention, and a control group receiving usual care were followed for 7 years. The interventions did not result in significant nor sustainable improvements in weight, cardiopulmonary fitness levels, or healthy physical activity behaviors.
Therefore, if industrial firefighters are better represented by US employees, will they be more likely to respond favorably to worksite wellness programs as supported by the RAND study; conversely, will they be more resistant to workplace interventions as suggested by the PHLAME study of municipal firefighters? It is evident from this review that inadequate attention has been given to industrial firefighters as a group; their demographic make-up and overall health status remains virtually unknown. It is, therefore, not possible at this time to predict the outcome of workplace interventions for this group of professionals. The implication is that studies directed toward industrial firefighters will be necessary to elucidate the best approach to achieving sustained changes in diet and exercise behaviors to reduce the risk of cardiovascular disease.
HOW DO US LAWS IMPACT FITNESS-FOR-WORK DECISIONS?
This document does not address Americans with Disabilities Act (ADA) or Genetic Information Nondiscrimination Act (GINA) considerations. The evaluating physician needs to review federal and state laws and regulations related to safety-sensitive positions, post-offer evaluation, medical accommodations, applicability of paid versus volunteer firefighting, public safety exemption for periodic examinations of employees, and family health inquiries related to cardiovascular disease risk. The safety-sensitive nature of firefighting duties and the volunteer status of firefighters in many industrial settings potentially allow for comprehensive annual fitness-for-duty assessments. It is important, however, that knowledgeable stakeholders, including legal and human resources, be consulted in the construct of the physical assessment process to ensure compliance with all relevant laws.
The Task Force has undertaken an extensive literature review in an attempt to provide an evidence-based guidance for assessing the fitness-for-duty of an industrial brigade firefighter. This was initiated due to the exclusion of industrial fire brigades from the very comprehensive NFPA 1582 medical standard and the paucity of information on the medical clearance process contained in the NFPA 600 standard, which is specifically intended to cover industrial fire brigades. The lack of specific studies of industrial firefighters within the medical literature excluded the possibility of an evidence-based guidance document. There was, however, sufficient information to draw some preliminary conclusions and to formulate a series of recommendations in terms of potential research opportunities as well as considerations for best practice approaches to the assessment of the cardiovascular fitness of industrial firefighters.
In general, there are many similarities between industrial fire brigades and community firefighters; however, there are distinct differences with industrial firefighters. These differences potentially place the industrial firefighter at an elevated risk by virtue of the greater hazards and more diverse fire types they encounter, their more rigorous training demands, the greater levels of mental stress, and a demographic of chronic disease, deconditioning, and obesity. Based upon responses from industrial firefighters surveyed by the Task Force, 90% had increased, high, very high, or extremely high risk for diabetes, hypertension, or coronary heart disease. How best to quantify this risk within the setting of a fitness-for-duty evaluation is a main objective of this Task Force. Risk calculators have not been validated in industrial firefighters, and the commonly used sub-maximal stress tests overestimate VO2 max and as a result underestimate potential cardiac risk and aerobic fitness.
A number of fitness-for-duty methodologies exist across industry, and many do adopt the NFPA 1582 standard to assess industrial firefighters. The presumption that any firefighter activities with similar peak demands will lead to similarly observed adverse cardiac events suggests that industrial firefighters should be screened aggressively for cardiac disease and aerobic capacity. One major problem with the NFPA 1582 standard is that the recommended approach to cardiovascular screening is sub-maximal stress tests (Gerkin WFI treadmill protocol) which, as noted, overestimate VO2 max and, if utilized in this setting, may lead to the erroneous medical clearance of aerobically unfit individuals for firefighting duties. Several studies exist that determine best practices for firefighters’ fitness-for-duty, but none focuses on industrial firefighting, likely due to a lack of assessment tools specifically developed for industry.
Preventive measures to reduce cardiovascular disease risk factors and improve aerobic fitness are critically important for industrial firefighters; unfortunately, no studies exist within this population to assess the effectiveness of any intervention. The only long-term, randomized, prospective trial in municipal firefighters identified in this review did not result in significant nor sustainable improvements in weight, cardiopulmonary fitness levels, or healthy physical activity behaviors.
Until additional specific medical information on industrial firefighters is available, the Task Force makes the following recommendations:
- Reference NFPA 1582 for all aspects of the physical assessment with the exception of cardiovascular fitness.
- Implement maximal exercise tolerance tests for the cardiovascular assessment since aerobic capacity and fitness has shown to be a good predictor of cardiac abnormalities as well as risk. Commonly used submaximal stress tests in firefighters, such as the Gerkin (WFI treadmill protocol) overestimate VO2 max.
- Eliminate use of submaximal stress testing as it has it has been shown to dangerously overestimate cardiovascular fitness.
- Encourage additional follow-up research in the following areas:
- Develop a careful analysis of job tasks with consideration for shiftwork, overtime, physical requirements for the tasks, as well as the psychological, cognitive, and environmental stressors for industrial firefighters.
- Conduct studies at local sites or across a particular industrial sector (eg, oil refineries, chemical manufacturing, etc) to evaluate the nature of the jobs and to assess whether fitness practices specific to those areas are valid and beneficial towards completing the job of an industrial firefighter in a safe and efficient manner.
- Investigate the demographic makeup of industrial firefighters and include an assessment of their cardiovascular risk profile, biometric data, and overall health.
- Conduct studies to identify barriers to implementing sustainable health promotion programs in industrial firefighters and assess the effectiveness of worksite programs in reducing the incidence of cardiovascular disease.
- Additional studies examining physiological characteristics of industrial firefighters based on NFPA standards would help determine if it will be beneficial to implement additional tools and/or tests specific to industrial firefighting.
- Develop and validate fitness-training programs for industrial firefighters.
In summary, industrial brigade firefighters share many characteristics with municipal firefighters, but their unique job responsibilities and the physical/mental demands under which they work have not been adequately studied. The Task Force found gaps in the medical literature as to demographic makeup, behavioral risk factors, and burden of chronic disease, effectiveness of preventive interventions to enhance wellness through risk factor reduction and aerobic fitness, and the proper methodology for a fitness-for-duty assessment. Due to these gaps, the Task Force will undertake the development of a guidance document for industrial firefighters emulating the model provided by the current ACOEM Guidance for the Medical Evaluation of Law Enforcement Officers (LEO).68
The Task Force wishes to thank reviewers Jeffrey Huth, MD, PhD, CDC/NIOSH, and Stefanos N. Kales, MD, MPH, Harvard Medical School & Harvard TH Chan School of Public Health, for their assistance, and to acknowledge ORCHSE for their work in implementing the survey.
Appendix 1: ORCHSE Survey of Industrial Firefighters. Turner D, Cathcart D, Glencross PM (2016). Unpublished Manuscript
- How old are you (years)? 21 to 25; 26 to 30; 31 to 35; 36 to 40; 41 to 45; 46 to 50; 51 to 55; 56 to 60; 61 to 65; 66 to 70; 71 to 75.
- Are you: male; female.
- What is your height? Feet; inches.
- What is your weight (pounds)?
- What is your waistband circumference (belt size in inches)?
- How many days per week do you exercise on average? Aerobic (defined as at least run 15 min/walk 10,000 steps/bike 30 min/swim 30 min/other 15 min); non-aerobic (defined as walking or similar activities that do not meet aerobic thresholds); resistance (defined as weight lifting /strengthening).
- Where have you exercised in the last 3 months? In company gym; not in company gym but on company grounds; outside of company; part of a fire team exercise program.
- How many years total have you been a firefighter?
- What type of fire fighter are you now? (Check all that apply) industrial fire team; volunteer community firefighter; paid community firefighter; medic in community; military/other firefighter.
- How would you characterize your role on the industrial fire team (select all that apply) fight fire in full bunker gear/SCBA; command and control only; support role only (ex. engineer/logistics/operations); medic; other.
- What level of industrial responder best describes what you do? Incipient responder; exterior firefighter; structural firefighter; exterior/structural firefighter; Hazmat operations level (defensive); Hazmat technician (offensive).
- What were the medical requirements to be cleared for the industrial fire team? (Select all that apply) Note from personal physician only; company physical examination required; functional capacity evaluation; treadmill or step testing; none.
- How often are you required to be medically cleared for the industrial fire team? Annually; periodically, based upon my age; periodically, based upon my personal health risk factors; other
- Which industrial fire team activities have you participated in over the last 3 months and how many hours would you estimate total? Response to actual fires; response to non-fire emergency; hands on training/drills; offsite firefighter school; classroom training; competitions.
- If you have not had to respond to actual fires in the last 3 months—have you responded in the last year? Yes; no. If yes, how many times?
- Do you have experience as a community firefighter? Yes; no. If yes, identify type of community: urban; suburban; rural; agricultural; combination.
- If you have experience as a community firefighter, do you consider industrial firefighting to have easier physical demands; the same physical demands, just less frequent; harder physical demands.
- If you have experience as a community firefighter, do you consider industrial firefighting to be more, the same or less physically stressful; mentally stressful; dangerous; training
- Why do you participate in the industrial fire team? (Rank all the following and add other as appropriate.) Pay; teamwork; pride; part of job; challenge; other
- Provide any additional comments regarding industrial firefighting.
1. National Fire Protection Association. Codes and Standards. NFPA 1582 – Standard on Comprehensive Occupational Medical Program for Fire Departments; 2013; 1.1.4.
2. National Fire Protection Association. Codes and Standards. NFPA 600 – Standard on Facility Fire Brigades; 2013.
3. Klaene B, Sanders R. Expert advisors provide strategic support: cooperation and pre-incident planning are essential to fighting at large industrial facilities. NFPA J
2002; 96:26Available at: http://www.nfpa.org/news-and-research/publications/nfpa-journal/2002/november-december-2002
. Accessed November 2, 2017.
4. Garver JN, Jankovitz KZ, Danks JM, Fittz AA, Smith HS, Davis SC. Physical fitness of an industrial fire department vs. a municipal fire department. J Strength Cond Res
5. Faulkner M, Levine E, Mitchell A, et al. National Response Team. Emerging Risks: Responder Awareness Training – Bakken Crude Oil [PowerPoint presentation]; 2015. Available at: https://nrt.org/sites/2/files/NRT%20Training%20Subcommittee%20Bakken%20Crude%20Oil%20presentation%20V28%20scrubbed.pdf
. Accessed November 2, 2017.
6. Vitalie T. Differences between federal, municipal, and private employees. Firerecruitcom [web site]; 2009.
7. Bureau of Labor Statistics, U.S. Department of Labor. Occupational Outlook Handbook, 2016–2017 ed. Firefighters [web site]. Available at: http://www.bls.gov/ooh/protective-service/firefighters.htm
. Accessed November 2, 2017.
8. Shelley C. Industrial and municipal fire department interface. Fireengineeringcom [web site]; 2009. Available at: http://www.fireengineering.com/articles/print/volume-162/issue-4/features/industrial-and-municipal-fire-department-interface.html
. Accessed November 2, 2017.
9. Centers for Disease Control and Prevention. Preventing Fire Fighter Fatalities Due to Heart Attacks and Other Sudden Cardiovascular Events. NIOSH publication 133; 2007. Available at: https://www.cdc.gov/niosh/docs/2007-133/pdfs/2007-133.pdf
. Accessed November 2, 2017.
10. Kales SN, Soteriades ES, Christoudias SG, Christiani DC. Firefighters and on-duty deaths from coronary heart disease: a case control study. Environ Health
11. Kales SN, Soteriades ES, Christiani CA, Christiani DC. Emergency duties and deaths from heart disease among firefighters in the United States. N Engl J Med
12. Kales SN, Smith DL. Sudden cardiac death in the fire service. Occup Med (Lond)
13. Kahn SA, Woods J, Rae L. Line of duty firefighter fatalities: an evolving trend over time. J Burn Care Res
14. Soteriades ES, Smith DL, Tsismenakis AJ, Baur DM, Kales SN. Cardiovascular disease in US firefighters: a systematic review. Cardiol Rev
15. Smith DL, Barr DA, Kales SN. Extreme sacrifice: sudden cardiac death in the US Fire Service. Extrem Physiol Med
16. Smith DL, DeBlois JP, Kales SN, Horn GP. Cardiovascular strain of firefighting and the risk of sudden cardiac events. Exerc Sport Sci Rev
17. Ratchford EV, Carson KA, Jones SR, Ashen MD. Usefulness of coronary and carotid imaging rather than traditional atherosclerotic risk factors to identify firefighters at increased risk for cardiovascular disease. Am J Cardiol
18. Byczek L, Walton SM, Conrad KM, Reichelt PA, Samo DG. Cardiovascular risks in firefighters: implications for occupational health nurse practice. AAOHN J
19. Geibe JR, Holder J, Peeples L, Kinney AM, Burress JW, Kales SN. Predictors of on-duty coronary events in male firefighters in the United States. Am J Cardiol
20. Angerer P, Kadlez-Gebhardt S, Delius M, Raluca P, Nowak D. Comparison of cardiocirculatory and thermal strain of male firefighters during fire suppression to exercise stress test and aerobic exercise testing. Am J Cardiol
21. Baur DM, Christophi CA, Kales SN. Metabolic syndrome is inversely related to cardiorespiratory fitness in male career firefighters. J Strength Cond Res
22. Donovan R, Nelson T, Peel J, Lipsey T, Voyles W, Israel RG. Cardiorespiratory fitness and the metabolic syndrome in firefighters. Occup Med (Lond)
23. Barger LK, Rajaratnam SM, Wang W, et al. Harvard Work Hours Health and Safety Group. Common sleep disorders increase risk of motor vehicle crashes and adverse health outcomes in firefighters. J Clin Sleep Med
24. Smith DL, Petruzzello SJ, Kramer JM, Misner JE. Physiological, psychophysical, and psychological responses of firefighters to firefighting training drills. Aviat Space Environ Med
25. Sen S, Palmieri T, Greenhalgh D. Cardiac fatalities in firefighters: an analysis of the U.S. Fire Administration Database. J Burn Care Res
26. Wolkow A, Netto K, Langridge P, et al. Coronary heart disease risk in volunteer firefighters in Victoria, Australia. Arch Environ Occup Health
27. Zapatka RE. Industrial firefighters are firefighters too. Excerpt. Fireengineeringcom [Web site]; 2005.
28. National Heart, Lung and Blood Institute. The Practical Guide: Identification, Evaluation, and Treatment of Overweight and Obesity in Adults; 2000. Available at: http://www.nhlbi.nih.gov/files/docs/guidelines/prctgd_c.pdf
. Accessed November 2, 2017.
29. Adams J, Roberts J, Simms K, Cheng D, Hartman J, Bartlett C. Measurement of functional capacity requirements to aid in development of an occupation-specific rehabilitation training program to help firefighters with cardiac disease safely return to work. Am J Cardiol
30. Perroni F, Tessitore A, Cortis C, et al. Energy cost and energy sources during a simulated firefighting activity. J Strength Cond Res
31. Williams-Bell FM, Villar R, Sharratt MT, Hughson RL. Physiological demands of the firefighter Candidate Physical Ability Test. Med Sci Sports Exerc
32. Durand G, Tsismenakis AJ, Jahnke SA, Baur DM, Christophi CA, Kales SN. Firefighters’ physical activity: relation to fitness and cardiovascular disease risk. Med Sci Sports Exerc
33. Baur DM, Leiba A, Christophi CA, Kales SN. Low fitness is associated with exercise abnormalities among asymptomatic firefighters. Occup Med (Lond)
34. Gulati M, Pandey DK, Arnsdorf MF, et al. Exercise capacity and the risk of death in women: the St James Women Take Heart Project. Circulation
35. Mark DB, Lauer MS. Exercise capacity: the prognostic variable that doesn’t get enough respect. Circulation
36. Delisle AT, Piazza-Gardner AK, Cowen TL, et al. Validation of a cardiorespiratory fitness assessment for firefighters. J Strength Cond Res
37. Dolezal BA, Barr D, Boland DM, Smith DL, Cooper CB. Validation of the firefighter WFI treadmill protocol for predicting VO2 max. Occup Med (Lond)
38. Klaren RE, Horn GP, Fernhall B, Motl RW. Accuracy of the VO2peak
prediction equation in firefighters. J Occup Med Toxicol
39. Mier CM, Gibson AL. Evaluation of a treadmill test for predicting the aerobic capacity of firefighters. Occup Med (Lond)
40. Ode J, Knous J, Schlaff R, Hemenway J, Peterson J, Lowry J. Accuracy of body mass index in volunteer firefighters. Occup Med (Lond)
41. Baur DM, Christophi CA, Tsismenakis AJ, Jahnke SA, Kales SN. Weight-perception in male career firefighters and its association with cardiovascular risk factors. BMC Public Health
42. Baur DM, Christophi CA, Cook EF, Kales SN. Age-related decline in cardio-respiratory fitness among career firefighters: modification by physical activity and adiposity. J Obes
43. Poston WS, Haddock CK, Jahnke SA, Jitnarin N, Tuley BC, Kales SN. The prevalence of overweight, obesity, and substandard fitness in a population-based firefighter cohort. J Occup Environ Med
44. Tsismenakis AJ, Christophi CA, Burress JW, Kinney AM, Kim M, Kales SN. The obesity epidemic and future emergency responders. Obesity (Silver Spring)
45. Nogueira EC, Porto LG, Nogueira RM, et al. Body composition is strongly associated with cardiorespiratory fitness in a large Brazilian military firefighter cohort: the Brazilian Firefighters Study. J Strength Cond Res
46. Farioli A, Yang J, Teehan D, Baur DM, Smith DL, Kales SN. Duty-related risk of sudden cardiac death among young US firefighters. Occup Med (Lond)
47. Korre M, Sampani K, Porto LGG, et al. Cardiac enlargement in US firefighters: prevalence estimates by echocardiography, cardiac magnetic resonance and autopsies. J Clin Exp Cardiol
48. Korre M, Porto LG, Farioli A, et al. Effect of body mass index on left ventricular mass in career male firefighters. Am J Cardiol
49. Yang J, Teehan D, Farioli A, Baur DM, Smith D, Kales SN. Sudden cardiac death among firefighters ≤45 years of age in the United States. Am J Cardiol
50. Jain A, Tandri H, Dalal D, et al. Diagnostic and prognostic utility of electrocardiography for left ventricular hypertrophy defined by magnetic resonance imaging in relationship to ethnicity: the Multi-Ethnic Study of Atherosclerosis (MESA). Am Heart J
51. Soteriades ES, Targino MC, Talias MA, et al. Obesity and risk of LVH and ECG abnormalities in US firefighters. J Occup Environ Med
52. Lindberg AS, Oksa J, Gavhed D, Malm C. Field tests for evaluating the aerobic work capacity of firefighters. PLoS One
53. von Heimburg E, Medbø JI, Sandsund M, Reinertsen RE. Performance on a work-simulating firefighter test versus approved laboratory tests for firefighters and applicants. Int J Occup Saf Ergon
54. Groeller H, Fullagar HH, Sampson JA, Mott BJ, Taylor NA. Employment standards for Australian urban firefighters: Part 3: the transition from criterion task to test. J Occup Environ Med
55. Roberts MA, O’Dea J, Boyce A, Mannix ET. Fitness levels of firefighter recruits before and after a supervised exercise training program. J Strength Cond Res
56. Smith DL. Firefighter fitness: improving performance and preventing injuries and fatalities. Curr Sports Med Rep
57. Fahy RF, LeBlanc PR, Molis JL. Firefighter Fatalities in the United States – 2015. Quincy, MA: National Fire Protection Association; 2016.
58. National Fire Protection Association. Codes and Standards. NFPA 1583 – Standard on Health-Related Fitness Programs for Fire Department Members
. 2015; 1583-1–1583-21.
59. Sheaff AK, Bennett A, Hanson ED, et al. Physiological determinants of the candidate physical ability test in firefighters. J Strength Cond Res
60. Shell Health. Fitness to Work Functional Specifications: Report HEMS.GL.2000.04
. 2015; 1–53.
61. Motiva Port Arthur Refinery. Fitness to Respond Agility Test Standing Instruction
62. Bhojani FA. Physical Fitness of Industrial Firefighters
. (Doctoral dissertation); 1999.
63. OSHA. Occupational Safety and Health Standards – Fire Protection. 190.156. Available at: https://www.osha.gov/pls/oshaweb/owadisp.show_document?p_table=STANDARDS&p_id=9810
. Accessed November 2, 2017.
64. National Fire Protection Association. National Fire Protection Association. Codes and Standards. NFPA 1081 – Standard for Industrial Fire Brigade Member Professional Qualifications
65. Mattke S, Liu H, Caloyeras JP, et al. Workplace Wellness Programs Study. 2013; Santa Monica, CA: Rand Corporation, Available at: http://www.rand.org/content/dam/rand/pubs/research_reports/RR200/RR254/RAND_RR254.pdf
. Accessed November 2, 2017.
66. Poston WS, Haddock CK, Jahnke SA, Jitnarin N, Day RS. An examination of the benefits of health promotion programs for the national fire service. BMC Public Health
67. MacKinnon DP, Elliot DL, Thoemmes F. Long-term effects of a worksite health promotion program for firefighters. Am J Health Behav
68. American College of Occupational and Environmental Medicine. Guidance for the Medical Evaluation of Law Enforcement Officers
[online publication]; 2017. Available at: https://www.leoguidance.org/
. Accessed November 9, 2017.