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Law Enforcement Officers&
Fire Fighters
FabriceFabrice Czarnecki, Czarnecki, M.D., M.A., M.P.H.M.D., M.A., [email protected]@gablesgroup.com
September 2011September 2011I have no disclosure to make.I have no disclosure to make.
Michigan Occupational Health Conference
Background Background -- ReviewReview
►►What?What?►►Why?Why?►►Who?Who?►► How?How?
WHAT?WHAT?
Document that provides guidance Document that provides guidance to physicians who are to physicians who are responsible for: responsible for:
►► Promoting the health & safety Promoting the health & safety of LEOof LEO
►► Ensuring the LEO has ability to Ensuring the LEO has ability to perform their jurisdictionperform their jurisdiction’’s s essential job functionsessential job functions
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WHY?CASE STUDY: DIABETES
45 year old officer with type II diabetes, on oral medications, poorly controlled, no hypoglycemic reactions.
One month ago is started on insulin regimen. Now sugars very well controlled.
His chief found out he was injecting medication,and is sending him in for a fitness exam as soon as hegets back from patrol.
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New York
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Kentucky
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Massachusetts
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Mississippi
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1. Take him off hazardous dutyfor 3 months
2. See if he fulfills the ACOEMrequirements.
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WHO?WHO?
►► Public Safety Medicine Section Physicians Public Safety Medicine Section Physicians ►► Medical Guidance for Law Enforcement Officers Task Medical Guidance for Law Enforcement Officers Task
GroupGroup
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WHO? WHO? ---- StakeholdersStakeholders
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WHO? WHO? ---- Content Experts and Advocacy Groups
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HOW?HOW?
►► Chapter LeadChapter Lead►► Review literatureReview literature►► Disease Disease ►► Risk of Sudden Risk of Sudden
IncapacitationIncapacitation
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HOW?HOW?
►► CA POSTCA POST
►► Pilots Pilots -- FAAFAA
►► Truck Drivers Truck Drivers –– DOTDOT
►► FF FF –– NFPANFPA
►► Soldiers Soldiers -- DODDOD
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How?How?
►► Chapter draftedChapter drafted►► Discussed during meetings and Discussed during meetings and
teleconferencingteleconferencing►► Subject matter experts reviewedSubject matter experts reviewed►► Meetings with stakeholders and Meetings with stakeholders and
advocacy groupsadvocacy groups►► Passed by ACOEM Board of Passed by ACOEM Board of
DirectorsDirectors
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Questions
►► Does the condition create a risk of sudden Does the condition create a risk of sudden incapacitation?incapacitation?
►► Does the condition make the officer unable Does the condition make the officer unable to perform the job?to perform the job?
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►► It is a guide for police physiciansIt is a guide for police physicians
►► It applies to patrol officersIt applies to patrol officers
►► It applies to applicants and incumbentsIt applies to applicants and incumbents
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AccomplishmentsAccomplishments
►► CompletedCompleted►► DiabetesDiabetes►► CardiovascularCardiovascular►► HearingHearing►► Eyes and VisionEyes and Vision►► MedicationsMedications►► PregnancyPregnancy►► Infectious Diseases*Infectious Diseases*
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Pending ChaptersPending Chapters
►► SeizuresSeizures►► ProsthesesProstheses►► Substance abuseSubstance abuse►►RespiratoryRespiratory►►Bleeding disordersBleeding disorders►►Risk assessmentRisk assessment
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Format
►►Web basedWeb based
►► Subscription Subscription -- $100/yr$100/yr
►► Access began June 1, 2010Access began June 1, 2010
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Acknowledgements
►► Dan Dan SamoSamo►► Tom HalesTom Hales►► Dave LouisDave Louis►► Stan Stan HaimesHaimes►► Kris ArnoldKris Arnold►► Ed Ed GalaidGalaid►► Richard MillerRichard Miller
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Contact Information
www.leowww.leo--medical.commedical.com
www.acoem.org/leoguidelines.aspxwww.acoem.org/leoguidelines.aspx
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Guidance for Fire Fighters
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NFPA 1582:Standard on Comprehensive Occupational Medical Program for Fire Departments
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NationalFireProtectionAssociation Non-profit
Mission - Reduce burden of fire and other hazards by:
• Codes & Standards• Research• Training & Education
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Quincy
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Standard Setting ProcessANSI ANSI
Consensus basedConsensus based5 Steps to Develop/Revise5 Steps to Develop/RevisePublic input at each stepPublic input at each stepwww.nfpa.orgwww.nfpa.org
Fire Service OSH CommitteeFire Service OSH Committee30 members 30 members
Open MeetingsOpen Meetings31
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FSOSH Committee
1500 Series1500 Series1500 1500 –– OSH ProgramOSH Program1521 1521 –– FD Safety OfficersFD Safety Officers1561 1561 –– Incident MgmtIncident Mgmt1581 1581 –– Infectious DiseaseInfectious Disease1582 1582 -- Medical ProgramMedical Program1583 1583 -- Fitness ProgramFitness Program1584 1584 -- Rehab Rehab
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Standard FormatFormatFormat
Body of text: RequiredBody of text: Required
Appendix Appendix For For ““informational purposes informational purposes
onlyonly””Recommended practicesRecommended practices
VoluntaryVoluntary
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Why Medical Standards for FF?
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Medical
Other
Internal traumaElectrocution
Burns
Asphyxiation
Source: NFPA
Fire Fighter Fatalities by Nature of Injury
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1992 – 1st Edition
1997 – 2nd Edition
2000 – 3rd Edition
2003 – 4th Edition
2007 – 5th Edition
2012 – 6th Edition
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Key Dates for 1582 Input
ProposalsProposals Nov 2010Nov 2010
Meeting to discuss proposalsMeeting to discuss proposals Feb 2011Feb 2011Report of ProposalsReport of Proposals Jun 2011Jun 2011Comments on AboveComments on Above Aug 2011Aug 2011Report on CommentsReport on Comments Feb 2012Feb 2012NFPA S Standards CouncilNFPA S Standards Council Jun 2012Jun 2012
Secretary Secretary –– Standards Council, NFPA Standards Council, NFPA 1 1 BatterymarchBatterymarch Park, PO Box 9101Park, PO Box 9101
Quincy, MA 02269Quincy, MA 02269--91019101 36
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Chapter 5: 13 Essential Job Tasks
►► FireFire--fighting tasksfighting tasks►► Wearing an SCBAWearing an SCBA►► Exposure to toxic fumesExposure to toxic fumes►► Physical workloadPhysical workload►► No sudden incapacitationNo sudden incapacitation
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Chapter 5: 13 Essential Job Tasks
►► Hyperthermia and dehydration from Hyperthermia and dehydration from ““encapsulating and insulatedencapsulating and insulated”” ““fire fire protective ensembleprotective ensemble””
►► Climbing ladders, operating from heightsClimbing ladders, operating from heights►► Prolonged periods of physical exertion Prolonged periods of physical exertion
without rest periods, meals or hydrationwithout rest periods, meals or hydration►► Operating fire apparatusOperating fire apparatus
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Chapter 6: Medical Evaluations of Candidates
Category A: Category A: A medical condition that would preclude a A medical condition that would preclude a person from performing as a member in a person from performing as a member in a training or emergency operational training or emergency operational environment by presenting a significant risk environment by presenting a significant risk to the safety and health of the person or to the safety and health of the person or others.others.
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Chapter 6: Medical Evaluations of Candidates
Category B: Category B: A medical condition that, based on its A medical condition that, based on its severity or degree, could preclude a person severity or degree, could preclude a person from performing as a member in a training from performing as a member in a training or emergency operational environment by or emergency operational environment by presenting a significant risk to the safety presenting a significant risk to the safety and health of the person or others.and health of the person or others.
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Chapter 7: Occupational Medical Evaluation of Members
•• Annual medical evaluationAnnual medical evaluation•• Preventive medicine programPreventive medicine program
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Chapter 9: Essential Job Tasks —Specific Evaluation of Medical Conditions in Members
By organ system:By organ system:9.4 Cardiovascular Disorders9.4 Cardiovascular Disorderstoto9.18 Pregnancy and Reproductive Health*9.18 Pregnancy and Reproductive Health*
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Annexes
Annex A: Explanatory MaterialAnnex A: Explanatory Material
Annex D: Informational ReferencesAnnex D: Informational References
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Examples from the LEO Guide
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Diabetes
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Duration of Treatment
►► 3 or 6 months if on insulin3 or 6 months if on insulin
►► 1 month if on oral agents1 month if on oral agents
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Hypoglycemia
► No episode within the past one year of severe hypoglycemia
► No more than two episodes in the past three years of severe hypoglycemia
►► Awareness of blood sugar lower than 60 Awareness of blood sugar lower than 60 mg/dlmg/dl
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Eyes and Vision
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Best Corrected Distant Visual Acuity
►► 20/20 binocularly20/20 binocularly►► At least 20/40 in each eyeAt least 20/40 in each eye
►► Individuals who cannot be corrected to 20/20 in Individuals who cannot be corrected to 20/20 in each eye, must be evaluated by an ophthalmologist each eye, must be evaluated by an ophthalmologist or optometristor optometrist
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Uncorrected Distant Visual Acuity
►► Soft contact lenses: No uncorrected distant Soft contact lenses: No uncorrected distant visual acuity recommendation visual acuity recommendation
►► Spectacles or hard contact lenses: 20/100 Spectacles or hard contact lenses: 20/100 binocularlybinocularly
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Refractive surgery
►► LASIKLASIK►► LASEKLASEK►► PRKPRK
►► Acceptable proceduresAcceptable procedures►► Limit exposure to oleoresin capsicum (pepper Limit exposure to oleoresin capsicum (pepper
spray)spray)
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Other issues
►► Color visionColor vision►► Visual field (120Visual field (120°°))►► Binocular visionBinocular vision
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Cardiovascular diseases
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Hypertension
►► SBP should be under 160SBP should be under 160►► DBP should be under 100DBP should be under 100
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Stress testing
► Male LEOs >45 years and female LEOs>55 years should have an exercise stress test if they have any of the following cardiac risk factors:
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Stress testing
► High cholesterol: total cholesterol >240 milligram per deciliter (mg/dl)
► High blood pressure: systolic BP >140 mmHg or diastolic BP >90 mm Hg, or any treated hypertension
► Tobacco smoking► Family history of heart attack or sudden cardiac
death in first-degree relative <60 years of age
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Cardiac events
►► Myocardial infarction: 3 monthsMyocardial infarction: 3 months►► PercutanousPercutanous coronary intervention: 1 monthcoronary intervention: 1 month►► Bypass surgery: 3 monthsBypass surgery: 3 months►► Heart failure: 12 METS on stress testingHeart failure: 12 METS on stress testing
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Pregnancy
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Concerns
►► TraumaTrauma►► LeadLead►► NoiseNoise►► Other chemicalsOther chemicals
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First Trimester
►► Modified duty if requested by officerModified duty if requested by officer►► Patrol duties: May be permittedPatrol duties: May be permitted►► Firearms qualification and practice: Not Firearms qualification and practice: Not
recommendedrecommended►► Alternative ways to qualifyAlternative ways to qualify
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Second Trimester
►► Patrol duties: Possible, if able and willingPatrol duties: Possible, if able and willing►► Modified duty if requested by officerModified duty if requested by officer►► Defensive tacticsDefensive tactics►► No ground fightingNo ground fighting►► No falls or blunt traumaNo falls or blunt trauma
►► Maternity uniform or civilian clothingMaternity uniform or civilian clothing
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Third Trimester
►► Patrol duties: Ability to perform?Patrol duties: Ability to perform?►► No standing for more than 30 minutesNo standing for more than 30 minutes►► No repetitive lifting over 25 lbsNo repetitive lifting over 25 lbs
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Recommendations - Firearms
►► No firearms practice or qualification during No firearms practice or qualification during pregnancypregnancy
►► Alternatives to firearms Alternatives to firearms qualification/Simulationsqualification/Simulations
►► Pregnant officers should avoid shooting Pregnant officers should avoid shooting rangesranges
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Medications
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Medications & the law enforcement officer
►► Potential effects on the officerPotential effects on the officer’’s ability to s ability to safely perform job functionssafely perform job functions
►► Risk of sudden incapacitation Risk of sudden incapacitation
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Significant side effects of drugs
►► CNS depression (drowsiness)CNS depression (drowsiness)►► CNS stimulationCNS stimulation►► Autonomic nervous system disturbance Autonomic nervous system disturbance
(thermoregulation, abnormal heart rate(thermoregulation, abnormal heart rate……))►► Disturbance of equilibriumDisturbance of equilibrium►► Anticoagulation, risk of bleedingAnticoagulation, risk of bleeding►► Vision changesVision changes►► Behavioral changes and judgment impairmentBehavioral changes and judgment impairment
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Categories of medications
►► A A –– Acceptable Acceptable ►► T T –– TemporaryTemporary►► S S –– ShiftShift►► R R –– RestrictedRestricted
►► D D –– Diagnosis Diagnosis
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A – Acceptable
►► Minimal or unlikely impact on job Minimal or unlikely impact on job performanceperformance
►► Approved while on dutyApproved while on duty►► May require specific monitoring of side May require specific monitoring of side
effectseffects
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A – Acceptable
►► Acetaminophen (TYLENOL)Acetaminophen (TYLENOL)►► AspirinAspirin►► Most antibioticsMost antibiotics►► Most blood pressure medicationsMost blood pressure medications►► Most supplementsMost supplements
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T – Temporary
►► Possible effect at the beginning of treatment Possible effect at the beginning of treatment that may adversely impact performance of that may adversely impact performance of job functionsjob functions
►► Appropriate restrictions on a temporary Appropriate restrictions on a temporary basis at the beginning of the treatmentbasis at the beginning of the treatment
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T – Temporary
►► Some blood pressure medicationsSome blood pressure medications►► Monitor for orthostatic hypotension and Monitor for orthostatic hypotension and
drowsinessdrowsiness
►► Diabetes medicationsDiabetes medications►► Monitor for low blood sugarMonitor for low blood sugar
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S – Shift
►► Known effect of short duration that may adversely Known effect of short duration that may adversely impact performance of job functionsimpact performance of job functions
►► These medications may be taken while the officer These medications may be taken while the officer is off duty, and does not return to duty, before a is off duty, and does not return to duty, before a minimum safe time has elapsed after taking the minimum safe time has elapsed after taking the medicationmedication
►► Usually two dosing periods, depending on the Usually two dosing periods, depending on the duration of action of the medication duration of action of the medication
[National Transportation Safety Board Safety Recommendation, Jan[National Transportation Safety Board Safety Recommendation, January uary 13, 2000]13, 2000]
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S – Shift
►► AlcoholAlcohol►► Anesthesia medicationsAnesthesia medications►► Most sedativesMost sedatives►► Most narcoticsMost narcotics►► Some supplements: chamomile, valerianSome supplements: chamomile, valerian
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R – Restricted
►► Known effect that may adversely impact Known effect that may adversely impact performance of job functionsperformance of job functions
►► Restrictions as long as the officer is taking Restrictions as long as the officer is taking or affected by the medicationsor affected by the medications
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R – Restricted
►► Long acting narcoticsLong acting narcotics►► MefloquineMefloquine (LARIAM)(LARIAM)
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Warfarin COUMADIN
► R – approved only if the officer is assigned to restricted duty
► Medication may cause significant bleeding (particularly intracranial), resulting in sudden incapacitation in case of altercation or fall.
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Varenicline (CHANTIX)
►► Risk of severe changes in mood and Risk of severe changes in mood and behaviorbehavior
►► FMCSA: Not approved for truck driversFMCSA: Not approved for truck drivers
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Varenicline (CHANTIX)
►► T categoryT category►► Monitor for behavior changes, hypertension Monitor for behavior changes, hypertension
and visual changesand visual changes
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Modafinil (PROVIGIL)
►► FMCSA: FMCSA: ProvigilProvigil has several has several concerningconcerningside effects such as chest pain, dizziness, side effects such as chest pain, dizziness, ((……) rapidly changing mood, problems with ) rapidly changing mood, problems with memory, blurred vision (memory, blurred vision (……) )
►► FMCSA: Drivers being prescribed FMCSA: Drivers being prescribed ProvigilProvigilshould not be qualified until they have been should not be qualified until they have been monitored closely for at least 6 weeks while monitored closely for at least 6 weeks while taking taking ProvigilProvigil. .
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Modafinil (PROVIGIL)
►► T categoryT category►► Monitor for behavior and visual changes Monitor for behavior and visual changes
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Medications with psychiatric side effects
►► SteroidsSteroids►► Thyroid hormonesThyroid hormones►► MefloquineMefloquine (LARIAM)(LARIAM)►► Interferon Interferon alfaalfa►► IsoniazidIsoniazid
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Useful Websites
►► California POST Medical Screening ManualCalifornia POST Medical Screening Manual►► www.post.ca.gov/medicalwww.post.ca.gov/medical--screeningscreening--manual.aspxmanual.aspx
►► FAA Guide for Aviation Medical ExaminersFAA Guide for Aviation Medical Examiners►► www.faa.gov/about/office_org/headquarters_offices/avs/offices/aawww.faa.gov/about/office_org/headquarters_offices/avs/offices/aam/ame/m/ame/
guide/guide/►► FMCSA Medical ProgramsFMCSA Medical Programs
►► http://www.fmcsa.dot.gov/ruleshttp://www.fmcsa.dot.gov/rules--regulations/topics/medical/medical.htmregulations/topics/medical/medical.htm►► US Coast Guard Medical ManualUS Coast Guard Medical Manual
►► http://www.uscg.mil/directives/cim/6000http://www.uscg.mil/directives/cim/6000--6999/CIM_6000_1D.pdf6999/CIM_6000_1D.pdf►► NFPA 1582 Standard on Comprehensive Occupational Medical NFPA 1582 Standard on Comprehensive Occupational Medical
Program for Fire DepartmentsProgram for Fire Departments►► http://http://www.nfpa.org/aboutthecodes/AboutTheCodes.asp?DocNumwww.nfpa.org/aboutthecodes/AboutTheCodes.asp?DocNum=1582=1582
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