Featured Topic

• Why Was the Program Developed?
• What Are the Standards?
• What Does the Exam Include?
• Why Are Tests Listed That Aren't Linked With a Standard?
• How Is the Program Implemented?
• What Happens When a Firefighter Isn't Medically Cleared?
• Who Has Access to Confidential Medical Records?

Interagency Wildland Firefighter Medical Standards

Why Was the Program Developed?

In 1998 the Federal Fire and Aviation Leadership Council (FFALC) asked an interagency team to review the medical examination processes in effect for arduous duty wildland firefighters among its member agencies, and to make recommendations (see National Interagency Incident Management System Wildland and Prescribed Fire Qualification System Guide, PMS 310-1, January 2000) regarding positions that are considered arduous. The FFALC, which oversees wildland firefighting activities for the Federal Government, assembled a team drawn from the Departments of the Interior and Agriculture, the Office of Personnel Management, and the U.S. Public Health Service. Team members had backgrounds from fields including firefighting, fire program management, safety, human resources, and medicine. For the past 5 years, the team has undergone basic firefighter training, observed firefighting activities on wildland and prescribed fires, gathered information on the procedures being used for physical exams, reviewed relevant studies and the available death and injury statistics, and interviewed fire managers and firefighters. They concluded that the medical exams, and the way they were being used, were inadequate to assure that employees' health was sufficient to avoid unnecessary risks, both for themselves and for others, in carrying out firefighting work. The team also was concerned that existing programs may lead to inconsistent or inadequate protection of employee rights under the Rehabilitation Act of 1973, and confidentiality under the Privacy Act of 1974, and that the existing programs could expose agencies to unnecessary liability.

For example, without standard procedures, firefighters with a specific medical problem in one district may experience different personnel actions than those in another district, whether from lack of knowledge, different local policies, or even personal grudges. A firefighter's confidential medical information may be revealed at the time of a pack test to a coworker who shouldn't have access to it, harming or embarrassing the firefighter. Without baseline and followup medical information, firefighters may not know they have a hearing loss, or how serious the loss is. They won't know how to tell if the loss has gotten worse from working around chain saws and heavy equipment. A crew boss may not know if a crewmember can't see colors normally and needs special escape-route flagging, or whether to assign fellow crewmembers to look out for the vision-impaired firefighter. A manager may not have an established basis and fair procedure to restrict individuals whose asthma, heart disease, diabetes, or bad knees may pose a direct threat to their safety or that of their fellow firefighters. The Government, as an employer, is obligated to treat employees fairly and equitably, and to avoid knowingly placing employees in situations in which they are likely to be harmed while carrying out the requirements of the job.

The FFALC charged the interagency review team with developing and implementing a medical standards program that would apply throughout the Federal firefighting community. The goal was to have a program that:

• Provides medical examinations focused on the requirements of wildland firefighting
  
  
• Assures the review of medical histories and examination findings in a uniform and consistent manner, and by medical officers knowledgeable in wildland firefighting
  
  
• Defines the process to follow in considering waivers or accommodations for firefighters unable to meet the medical standards

The program also needed to meet the requirements of the Rehabilitation Act and the Privacy Act, and be acceptable to the Office of Personnel Management.

After the team members drafted the standards, and the forms and guidelines for their use, they recommended a pilot test to refine the materials and the procedures to implement them. They also recommended a series of field validations and research into the effects some of the specific standards might have. Finally, the waiver and accommodation process, a major part of the medical standards program, was set up to assure firefighters a fair and consistent system was in place when the process identified medical conditions that could pose a risk to safe and efficient job performance. The next step involved a series of reviews and approvals by the Government agencies involved.

The standards, forms, and procedures were approved by the FFALC in January 2000. The pilot program implementation began during 2001 with firefighters in the Southwest. The pilot program will be expanded over the next few years, to include the Northwest during the 2003 fire season. Alaska, California, Hawaii, and Nevada will follow in 2004, with the Mountain States in 2005 and the Central and Southeastern States in 2006. Lessons learned during the phased implementation will be incorporated into the overall program.

What Are the Standards?

All medical standards are subject to clinical interpretation by the medical review officer, incorporating knowledge of the job of firefighting and the environmental conditions in which firefighters work. Also, because the standards must relate directly to the actual requirements of the job of a wildland firefighter, they are written in a format such as "The firefighter must have [specified body systems or functions] that will provide for the safe and efficient conduct of the requirements of the job." In many cases, examples or ways in which compliance with the standard might be demonstrated are provided. Individual assessments must be made on a case-by-case basis (see the wildland firefighter Web site, http://medical.smis.doi.gov/nifcmedicalstds.htm, for a more complete presentation of the examples used in the standards). The medical standards are distinct from "performance requirements" for the wildland firefighter, such as the pack test. This test is discussed in detail in the report by Brian J. Sharkey, Ph.D., Fitness and Work Capacity, Second Edition, National Wildfire Coordinating Group, April 1997.

The medical standards for individual wildland firefighters are summarized below. For each body function or topic area, the medical review officer looks for evidence from the physical examination, laboratory tests, or medical history of any impairment that might present a safety risk, or that could worsen as a result of a firefighter's work.

Psychiatric Standard—The applicant/incumbent must have judgment, mental functioning, and social interaction/behavior that will provide for the safe and efficient conduct of the requirements of the job.

Prosthetics, Transplants, and Implants Standard—The presence or history of organ transplantation or use of prosthetics or implants are not of themselves disqualifying. However, the applicant/incumbent must be able to safely and efficiently carry out the job of wildland firefighting.

Immune System/Allergic Disorders Standard—The applicant/incumbent must be free of communicable diseases, have a healthy immune system, and be free of significant allergic conditions that would impede the ability to safely and efficiently carry out the requirements of the job.

Medication Standard—The need for and use of prescribed or over-the-counter medications are not necessarily disqualify-ing. Each of the following points should be considered:

• Medication(s) (type and dosage requirements)
• Potential drug side effects
• Drug-environmental interactions
• Adverse drug reactions
• Drug toxicity or medical complications from long-term use
• Drug-drug interactions
• Drug-food interactions
• History of patient compliance

Vision Standard—The applicant/incumbent must be able to see well enough to safely and efficiently carry out the requirements of the job. This requires binocular vision, far visual acuity, depth perception, peripheral vision, and color vision, which may be demonstrated by:

• Far visual acuity of at least 20/100 in each eye, without corrective lenses
  
• Far visual acuity of at least 20/40 in each eye, with cor-rection (if necessary) with contact lenses or glasses
  
• Color vision sufficient to distinguish at least red, green, and amber (yellow)
  
• Peripheral vision of at least 85 degrees laterally in each eye
  
• Normal depth perception
  
• No ophthalmologic condition that would increase ophthalmic sensitivity to bright light, fumes, or airborne particulates, or susceptibility to sudden incapacitation.

Head, Nose, Mouth, Throat, and Neck Standard—The applicant/incumbent must have structures and functions of the head, nose, mouth, throat, and neck that are sufficient for the individual to safely and efficiently carry out the requirements of the job.

Hearing Standard—The applicant/incumbent must be able to hear well enough to safely and efficiently carry out the requirements of the job. This requires binaural hearing (to localize sounds) and auditory acuity, which may be demonstrated by an audiogram showing hearing thresholds of no greater than 40 decibels at 500, 1,000, 2,000, and 3,000 hertz in each ear, and no evidence of ear conditions likely to present a safety risk or to worsen as a result of carrying out the essential functions of the job. The use of hearing aids to meet this standard is not permitted, because firefighters need to localize sounds accurately.

Dermatology Standard—The applicant/incumbent's skin must be sufficient for the individual to safely and efficiently carry out the requirements of the job.

Vascular System Standard—The applicant/incumbent's vascular system must be sufficient for the individual to safely and efficiently carry out the requirements of the job. This may be demonstrated by an exam showing no evidence of phlebitis, thrombosis, or venous stasis, and no evidence of arterial insufficiency.

Cardiac Standard—The applicant/incumbent's cardiovascular system must be sufficient for the individual to safely and efficiently carry out the requirements of the job. This may be demonstrated by a normal physical exam of the cardiovascular system (blood pressure less than or equal to 140 millimeters mercury systolic and 90 millimeters mercury diastolic, and a normal baseline electrocardiogram).

Chest and Respiratory System Standard—The applicant/incumbent's a respiratory system must be sufficient for the individual to safely and efficiently carry out the requirements of the job. This may be demonstrated by a normal physical exam of the respiratory system and a normal pulmonary function test (on the baseline exam). Note: the requirement to use an inhaler (such as for asthma) requires agency review.

Endocrine and Metabolic System Standard—Any excess or deficiency in hormonal production can produce metabolic disturbances affecting weight, stress adaptation, energy production, and a variety of symptoms or pathology, such as elevated blood pressure, weakness, fatigue, and collapse. The applicant/incumbent's endocrine and metabolic functions must be sufficient for the individual to carry out the requirements of the job safely and efficiently.

Hematopoietic System (Blood-Forming) Standard—The applicant/incumbent's hematopoietic (blood and blood-producing) system must be sufficient for the individual to carry out the requirements of the job safely and efficiently.

Musculoskeletal System Standard—The applicant/incumbent's musculoskeletal system must be sufficient for the individual to carry out the functional requirements of the job safely and efficiently. This may be demonstrated by a physical exam of the upper and lower extremities, neck, and back that is within the range of normal variation for strength, flexibility, range of motion, and joint stability. Individuals who require the use of a prosthetic device will have to provide documentation from their surgeon or physician that they (and, if applicable, their prosthetic device) are considered to be fully cleared for the essential functions of the job.

Central and Peripheral Nervous System Standard, and Vestibular System Standard— The applicant/incumbent's nervous system must be sufficient for the individual to carry out the requirements of the job safely and efficiently. This may be demonstrated by a physical exam of the cranial and peripheral nerves and the vestibular and cerebellar system that is within the range of normal variation, and by a normal basic mental status evaluation (giving correct responses to questions about, person, place, time, and current events).

Gastrointestinal System Standard—The applicant/incumbent's gastrointestinal tract must be sufficient for the individual to carry out the requirements of the job safely and efficiently.

Genitourinary System Standard—The applicant/incumbent's genitourinary system must be sufficient for the individual to safely and efficiently carry out the requirements of the job.

What Does the Exam Include?

The exam, while focused on the requirements of wildland firefighting, is a basic physical evaluation that includes:

• Medical history
  
  
• General appearance and vital signs (height, weight, blood pressure, and heart rate)
  
  
• General physical examination
  
  
• Audiogram (including 500, 1,000, 2,000, 3,000, 4,000, 6,000, 8,000 hertz in both ears)
  
  
• Visual acuity, near and far vision, corrected and uncorrected
  
  
• Peripheral vision, depth perception, and color discrimination (red/green/yellow)
  
  
• Pulmonary function test-spirometry
  
  
• Chest x-ray, (baseline exam only)
  
  
• Electrocardiogram—resting (baseline exam only)
  
  
• Tuberculosis (Mantoux) skin test (baseline exam only)
  
  
• Tetanus vaccination (to maintain as current)
  
  
• CBC (hemoglobin, hematocrit, platelets, white blood cell, dipstick UA (baseline/exit exam only), and blood chemistries: (LDH, SGOT/AST, SGPT/ALT, GGT, bilirubin [baseline/exit exam only]); (total cholesterol, LDL-C, HDL-C, triglycerides, blood glucose [each exam])
  
  
• Cholinesterase (red blood cell/plasma; baseline exam only)

Why Are Tests Listed That Aren't Linked With a Standard?

Your firefighter medical exam is being done because of the employment relationship that exists between Federal firefighters and the Federal Government, and the responsibility that your agency has to you and to the public. As an employment-based exam, information that may be important to you and to the agency is recorded to provide a baseline set of data for comparison if you develop a health problem later that may be work related.

For example, a chest x-ray and an electrocardiogram are done at your baseline exam to record the initial status of your lungs and heart. These are not repeated in subsequent medical standards exams, although your own doctor may choose to repeat the tests later as part of a workup if you develop a pulmonary or cardiac condition, such as pneumonia or heart disease. Also, baseline cholinesterase levels are recorded because of the potential for firefighters to be exposed to pesticides in the course of their work, and for baseline data that can be compared with postexposure data to see whether exposure has been significant.

How Is the Program Implemented?

The medical program involves a designated Interagency Medical Standards Program manager to oversee the entire process, a medical review officer to review medical information and provide medical clearances and consultative recommendations, standard physical examination forms and procedures, and standard waiver and accommodation procedures. It also depends on fire management officers, personnel officers, and firefighters themselves.

For permanent firefighters, exams usually can be scheduled before the fire season starts. Their medical clearances, waivers, or accommodations can be resolved before fire assignments begin for the year. For temporary firefighters, their plans to fight fire may not be known until the fire season, or even a specific fire, is underway. Exams and followup work may have to be done under time constraints. In either case, the fire management officer works with the interagency medical standards program manager to schedule firefighters for their exams or screenings, and to supply them the forms they need to complete.

The specific forms used and the exam a firefighter receives will depend on the firefighter's age and employment status:

Baseline (or Initial) Exam: Used by firefighters in permanent positions, and by temporary firefighters once they reach the age of 45, this full medical exam is based on the interagency medical examination and clearance form. It is more comprehensive than the periodic exam because baseline employment- and age-related information needs to be recorded for the firefighter.

Periodic Exam: This exam is for permanent firefighters and temporary firefighters older than 45. It is also based on the interagency medical examination and clearance form, but is less comprehensive than the baseline exam. For permanent firefighters, this exam is conducted every 5 years until age 45 and every 3 years thereafter. Temporary firefighters older than 45 receive the periodic exam every 3 years.

Annual Medical History: A brief medical history questionnaire and medical screening are required for firefighters in years when a more complete medical examination is not scheduled. This questionnaire is used by temporary firefighters until they are 45.

Exit Exam: The exam permanent employees receive when they leave an arduous duty wildland firefighter position.

Some circumstances may make a full medical examination impractical. When local medical services are not available or when firefighters must be hired quickly (especially during fire emergencies), agencies may need to obtain medical clearances very quickly. In these situations, the annual medical history and clearance form may be used. In addition, a brief medical screening is performed by a health care professional. In all cases, a medical clearance must be completed before taking the pack test.

The Interagency Medical Standards Program manager will provide to your fire management officer a program orientation and guidance on the steps that are to be followed to complete the medical clearance process under the new medical standards. Contact your fire management officer, or the wildland firefighter Web site, http://medical.smis.doi.gov/nifcmedicalstds.htm, for more information.

What Happens When a Firefighter Isn't Medically Cleared?

Just because an employee has a medical condition identified through the medical standards program, doesn't mean the employee won't be allowed to work as a firefighter, even at the arduous level. It does mean that further information may be needed from the individual's personal physician to clarify the problem noted during the exam. The individual's past performance may need to be reviewed to see whether the medical finding may have caused work difficulties. Some form of accommodation may be needed to allow the firefighter to do the job safely. Under the Rehabilitation Act of 1973 (or the Americans With Disabilities Act, for nonFederal workers), an employee who can safely and efficiently perform his or her duties, with or without a reasonable accommodation, can't be prevented from doing so based upon a disability or a medical finding. An interagency medical review board convenes to consider medical restriction cases. The established waiver and accommodation process is designed to ensure that the firefighter is treated fairly under the law. The goal is to keep firefighters fighting fire, not to prevent them from doing so, as long as they can do their jobs safely and efficiently without significant risk of harming themselves or others.

Who Has Access to Confidential Medical Records?

Under the Privacy Act, and the various regulations that implement the provisions of the act, individuals have a right both to know the records the Government maintains about them and how those records may be used. The results of a firefighter's medical history and exam are kept in safe, secure locations. Access to the records is limited to the individual firefighter and to a limited group of others who have a specific, justifiable, work-related "need to know," as covered in the regulations. For further information, refer to the Interagency Medical Review Board Guide, which may be found at http://medical.smis.doi.gov/IMRB%20Guide.pdf.

Kevin Jensen is the manager of the Interagency Medical Standards Program. Jay Paulsen, M.D., of the U.S. Public Health Service's Federal Occupational Health Program is the program's medical advisor.