North Greenville Fitness
Firefighter Screening Protocols
The concept of graded exercise testing is not new in screening for coronary artery disease. The actual testing has gone from a V5, or one-lead, test in the 1960s and 1970s to the 12 to 17 lead EKG test it is today.
Screening for heart disease cannot be accomplished without a proper protocol or electrocardiographs while testing. Putting a stethoscope on a firefighter’s chest to determine heart disease is not an answer. Protocols which are academically and medically verifiable are the only answer. Heart rate and blood pressure protocols are not medically acceptable in screening for heart disease. This is part of the reason the Gerkin protocol is called the “pickle” protocol. It is not the “Gold Standard” in graded exercise testing for heart disease.
While screening protocols may vary according to method, EKG monitored testing is the “Gold Standard” academically and medically for heart disease screening. The treadmill, bike, step test and arm ergometer are all acceptable methods for screening, according to research.
Two questions that matter
The first issue is the method of testing while being EKG monitored.
The second issue is whether the testing is being performed by personnel who are academically and medically qualified to perform the tests.
The monitoring physician is not qualified for graded exercise testing just because he or she has an “M.D.” or “D.O.” after his or her name. This is not meant to be critical of any physician, but many physicians do not perform graded exercise tests, nor do they have experience in reading them. Their practices are not such that they perform these tests. This is the critical point in asking whether the personnel running the tests are qualified: specifically, whether they are Advanced Cardiac Life Support (ACLS) certified, and whether the physician is trained and versed in performing the screenings and has experience in graded exercise testing.
Remember, this is your program, so ask the questions. You wouldn’t go to a family practice physician for major surgery, so do not accept a physician who is not qualified to perform these tests.
Again, this is not to be critical of any physician or physician group.
How the protocols work
Graded exercise testing protocols, whether treadmill, bike, step or arm ergometer, are all designed around heart rates and age. The Bruce Protocol is the most widely used for a treadmill test, while the YMCA cycle ergometer submaximal test protocol is the most widely used for a bike or arm test.
The bike test is designed closest to the actual heart rate increase that a firefighter experiences when a call comes in. The average firefighter goes seven to nine minutes in performing a graded exercise test, while responding to a fire call to arriving on scene is seven to ten minutes. Remember that the graded exercise test is screening for heart disease, which is the number one killer in the fire service. It makes no difference how you get the heart into the proper heart rate range (bike, treadmill, arm or step), but EKG monitoring must be performed during the test. The Gerkin Protocol only looks at heart rate and blood pressure. There is no EKG monitoring during the test.
The use of a protocol which takes the firefighter to exhaustion, or is symptom limited, should never be used except in an inside clinical setting for the specific purpose of diagnosing heart disease, and not for screening purposes. A firefighter who has been tested to exhaustion cannot be expected to go directly on a call with seventy pounds of gear on and fight a structural fire. Symptom limited testing should also be performed for diagnostic purposes only, in an inside clinical setting.
Health screenings cannot be confined to cardiovascular testing. Other aspects of health should also be given prime consideration.
Blood work
- A SMAC 25 panel, or executive blood panel, should be mandatory for all screenings. It should be a 25 panel because of the thyroid screening. With the amount of thyroid disease in the fire service, thyroid testing should be a mandatory part of the blood work.
- As part of the SMAC 25, uric acid should be included because this is the panel that screens for gout.
- Gamma Glutamyl Transferase, or GGT, should be included with liver enzymes. It applies to the pancreas and is useful in the diagnosis of metastatic carcinomas in the liver, liver disease and adult onset diabetes mellitus.
- Iron should also be included, as it applies to anemia as well as to other diseases.
This is a cursory look at blood panels and will be a topic for future discussion.
The purpose of this article is educational. The better trained and better educated the fire service is, the more lives can be saved.
Schedule a screening
We bring the clinic to your department.
Tell us how many personnel you need screened and where. We’ll build a testing schedule around your shifts.