Medical surveillance is the analysis of health information to uncover problems in the workplace. For Timothy Raycob, director of compliance for medical surveillance at Phillips 66, much of the job means closely monitoring personnel for exposure to hazardous materials.
“We have more than 9,000 people in Phillips 66 who are enrolled in various regulatory programs,” Raycob said. “With specific hazards, they have to get exams at specific frequencies. I’m responsible for tracking compliance.”
Carcinogens such as benzene and organic lead rank highest on Raycob’s watch list. But in 2012, Stephen Pepper, Phillips 66 director of crisis management HSE compliance and services, asked him to extend monitoring to include hazards common to industrial firefighting – heat and stress.
“He asked us to develop a medical rehab and monitoring program for his crisis management schools, which include the corporate fire and rescue school,” Raycob said.
Trained as a physician assistant, he served 24 years as a flight medic with the U.S. Coast Guard before joining Phillips 66 nearly a decade ago. However, firefighting was something completely new to him.
“So I came to my first fire school just to see what they did and what Health Services could provide in the way of crisis management,” Raycob said.
According to National Fire Protection Association statistics, 60 firefighters died in the line of duty during 2017. Only 17 of those occurred at the scene of a fire. Far more deadly than burns or smoke inhalation, nearly half of the 60 fatalities reported were attributed to sudden cardiac events.
“Statistically, sudden cardiac events account for less than half of one percent of all firefighter illnesses and injuries,” Raycob said. “That’s one out of every 200 injuries or illness reported by a firefighter is cardiac related.”
While that might not seem very high, sudden cardiac events account for 52 percent of all line-of-duty deaths.
“You’ve got this tiny little minority of patients or firefighters with a tiny percentage of illness and injury that accounts for the majority of line-of-duty deaths,” Raycob said.
Firefighters not employed by public fire departments, such as those belonging to industrial fire brigades, accounted for only seven line-of-duty deaths last year. Despite that otherwise comforting statistical gap, industrial firefighters are just as susceptible to sudden cardiac events as any other member of the fire service, Raycob said.
Other than during an actual fire, fire service responders find themselves exposed to the principal risk factors for cardiac events during training.
“Numerous factors are involved in cardiac events in firefighters,” Raycob said. “But, basically, it comes down to dehydration. It triggers the coagulation cascade.”
When a firefighter is dehydrated, the clotting mechanism in his blood activates. The blood becomes thicker and, in a way, more sludgy.
“The only thing that prevents you from forming a clot while you’re actively fighting fire is your heartrate is racing so high it keeps that blood flowing,” Raycob said.
However, once the fire is under control the responder’s heartrate slows. That is when the clot forms.
“The next thing you know is one to four hours after the incident the firefighter dies from a sudden cardiac event,” Raycob said.
Medically treating the coagulation cascade in the field is all but impossible, he said.
“We can’t shove an aspirin at everyone and say ‘Here, chew this real quick before you go out there,” Raycob said. “You push oral fluids as much as possible to replace that volume loss the firefighter suffers while they’re out in the sun.”
Breaks built into the training evolution give firefighters a chance to rest while medical personnel check the appropriate vital signs.
“The individual is going to sit down for 10 minutes,” Raycob said. “We want to make sure that medically there is nothing else going on that will compromise their safety.”
National Fire Protection Association Standard 1584 requires that any firefighter who uses two standard SCBA air tanks or one extended air tank must come out of the hot zone to rest or “rehab,” regardless of how good they might feel.
“When they come out of the hot zone the first thing we do is have them remove as much of their bunker gear as possible,” Raycob said. “We want as much air moving across their body as we can.”
Next, the firefighter’s pulse is taken, he said.
“Most studies have shown that your heartrate is a much better indicator of heat stress and heart strain than doing a full set of vitals,” Raycob said. “If you’re beginning to suffer heat stress your heartrate skyrockets to compensate.”
If the heartrate is 110 beats a minute or less the firefighter returns to firefighting. However, if the heartrate is greater than that, the firefighter is asked to rest for an additional five minutes before the pulse is checked again.
Core body temperature becomes the concern if the heartrate exceeds 110, Raycob said. However, most medical devices used to establish core body temperature are a bit too invasive for the fire scene.
“So we use a digital thermometer to take the temperature orally,” he said. “We know that an oral temperature plus 1.8 degrees Fahrenheit is roughly equivalent to a core body temperature.”
Based on a 1973 study by the National Institute for Occupational Safety and Health (NIOSH) any firefighter with a core body temperature greater than 102.5 degrees F is judged to be at significant risk of heat stress injury.
“At least 50 percent of people will suffer heat stress injury if not immediately removed from that environment,” Raycob said.
Failure to meet the guideline for either core body temperature or heartrate graduates a firefighter from medical monitoring to full rehab which requires mid-level medical personnel take a complete set of vital signs.
“We do a full assessment on the patient,” Raycob said. “We do a full interview which includes a bit of family history, medical history and a list of the medications being taken. This is followed by a brief physical exam.”
Rehab allows firefighters to rest and recover to rejoin training. But based on the assessment, medical personnel have full authority to make the firefighter sit out the rest of the evolution and more.
“Occasionally we have pulled people out for an entire afternoon just because we don’t feel comfortable with their vitals,” Raycob said.
He streamlined the list of vital signs needed to monitor heat stress for the sake of efficiency. But medical monitoring for up to 140 student firefighters conducting simultaneous live-burn training in one-hour rotations requires an expanded team of 10 medical personnel on duty.
“However many battalions are established we embed a rehab officer with them for the entire week,” Raycob said. “Each rehab officer gets adjusted and accustomed to the people he or she treats. They get to know which people they have to keep a closer eye on.”
Developing a uniform standard for medical monitoring under real world conditions is more difficult, Raycob said. Each refinery has specialized hazards that their fire brigades must manage.
“What we’ve done instead is come up with a guideline that we strongly recommend,” he said. “We know that ultimately it will decrease mortality and morbidity.”