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January 27, 2008

To: Firefighter Wellness and Fitness Initiative Physicians

From: Rayburn Lewis MD, Medical Director

re:Physician responsibilities

Morning exam:

  1. Welcome the firefighter to this portion of the day. He/she will have already had lab draw, and should be changed into exercise clothing.
  2. The firefighter will have the chart with them
  3. You will do your own vital signs, including height, weight, bp (both arms and a foot, if high), pulse, vision screen (Snellen chart inside the cabinet).
  4. Review the history form as you would with any new patient. Pay particular attention to historical factors targeted in the Wellness and Fitness Initiative which include potential work related illness/injuries:
  5. Cardiac and Vascular
  6. Cancer, including skin, breast, GIT, GU, lung, immune system
  7. Lung disease, and history of smoking
  8. Family history of any of the above
  9. Physical exam:
  10. The exam form attached to this outlines the major points.
  11. Use the 256 hz tuning fork to test for HF hearing loss (they get yearly audiograms)
  12. Female firefighters should be asked when their last women’s health exam occurred, and if out of date, encouraged to be checked asap. This includes mammography if indicated. We have not been performing breast nor pelvirectal exams.
  13. Male get prostate exams as indicated (over 50 minimally, or over 40 with risks), all get scrotal exams. You need not check FOBT. All FF will have had three cards given to them prior to coming to the exam. The results should be on the labs, which you will see later in the morning.
  14. Careful skin exam, especially in vulnerable areas of neck, ears, face and hands.
  15. The musculoskeletal exam can be brief. They will get a comprehensive exam by physical therapy.
  1. The FF is then escorted to the Treadmill, which is also in the CCVW. You are not responsible for supervising the treadmill. However, you are to determine if the firefighter is fit to have this test performed. For most who have few or no risks, this is a fitness test and they will be tested to maximal performance. THIS IS AMAXIMAL TEST, NOT SUBMAXIMAL. IF YOU FEEL THE FF IS AT RISK, NOTIFY THE CARDIOLOGIST (DR. SPECK) OR THE NURSE PRACTITIONER, ANDHAVE THE TEST SUPERVISED BY ONE OF THEM. IF THERE IS CONCERN OF HIGH RISK, DO NOT HAVE IT PERFORMED AT CCVW. WE WILL ARRANGE FOR A DIAGNOSTIC TREADMILL AT THE HEARTCENTER.
  2. If the FF has an emergency event during the treadmill (chest pain of cardiac origin, dangerous arrhythmia, etc) a code 199 will be called. The FF will be treated emergently as any other patient.
  3. If the treadmill is positive or equivocal, a stress echo can be done under the agreement of this contract. The project coordinator Kat Yun at 16375 (Ballard Rehab) or 405-6703 (pager) should be notified.
  4. You will examine 4-6 FF in a morning.

2ndvisit:

  1. The FF will return, in rough order as the exams, with their chart.
  2. Review the following, organize and summarize on the FF exit form (attached)
  3. History form
  4. Your physical exam
  5. EKG and treadmill results
  6. VO2 max and lactate. There will be an accompanying form stratifying the VO2 max into poor to excellent performance. Make sure to give this to the FF on exit. They like scores!
  7. Musculoskeletal exam. The PT will summarize the pertinent findings on the last page
  8. Spirometry results
  9. Chest X-ray. You can read it yourself from the PACS. The radiology result is also there. If there is any additional question or history, you can ask for a second interpretation.
  10. Labs: If you need additional labs you may order them (TSH/T4 and PSA are most common).
  11. This time is very important for the FF. Spend up to 30 minutes with each one, explaining the results, need for additional workup, and suggestions. Make sure to tell them to follow up with their PCP. If they don’t have on, feel free to make a referral.
  12. Give them copies of appropriate portions of the exam. Certainly they get a copy of the exit form. Additionally, lab results, abnormal spirometry results, and the VO2 max comparison table. The firefighter liaison who directs the FF to the next stop can make copies. The chart stays at the CCVW.
  13. During “down time” please review the charts from the previous day’s exam. These will have been done by another of the firefighter physicians. This is a brief “quality” check. Please check for late labs, and any abnormals which may have been omitted. Note this for the medical director to follow up.
  14. The medical director will also review all charts and late results, for completeness. We are attempting to send brief follow up letters as well.