cpg wellness by 31sY3c3

VIEWS: 3 PAGES: 24

									              OCCUPATIONAL HEALTH PROGRAMS
                 CHIEF EXECUTIVE OFFICE
                  LOS ANGELES COUNTY


FITNESS-FOR-LIFE AND EXECUTIVE MEDICAL
     CLINICAL PRACTICE GUIDELINES
                            Revised July 1, 2009

                                                                                   Page

  Purpose                                                                             2


  General Guidelines
      Taking an Adequate Medical History ..................................... 2
      Performing Complete Physical Exam .................................... 4
      Cardiologist Reading of ECG's………………………………… 6
      Discussion of Test Results .................................................... 7
      Medical Referral Assessment ................................................ 7
      Work Fitness Triage Assessment .......................................... 7
      Support Resources for Fire Department Employees…………8



  Program Specific Guidelines
      Fitness-for-Life Evaluation ..................................................... 9
      Firefighter Commercial License Exam .................................. 13
      Firefighter HAZMAT Exam ................................................... 17
      SCUBA Evaluation (on day of FFL) ..................................... 19
      Executive Medical Evaluation ............................................... 22
PURPOSE
The purpose of these guidelines is to clearly express the County’s expectations for
contract physicians regarding medical history taking, physical examinations, work
fitness assessments, medical referral assessments, and various communications. It is
meant to supplement the information contained in the Statement of Work (SOW) in
your contract. If there is any conflict between these two documents, the SOW takes
precedence.

It is the intent of these guidelines to ensure that the services provided by the County’s
contractors represent the best practices in the field of Occupational Medicine.
However, it is acknowledged that in many areas of Occupational Medicine, best
practices are not well-defined, and that several alternate approaches may be equally
appropriate. For this reason, the Occupational Health Program (OHP) welcomes
comments from its contractors, and intends to update these guidelines as often as
necessary to improve their clarity, and consistency with best practices.




GENERAL GUIDELINES
Taking an Adequate Medical History:
An adequate history is the critical foundation of any work fitness or medical referral
assessment. Therefore, the County will expect the contract physician to obtain a
history with sufficient detail to facilitate both assessments. This will require that the
contract physician do the following:


1) Ensure that there is a clear response to every mandatory question on the
  applicable medical questionnaire. Mandatory questions include any question
  preceded by an asterisk (*) on the Fitness-for-Life questionnaire when a HAZMAT
  evaluation is required, and all questions on the Commercial Driver’s License form
  DL51, and the supplemental questionnaire for SCUBA. If an employee refuses to
  answer a mandatory question, this refusal needs to be documented.

  Note that there are no mandatory questions if only a Fitness-for-Life or Executive
  Medical is being performed. However, contract physicians are encouraged to
  discuss non-responses with the employee. To encourage disclosure on non-
  mandatory questions, the contract physician may go “off record” if necessary, and
  forgo written documentation of responses. It is hoped that this will facilitate
  discussion of sensitive issues such as substance abuse, and provide opportunities
  for voluntary interventions.


2) Fully elaborate all conditions which have relevance to a work-fitness or
   medical referral assessment. Conditions of relevance to work-fitness will vary by
   the type of examination being performed, but at a minimum, include any condition
                                            2
  listed in the triage guidance. For each of relevant condition, make sure that the
  following information is clearly elicited:
      a. Date of onset.
      b. Cause of injury or illness.
      c. Nature and duration of symptoms. This must include the date of the last
         symptom occurrence.
      d. Results and dates of any diagnostic testing completed.
      e. Treatment details including dates and utilization of various modalities
         including medications, manipulation, and/or surgery.
      f. Date of last treatment or follow-up evaluation by any health care provider.
      g. The functional significance of the condition:
             ●Did the employee have to stop any recreational activities or be placed
                   on restricted duty at work?
             ●When did any functional impairment begin and end? Are there any
                  functional residuals?
             ●Has the employee been assigned permanent disability by any legal
                  system including Worker’s Compensation?

3) Make additional inquiries regarding any clinical testing data that is out-of-
   range. The purpose of these inquiries is to determine if there are contemporaneous
   factors which may render the testing data inaccurate or non-representative, and to
   ascertain the employee’s prior knowledge of any abnormalities. These inquiries
   would include, but are not limited to the following:

      a. Abnormal dipstick:
             ● Any history of diabetes, renal disease, or positive dipstick?
             ● For females with blood, menstruation status?

      b. Blood pressure ≥140 systolic or 90 diastolic:
             ● Any history of prior elevated readings?
             ● Any current or recent use of medication? Was it taken today?

      c. Best distant vision (corrected or uncorrected) worse than 20/40 in either eye:
             ● Inquire regarding status of corrective lens use if not wearing correction
             ● Date of last eye exam if wearing correction

      d. Significantly Abnormal Audiogram (i.e., 25 dB average loss at 0.5, 1, 2, and 3
             kHz in either ear; or asymmetrical loss with threshold differences of >15
             dB averaged at 0.5, 1, and 2 kHz, or >30 dB averaged at 3, 4, and 6
             kHz): Inquire regarding
             ● Symptoms

                                           3
              ● Noise exposure within last 14 hours
              ● Prior audiometric testing
              ● Prior ENT evaluations
              ● Off duty noise exposures

      e. Abnormal Spirometry: Inquire regarding
              ● Any chest infections or bronchitis in the last two months,
              ● Recent smoke or chemical exposures,
              ● Any current symptoms or physical limitation
              ● History of pulmonary disease

      f. Abnormal EKG with significant abnormalities (arrythmias, LVH, old MI):
         Inquire regarding
              ● Any relevant symptoms,
              ● Prior knowledge of abnormality.

4) Make additional inquiries regarding any unexpected physical findings. When
   the physical reveals conditions that were not disclosed during formal history taking,
   history taking must be re-initiated.



Performing and Documenting Complete Physical Exam:
A “Complete” physical examination is part of both the Fitness-for-Life and Executive
medical evaluations. Note that several of the components of this examination differ
from the “Complete” examination done for Pre-placement and Periodic Examinations.
At a minimum, a “Complete” physical examination shall include the following:

      Eyes:        Pupillary reaction to light, check ocular motility for conjugate gaze
                   in all quadrants, ophthalmoscopic exam to check for lenticular and
                   retinal abnormalities

      ENT:         Routinely check cervical nodes and thyroid. Otoscopic exam must
                   be performed if the audiogram shows a conductive hearing loss
                   pattern, or there are symptoms referable to the ear

      Cardiac:     Auscultation is required. For any murmur, specify the location,
                   intensity from I-VI, timing (systolic vs. diastolic), and radiation
                   (audible in the axilla or carotid areas?)

      Pulmonary: Auscultation is required. For restrictive spirometry, chest expansion at
                 the level of the nipples must be measured with a tape, and recorded
                 as the difference between maximal inhalation and exhalation.

                                            4
      Abdomen: Palpation of spleen and liver for enlargement, abdominal wall for
               umbilical hernia, and deep abdomen for aortic aneurysm (if age
               ≥50). Any suspected liver enlargement must be followed up with
               percussion of the liver span.

      Vascular:    Auscultation of the carotid areas for bruits, inspection of lower legs
                   for gross venous insufficiency. Examination of lower extremities for
                   edema is indicated if a urine dipstick reveals more ≥2+ proteinuria.

      GU:          Males- check for inguinal hernias, perform rectal with guiac testing.
                   Under routine circumstances, an examiner should not ask a female
                   client to remove underpants, nor palpate under a female’s
                   underpants, or perform deep abdominal palpation for ovaries. The
                   only exception to this is when a female client requests to have a
                   pelvic exam performed.

      Neuro:       Patellar, ankle reflexes. Sensory, motor, or cerebellar testing if
                   indicated by history or observation. . If history of tremors, evaluate
                   during rest, sustention, and intention (finger-to-nose and heel-to-
                   shin testing). Attempt to describe severity of tremor.

      Skin:        Note lesions suspicious of skin cancer, and any dermal
                   manifestations of systemic conditions (such as psoriasis).

      Musculo-
      Skeletal:    Note any abnormalities of posture or gait. Inspect all joints (except
                   the hip in females) for any surgical or arthroscopic scars. Any joint
                   deformity must be described with degrees of angulation and ROM.
                   The following minimum examinations are required if there is a
                   history of the following within the last 12 months:

                           Lumbar pain: Heel/toe walk, ROM, palpation, sensory at
                            L4, L5, S1, bilateral calf and thigh circumference, active
                            straight leg raise, ankle/patellar reflexes.
                           Cervical pain: ROM, inspection of hand for atrophy,
                            muscle testing of the arm and hand, sensory testing of the
                            hand.
                           Wrist pain: ROM, Tinel’s test, Phalens test, sensory, and
                            muscle testing of the hand to include gross grip strength.
                            Note any muscle wasting.
                           Shoulder instability/pain: ROM, rotator cuff strength,
                            anterior apprehension test.
                           Knee injury/pain: Duck walk, ROM, check for effusion,
                            and measure bilateral thigh circumference


All positive findings, and pertinent negatives must be legibly recorded in full detail on
the Fitness-for-Life/Executive Examination Data Form. Negative findings are
                                            5
considered “pertinent” when they contribute to the assessment of a specific condition
or clinical test result. Failure to properly document will be considered as
equivalent to failure to perform these components.



Cardiologist Reading of ECG's:

All resting ECG’s must be read by a cardiologist unless a computerized interpretation
indicates that the tracing is normal or has insignificant findings. Insignificant findings
are defined as (and limited to) the following:

              1) Atrial arrhythmia
              2) Ectopic atrial rhythm
              3) Non-specific intraventricular delay without axis shift, BBB, or
                 hemiblock
              4) Non-specific ST changes
              5) Mild bradycardia (rate of 50 or more)
              6) 1st degree AV block (rate of 50 or more)
              7) Incomplete RBBB
              8) Early repolarization
              9) Decreased anterior forces in person without history of MI

All stress ECG’s must be read by a cardiologist regardless of the initial impression by
the attending physician. If the attending physician suspects ischemia or significant
arrhythmia in a Fire Department employee, the interpretation from the consulting
cardiologist at UCLA-Harbor Cardiology may satisfy this requirement. Otherwise, all
stress ECG’s must be reviewed by the contractor’s cardiologist. Note: Do not use
UCLA-Harbor Cardiology for Parks & Recreation Department employees.



Discussion of Test Results:
The contract physician is responsible for discussing all clinically significant test results
directly with the employee whenever possible. Additionally, the physician must review
the employee’s major risk factors for cardiac disease with the employee. Physicians
are encouraged to compute and inform the employee of their Framingham 10-year
cardiac disease risk (see http://hp2010.nhlbihin.net/atpiii/calculator.asp?usertype=
prof).

When results are received after the employee’s visit, at least one phone call to the
employee should be made to attempt a discussion of clinically significant test results.
This call must be documented in the medical records received by OHP.




                                             6
Medical Referral Assessment:
The responsibility for notifying employees of the need for medical follow-up with their
private health care provider is the sole responsibility of the contract physician.
Recommendations for follow-up must be consistent with the standards of care in the
community, and applicable consensus guidelines from respected national medical
organizations. Examples include, but are not limited to, those from the National
Cholesterol Education Program and Joint National Committee (blood pressure). In
borderline cases, the contract physician is advised to err on the side of caution, and
advise an employee to see their private health care provider.



Work Fitness Triage Assessment:
The contract physician is responsible for making a work fitness “triage” when
performing Fitness-for-Life and associated evaluations as follows:


    No                Employees who do not warrant any restrictions within the
    Restrictions      narrow work-fitness focus of the specific testing program in
                      which they are participating.

    Restricted        Employees who warrant program-specific restrictions, and the
                      contract physician is authorized by the guidelines below to
                      place these restrictions on the employee.

    OHP Review        Employees whose medical conditions need further
                      consideration by OHP staff to determine whether program-
                      specific restrictions are needed.



The triage must be made using the guidelines found below under each examination
type. Please note that these guidelines limit the scope of any work-fitness assessment
to the purpose of the examination program.

Additionally, while the guidelines authorize contract physicians to assign work
restrictions, the contract physician is not authorized to remove restrictions. This
must be done by OHP staff.




                                           7
Support Resources for Fire Department Employees:

The Fire Department has various resources to provide assistance to its employees.
Please provide the following information to Fitness-for-Life participants when
appropriate:

County of LA Domestic
                                                                       (800) 978-3600
Violence Hotline
                          Professional assessment and referral
                                                                       (213) 738-4200
County of LA Employee     assistance for stress, marital/family
Assistance Program        discord, bereavement, alcohol & drug
                          problems, or interpersonal problems
                          Peer support by Fire Dept employees
LACoFD Cancer Support                                                  FF/P Mike Dubron
                          who have personal experience with
Network                                                                (818) 890-5755
                          cancer
                          Emotional support, counseling and
LACoFD Chaplains Office   assistance for employees and their           (323) 881-2427
                          families.
                                                                       Jamey Stephens, FNP.
LACoFD Health Programs    Medical resource and referral assistance     (323) 881-3043
Coordinator               for all programs and return-to-duty issues   (323) 881-3037
                                                                       (213) 391-6025 Pager
                          Mental health resource with team of
                          mental health professionals contracted       Anne Kellogg, MA
LACoFD Mental Health      directly by the LACoFD who have               (800) 573-7808
Coordinator.              extensive experience helping firefighters    (323) 881-2485
                          and their families with appropriate          (213) 391-4151 Pager
                          referrals.
                                                                       Captain Claudio
                          One to one peer support as well as
LACoFD Peer Support                                                    Medina
                          Critical Incident Stress Management
Coordinator                                                            (909) 620-2216
                          support.
                                                                       (213) 391-1275 Pager
                          Medical facility liaison and health,
                                                                       Captain Kevin Klar
LACoFD Fitness-for-       Fitness-for-Life and exercise information.
                                                                       Bob Karwasky
Life/Fitness Office       Peer fitness trainers for additional help
                                                                       (323) 881-2371
                          with exercise recommendations
                                                                       Contact Mental Health
Widow/Widower Support     Civilian support network to help deal with
                                                                       Coordinator for
Coordinator               the stress of losing a loved one.
                                                                       Resource.




                                            8
PROGRAM SPECIFIC GUIDELINES

Fitness-for-Life Evaluation

Obtaining Prior Test Results:

It is necessary to obtain prior test results from the OHP before making a work-fitness,
or medical referral assessment in the following clinical situations:

a) Current PSA is ≥ 2.0: Obtain prior PSA results computation of PSA velocity
   (average yearly change in PSA over three or more yearly measurements).

To obtain necessary records, please fax the request with the Fitness-for-Life Consent
and Release Form Release Form to the OHP (213-637-0822).


Referrals to Harbor-UCLA Cardiology Group:

The Fire Department has contracted with the Division of Cardiology at the Harbor-
UCLA Medical Center to provide same day consultations. These must be obtained for

        CST is positive for ischemia (regardless of prior cardiac history or
         evaluations at Harbor-UCLA)
        VT run of 4 beats or more
        SVT ≥15 seconds
        Two or more triplets
        PVC’s totaling ≥10% of beats within an exercise stage or during the early
         recovery period.
        “Probable” LVH on resting EKG (unless there is a history of hypertension)

Referrals may not be made for any other findings without prior consultation with OHP.

The consultative process must be initiated as soon as one of the findings above is
apparent to either the contractor’s physician or over-reading cardiologist. To obtain a
consultation, follow the steps below:

   Step 1: Call Harbor-UCLA to notify them of an incoming consultation request
    (primary 310-222-2773; 1st alternate 310-222-2515; 2nd alternate 310-386-4354; 3rd
    alternate 310-938-6175).

   Step 2: Complete a referral sheet and fax with tracings to 310-222-2694; Alternate
    fax 310-320-5573. If the employee has been evaluated in the past at Harbor-
    UCLA, indicate this on the referral sheet.

   Step 3: If further testing is recommended and the employee is still in your clinic, the
    employee may be sent immediately to the facility in Torrance if arrival by 3 p.m. is
    possible. If not, the employee should call Harbor-UCLA for an appointment. If the
                                             9
    employee has gone home, and the Harbor consultation was triggered by your over-
    reading cardiologist, please give the employee a courtesy call to explain the
    reason for the delayed notification, and tell them to call Harbor for an appointment
    (document at least one attempted call in chart).

   Step 4: Harbor-UCLA will fax the test results and recommended duty status to the
    referring physician. These must be noted in the examining physician's SOAP note.

Please note:

    a) The consultative process is not available for Lake Lifeguards from the
       Department of Recreation & Parks.
    b) Over-reading of tracings by the clinic’s cardiologist is not necessary if these
       have already been read by Harbor-UCLA.
    c) OHP does not require any employee to utilize the testing services at Harbor-
       UCLA. In all cases, testing can be alternatively done by other providers. In
       many cases (such as an ischemic CST without a history of MI, symptoms,
       ectopy, or low VO2 max), Harbor-UCLA’s recommendations for further testing
       may be disregarded by the employee without any work status consequences
       (see triage criteria below).


Physical Fitness Counseling:

The Fitness-for-Life evaluation includes testing of the employee’s strength, endurance,
flexibility, and aerobic capacity. Counseling shall be done by an exercise physiologist,
physical therapist, physician, or other qualified health care professional who is capable
of applying the American College of Sport’s Medicine’s (ACSM) recommendations for
exercise prescription. These can be reviewed at http://www.mhhe.com/hper/nutrition/
williams/student/appendix_i.pdf. Contractor shall also provide counseling regarding
the employee’s physical fitness in relation to that necessary for the effective
performance of firefighter duties.


Work Fitness Triage Assessment:

It is inevitable that a comprehensive medical screening program such as this one will
yield a wide range of findings of potential relevance to the performance of a high
demand jobs such as firefighting. However, a goal of the Fire Department is to have
as many employees as possible participate in this “mandatory, non-punitive” program.
To pursue this goal, it is necessary to de-emphasize the work fitness component of
the program to the greatest extent possible. Therefore, at the present time, the scope
of the work fitness assessment will be limited to conditions that are associated with a
substantial and imminent risk of sudden loss of consciousness.

Any restrictions assigned by either the examining physician or the Harbor-UCLA
cardiology group must remain in effect until removed by OHP staff. However, the Fire
Department Health Programs Coordinator (phone 323-881-3043, pager 213-391-
6025), is available to assist the employee with medical questions, concerns, and
administrative assistance for an efficient return to duty.
                                           10
No Restrictions:

  ►   Employees not at substantial and imminent risk of sudden loss of
      consciousness.

Restricted: Fax to RTW Unit (323-881-3040) and OHP (213-637-0822)

   ►BP (resting) >179 systolic or >109 diastolic on lowest resting reading:

               "No lifting more than 10 lbs"


   ►Restrictions recommended by Harbor-UCLA
   ►Sustained SVT on CST associated with symptoms or drop in BP
   ►Syncope during or after CST
   ►V tach run of 8 beats or more on CST

              "No firefighting duties" [Firefighters]
              “No swimming”             [Lifeguards]

   Note: If other conditions arise that the contract physician believes are
         associated with a substantial and imminent risk of sudden loss of
         consciousness, please call OHP staff physician to discuss.


OHP Review:
   ► Loss of consciousness in the last 2 years for any reason
   ► Evaluation for lightheadedness in the last 2 years
   ► Epilepsy
   ► Use of medication to prevent a seizure
   ► FBS ≥200 regardless of history
   ► A1c ≥ 7.5
   ► Hypoglycemia which required the assistance of others in the last year
   ► Diabetes: if insulin is used either regularly or intermittently in past 2 years
   ► Untreated atrial fibrillation or flutter
   ► Second degree AV block
   ► Complete heart block
   ► V tach run of 4-7 beats on CST
   ► Triplets: ≥2 on CST
   ► SVT lasting ≥15 seconds on CST
                              [See next page]
                                      11
           ►PVC’s totaling ≥10% of beats within an exercise stage or during the
            early recovery period.
           ►CST positive for ischemic changes and any ectopy is present.*
           ►CST positive for ischemic changes and VO2max < 33.5 ml/O2.*
           ►CST positive for ischemic changes and symptoms are present.*
           ►CST positive for ischemic changes and there is a history of MI.*
           ►LVH on EKG ("probable") without history of hypertension. Does not
            include "possible" LVH on EKG
           ► Pacemaker or defibrillator
           ►Aortic stenosis or regurgitation
           ►Grade III murmur without previous echo to rule out aortic valve disease
           ►History of MI or angina, and declines CST
           ►Arrhythmogenic right ventricular cardiomyopathy

            *These cases must be made OHP Review regardless of                        any
            recommendation, further testing, or intervention by Harbor-UCLA

Written Communications:

To Employee: Written communication to the employee shall include any
recommendations for medical follow-up (see above), a summary of any
recommendations regarding improvements in physical fitness, and at a minimum, the
results of the following tests: serum glucose, total cholesterol, HDL, LDL, triglycerides,
total cholesterol/HDL ratio.

The general format of this communication is presently at the discretion of the
contractor. However, at some point in the future, the County may develop a format
which would have to be used by all contractors.

Additionally, Fire Department employees will bring a Compliance Form with them for
completion. This form should be copied for the chart with the original given to the
employee.

To Department: None is required unless the employee is restricted. Restrictions
should be written on the Contract Physician Medical Examinations Results form, and
faxed to the RTW Unit (323-881-3040) in the Fire Department, and to the OHP (213-
637-0822). Additionally, the supporting medical information which documents the need
for the restriction must be faxed to the OHP. However, do not fax medical information
to the Fire Department.




                                            12
Commercial Driver’s License Examination
(completed concurrently with Fitness-for-Life Evaluation)

Firefighters must maintain proper licensure for driving of firefighting equipment and
rescue ambulances. This requires that firefighters maintain either a “restricted” Class
B, or an unrestricted Class A/B. “Restricted” means the license is only valid for driving
firefighting equipment. It can not be used for driving of other heavy vehicles or 11-seat
vans.

County of LA firefighters are given a choice as to which license they wish to maintain.
The advantage of a restricted Class B is that the medical "examination" is limited to a
health questionnaire (DMV form 546) which is completed by the firefighter and
submitted directly to the DMV. This form does not require review by a physician. No
specific medical testing is required. Whether a firefighter passes or not is determined
by a non-medical administrative person in the DMV.

If the firefighter chooses to maintain an unrestricted Class A/B, they do have to obtain
periodic medical examinations, just as anyone else holding a commercial driving
license. County of LA firefighters are given a choice as to whether the         medical
examination is performed by their private health care provider, or by a County contract
physician at the time of their Fitness-for-Life examination.

If a firefighter choses to have the DMV examination done at the time of their Fitness-
for-Life exam, they should be aware that they will be required to undergo the same
evaluation process as other County employees. Therefore, the following guidelines
are very similar to those found in the Periodic Clinical Practice Guidelines
(http://cao.lacounty.gov/OHP/misc/cpg.PERIODIC.doc).         Minor    differences    are
generally due to differences in the availability of various tests under the Periodic vs.
Fitness-for-Life contracts.

While the County recognizes that most of our contractors have extensive experience
in conducting DMV exams, the County must insist that firefighters with certain
conditions only be certified for a three month period while their medical files are
reviewed by OHP staff. These “OHP Review” conditions typically involve the potential
for sudden incapacitation, are characterized by DMV medical guidelines which are
open to interpretation, and/or warrant verification of the firefighter’s medical history by
review of personal medical records.

OHP staff will subsequently review the case, may request treatment records, and/or
further testing by the firefighter’s health care provider. If OHP’s review indicates that
the firefighter meets the County’s risk management criteria for certification, OHP will
issue an OHP Work Order requesting that the contract physician reissue the
Commercial Drivers DMV form DL51 and the green Medical Examiner’s Certificate
with a new expiration date. Note that the same process will occur when a driver can
only be issued a three-month clearance due to hypertension.




                                            13
Regarding sleep apnea, a recent review in the JOEM (Vol 48, #9, Suppl 9/06) stresses
that this condition is a major risk factor for accidents (OR = 2-7X). It recommends a
very aggressive screening program to identify unreported sleep apnea. We currently
do not have the internal staffing to handle all of the "OHP Reviews" this proposal
would generate. However, we have updated the OHP Review list to better reflect
these recommendations. This will require that examiners carefully question and
observe drivers who admit to snoring or sleep apnea to determine if they have any of
the related OHP Review conditions listed below.

On the topic of sleepiness, be sure to discuss this with any employee who admits to
use of sedating prescription medication in the last month. Note that the DMV form
does not ask about general medication use, but the Fitness-for-Life form does. Use of
sedating prescription medication in the last month, regardless of symptoms, is an OHP
Review condition (warranting a 3-month temporary card) when a DMV is done
concurrently with the Fitness-for-Life exam.

Note that the DMV form and card cannot be issued when follow-up testing with Harbor
Cardiology group is pending. After Harbor testing rules out obstructive disease, the
form and card be picked up or mailed to the employee.



Work Fitness Triage Assessment:

Note: please use the lowest measured resting blood pressure readings for the algorithm
below.

      No Restrictions:

      ► All conditions must be acceptable per the medical guidelines that are issued
        by the State and are attached to the DL51 form. Examiners are also
        encouraged to gain familiarity with the various consensus guidelines that are
        posted on the F.M.C.S.A. website (http://www.fmcsa.dot.gov/rules
        regs/medreports.htm), especially the recent publication by the
        Cardiovascular Advisory Panel.

      ►Do not have any of the conditions list below under "OHP Review"

      Note that drivers with a history hypertension (even if normo-tensive on
      medication currently.), or s/p MI/stent may not be qualified for more than 1 year.




                                          14
Restricted: Fax to RTW Unit (323-881-3040) and OHP (213-637-0822)

Employees with any of the following must be given a restriction of "No driving
vehicles that require an A/B license."

► Does not meet DMV criteria for certification or temporary clearance. Note
     that this includes amputees and monocular drivers who report having
     DMV "clearence", but whose license does not indicate a restriction
     against passengers or interstate commerce (look at license).

►Blood pressure ≥180 systolic or ≥110 diastolic on lowest resting
     measurement: (for drivers who checked the “New Certification” box
     checked on DL51 form.)

►Blood pressure ≥160 systolic or ≥100 diastolic on lowest resting
     measurement: (for drivers who checked the “Recertification” box on the
     DL51 form.)

►Current use of Chantix

OHP Review: Issue a three month temporary Medical Certificate

► Blood pressure ≥160/100, but < 180/110 on lowest resting measurement (for
     drivers who checked the “New Certification” box checked on DL51 form.)
► Blood pressure ≥140/90, but < 160/100 on lowest measurement (for drivers
     who checked the “Recertification” box on the DL51 form.)
► Color Vision Impairment—missed one or more Titmus spots on 16 spot slide
► Loss of consciousness in the last 2 years for any reason
► Evaluation for lightheadedness in the last 2 years
► Epilepsy
► MI in the last two years
► Complete heart block
► V tach run of 4-7 beats on CST
► Triplets: ≥2 on CST
► SVT lasting ≥15 seconds on CST
►PVC’s totaling ≥10% of beats within an exercise stage or during the early
    recovery period.
►CST positive for ischemic changes and any ectopy is present.*
►CST positive for ischemic changes and VO2max < 33.5 ml/O2.*
►CST positive for ischemic changes and symptoms are present.*
                   (Continued on next page)
                                   15
      ►CST positive for ischemic changes and there is a history of MI.*
      ► CHF in last two years
      ► LVH "probable" on EKG without history of hypertension
      ► Atrial fibrillation, uncontrolled
      ► Any other heart disease with onset in the last two years
      ► FBS ≥200 regardless of history
      ► A1c > 7.5%
      ► Insulin use on an intermittent or regular basis

      ► Hypoglycemia which required the assistance of others in the last 2 years
      ► Serum creatinine > 3.0 (Do not hold card while waiting for lab result)
      ► Dialysis
      ► Liver disease, if symptomatic or physical evidence of liver failure
      ► Sedating prescription medication: Use in the last month on either a regular
        or intermittent basis based on history or positive urine test
      ►Major psychiatric condition (bipolar, schizophrenia, major depression)
        requiring medication for control
      ►Sleepiness observed in waiting or exam room
      ►Sleepiness in daytime by history
      ►Sleep apnea, if untreated or admits poor compliance with CPAP
      ►Sleep apnea, if treated by surgery or dental appliance
      ►Snoring, with daytime sleepiness, or partner reports apneic or choking
        episodes
      ►History of drug, alcohol abuse, or DUI in the last two years
      ►Neck, decreased range of motion affecting far lateral gaze
      ►Thyroid disease with abnormal TSH
      ► Stroke or fixed neurological deficit
      ► Recurring neurological deficits including transient ischemic attacks
      ►One or more medical questions or exam components on the DMV form
        refused by employee

        *These cases must be made OHP Review regardless of                         any
           recommendation, further testing, or intervention by Harbor-UCLA

Written Communications:

To Employee: Written communication must include restrictions (if any), and
recommendations for medical follow-up. Additionally, the employee must receive a
completed and signed original DL51 form and Medical Certificate (unless restricted
against A/B driving). Employees who require OHP review, and are therefore issued a
                                          16
3-month temporary Medical Certificate, should be informed that they will receive either
a regular Medical Certificate, or a written request to provide further information from
the OHP before their temporary certificate expires.

To Department: None unless restricted. Restrictions should be written on the
Employee Medical Examinations Results form, and faxed to the RTW Unit (323-881-
3040) in the Fire Department, and to the OHP (213-637-0822). Additionally, the
supporting medical information which documents the need for the restriction must be
faxed to the OHP. However, do not fax medical info to the Fire Department




                                          17
Firefighter Hazmat Evaluation(done concurrently with Fitness-for-Life)
While there is no additional questionnaire or testing when this evaluation is required in
conjunction with a Fitness-for-Life exam, the physician must perform a subsequent
work fitness assessment which is much broader in scope. Unlike the work fitness
assessment of the Fitness-for-Life program which focuses narrowly on the risk of
sudden loss of consciousness, the work fitness assessment below includes
consideration of liver, pulmonary, and kidney conditions that increase firefighter’s
vulnerability to the potential health effects of a broad range of toxic chemicals, and
consideration of potential cardiac limitations to the use of full protective suits.

Participation in this program is required by Cal/OSHA if firefighters are assigned to a
HAZMAT station (FS #43, 76, 105, or 130), or who are HAZMAT certified and may
work at a HAZMAT station on an overtime basis.


Work Fitness Triage Assessment:

      No Restrictions:

      ► Employees without any of the conditions listed below


      Restricted: Fax to RTW Unit (323-881-3040) and OHP (213-637-0822)

      ► Blood pressure >179 systolic or >109 diastolic
               “No HAZMAT duties”


      OHP Review:

      ► SGOT and SGPT ≥ 50% above normal
      ► Serum creatinine above normal
      ► Urinalysis positive for protein or blood (and no menses)
      ► Chronic liver disease including hepatitis B or C
      ► Chronic kidney disease
      ► FEV1 or FVC < LLN
      ► Shortness of breath that interferes with work
      ► Frequent coughing (i.e., occurring during employee interview)
      ► History of cardiac disease, unless stress test is performed concurrently with
            this examination, is normal, and VO2 max is at least 33.5 ml/kg/min
      ► Pregnant
      ► Any problems that are self-reported as interfering with respirator use
      ► One or more “mandatory” medical questions or exam components refused
            by employee


                                           18
Written Communications:

To Employee: Written communication must include restrictions (if any), and
recommendations for medical follow-up.

To Department: The Fire Department is sent an Employee Medical Examinations
Results form on all Firefighters regardless of triage status. Restrictions must be faxed
to the RTW Unit (323-881-3040) in the Fire Department, and to the OHP (213-637-
0822). Additionally, the supporting medical information which documents the need for
the restriction must be faxed to the OHP. However, do not fax medical info to the Fire
Department

.




                                           19
S.C.U.B.A. Evaluation (done concurrently with Fitness-for-Life)
The County has a small number of employees who use self-contained underwater
breathing apparatus during the course of their work duties. The purpose of this
medical evaluation is to determine whether this activity can be performed safely.

Work Fitness Triage Assessment:

      No Restrictions:

      ► Employees with none of the conditions listed below .


      Restricted: [fax to Department and OHP]

      ► Perforated or non-mobile tympanic membrane,
      ► Tympanic membrane totally occluded by wax, cholesteatoma, or exostosis,
      ► History of intracranial aneurysm/hemorrhage or vascular malformation,
      ► History of pneumothorax unless treated with sclerotherapy,
      ► Radiographic evidence of pulmonary blebs, bullae, or cysts
      ► Atrial septal defects
      ► Pregnancy

      ► FEV1/FVC ratio < LLN and FEV1 %Pred < LLN

                           "No Diving"


      OHP Review:

      ► Vertigo including Meniere’s Disease in the last five years
      ► Middle ear reconstructive surgery or stapedectomy
      ► Chronic mastoiditis or mastoid fistula
      ► Psychiatric disorders
      ► History of drug, alcohol abuse, or DUI in the last two years

      ► Stroke or fixed neurological deficit
      ► Recurring neurological deficits including transient ischemic attacks
      ► Hematological disorders

      ► FEV1/FVC ratio < LLN and FEV1 %Pred <100% but >LLN
                          [continued on next page]

                                          20
      ►CST positive for ischemic changes and <13.6 Mets
      ► Asthma, if Rx use in the last two years
      ► Kidney Disease
      ► One or more medical questions or exam components refused by employee


Written Communications:

To Employee: Written communication must include restrictions (if any), and
recommendations for medical follow-up.

To Department: The Fire Department is sent an Employee Medical Examinations
Results form on all Firefighters regardless of triage status. Restrictions must be faxed
to the RTW Unit (323-881-3040) in the Fire Department, and to the OHP (213-637-
0822). Additionally, the supporting medical information which documents the need for
the restriction must be faxed to the OHP. However, do not fax medical info to the Fire
Department




                                           21
Executive Medical Evaluation
The Executive Medical evaluation is a comprehensive medical evaluation intended to
assess the Executive’s current state of health, provide health education when
indicated, and to recommend appropriate medical follow-up with the private health
care providers.

Prior to the day of the evaluation, the Executive should have reviewed OHP’s
recommendations regarding optional testing components (see Table below), and
notified the contract clinic regarding his/her preferences. The contract physician must
be familiar with the OHP’s recommendations, and be prepared to discuss them if
requested to do so by the Executive.

Table: OHP Recommendations Regarding Optional Tests

 Tests            Description                Should I Get This Test?

 Bone Density     Various devices are        Yes, if you are female age 65, or age 60 with risk
                  available for measuring    factors for bone fractures. For more information,
                  bone density. All are      please see
                  painless, but some         http://www.mayoclinic.com/health/bone-density-
                  involve small amounts of   tests/WO00024
                  radiation exposure

 Cardiac Stress   Walking/running on a       Maybe. Stress tests are not generally
 Treadmill        treadmill with cardiac     recommended in persons without chest pain or
                  monitoring                 tightness during exercise. However, they can be
                                             of value if you are middle-aged or older, haven't
                                             been physically active, and plan to start a
                                             relatively vigorous exercise program. Otherwise,
                                             the risks and emotional stress associated with
                                             having to undergo extensive follow-up studies to
                                             evaluate “false positives” probably outweighs the
                                             benefits of screening.

 Chest X-ray                                 No. Chest X-rays in persons without symptoms
                                             are not generally recommended. The risks and
                                             emotional stress associated with having to
                                             undergo extensive follow-up studies to evaluate
                                             “false positives” probably outweighs the benefits
                                             of screening. This is true even in smokers at high
                                             risk of lung cancer.

 Coronary         CT scanning to detect      No. To find out why, please see
 Calcium Study    calcified plaque           http://www.mayoclinic.com/ health/heart-
                                             disease/HB00015
 Fecal Blood      Rectal exam with testing   Yes, if you are age 50 or more. Blood in the stool
                  for traces of blood        may be caused by cancer. The rectal exam may
                                             also reveal prostate abnormalities in men.

 Full Body CT                                No. To find out why, please see
 Scan                                        http://www.fda.gov/cdrh/ct/ctscansbro.html



                                               22
 Mammogram                                  Yes, if you are 40 or more.


 PAP Smear                                  Maybe, depending on your age and previous PAP
                                            smear results. Please see
                                            http://www.mayoclinic.com/health/pap-
                                            smear/HQ01177

 PSA             Blood test for prostate    Maybe, if you are age 50 or more. This test has a
                 cancer                     lot of pros and cons. Please review
                                            http://www.mayoclinic.com/ health/prostate-
                                            cancer/HQ01273

 Sigmoidoscopy   Examination of the lower   Yes, if you are age 50 or more. This test (or it's
                 bowel requiring liquid     more comprehensive cousin, colonoscopy) is
                 diet on prior day, or      universally recommended as an effective cancer
                 enema on day of test.      screening procedure.

 Strength and    Assessment using           Yes, if you would like to assess and improve your
 Flexibility     resistance equipment       physical fitness
 Assessment      and performance of
                 push-ups and sit-ups




Obtaining Prior Test Results:

It is necessary to obtain prior test results from the OHP before making a medical
referral assessment in the following clinical situations:

a) Current PSA is ≥ 2.0: Obtain prior PSA results computation of PSA velocity
   (average yearly change in PSA over three or more yearly measurements).

b) Positive prior positive treadmill: Tracings must be obtained for the tracing that
   corresponds to the year in which further cardiac testing was done to rule-out
   coronary disease. This prior tracing and the new tracing can then be reviewed by
   the Contractor’s cardiologist to determine if any significant changes have occurred
   which would warrant a repeat cardiac evaluation.

To obtain necessary records, please fax one of your clinics medical release forms to
the OHP (213-637-0822).


Physical Fitness Counseling:

The Executive may elect to undergo testing of the muscular strength, endurance,
flexibility, and aerobic capacity. If so, counseling shall be done by an exercise
physiologist, physical therapist, physician, or other qualified health care professional
who is capable of applying the American College of Sport’s Medicine’s (ACSM)
recommendations for exercise prescription. These can be reviewed at
http://www.mhhe.com/hper/nutrition/williams/student/appendix_i.pdf.


                                              23
Work Fitness Triage Assessment: This is not performed as part of this exam.


Written Communications:

To Executive: Written communication to the employee shall include any
    recommendations for medical follow-up (see above), a summary of any
    recommendations regarding improvements in physical fitness, and at a
    minimum, the results of the following tests: serum glucose, total cholesterol,
    HDL, LDL, triglycerides, total cholesterol/HDL ratio.

      The general format of this communication is presently at the discretion of the
      contractor. However, at some point in the future, the County may develop a
      format which would have to be used by all contractors.

To Department: None is permitted.




                                        24

								
To top