Officer Safety Corner: Prevention, Compassion, and Survival: Managing the Health of First Responders

Rob Hilvers, MD, Emergency Responders Health Center, Boise, Idaho A seemingly healthy 45-year-old police officer on a routine patrol shift receives an emergency 3 a.m. dispatch call. Almost immediately, the physiologic “fight or flight” response ensues; the officer experiences escalated blood pressure and heart rate, which is further compounded as he engages in intense exertion at the scene. Will this officer return to his family at the end of his shift, or will he be among a number of first responders who suffer a fatal heart attack before underlying cardiac disease is ever detected? hat if the police officer in the above scenario, upon being hired into the force, had access to a comprehensive annual wellness program focused on prevention and early detection strategies? Would specialized care have mitigated occupational stressors, lowering the risk of cardiac episodes and increasing the likelihood of a safe return home? In 2007, Stefanos Kales published his landmark study in The New England Journal of Medicine, which demonstrates a significantly higher risk of on-duty cardiac death among police officers and firefighters—22 percent and 44 percent, respectively—compared to the general population (15 percent).1 While Kales’ findings raised awareness of the increased health risks experienced by first responders, they also raised additional questions. For instance, are higher cardiac death rates due to an increased predisposition for coronary disease among police officers and firefighters, or are they the result of the unique stressors experienced by first responders during their shifts in the line of duty? While the prevalence of coronary artery disease (CAD) and the risk of cardiac death among active-duty firefighters has been well documented, less attention has been given to the corresponding risk among police officers.2 The Emergency Responders Health Center (ERHC) in Boise, Idaho, was established in 2004 (three years before the publication of Kales’ study) to manage the specific medical needs of police, fire, and emergency medical services (EMS) responders with the simple mission of “Prevention, Compassion and Survival.” Founded in response to specific needs cited by the Boise Fire Department dive team, ERHC has evolved to offer highly specialized, proactive care designed to address the elevated health and injury risks experienced by all first responders. The center’s primary areas of focus include cardiovascular disease, sports medicine, cancer screening, and behavioral health. ERHC offers comprehensive annual exams, preventative guidance, continuity care, and worker’s compensation care for approximately 15 Idaho police, fire, and EMS agencies. Services are not only adapted to each respective profession and its unique associated risks, but also are customized further to each individual patient. In response to heightened concerns surrounding heart attacks in the line of duty, one of the pillars of ERHC outreach is cardiovascular screening, awareness, and education. Based on their elevated risk to experience a cardiac arrest, police officers undergo advanced heart screenings designed exclusively for first responders and not yet available to the general population. During an annual exam, mainstream patients are likely to undergo minimal screening to include a blood pressure check, blood lipid panel analysis, fasting glucose, and family history assessment. At most, patients identified with elevated risk will undergo a resting EKG test. Conversely, emergency responders seen at ERHC undergo aggressive cardiac surveillance to include standard assessments paired with cardiac stress testing (age-stratified), abdominal circumference measurements, and comprehensive baseline questionnaires.3 Health screenings are further adapted to the unique occupational exposures of different first responder professions. The ERHC’s specialized annual exams are used to generate individual cardio-risk assessments, which are graphed into “heart scores” using a proprietary Fire and Police Metabolic Syndrome Score. Each officer’s score includes seven risk traits known to increase coronary heart disease: five metabolic syndrome traits (abdominal circumference, blood pressure, fasting glucose, triglycerides, and HDL cholesterol); aerobics capacity (VO2 max); and tobacco use. Each of the seven health indicators is depicted in corresponding zones to provide a readily understandable, visual representation of the officer’s current health status: green (optimal), yellow (concerning), and red (high-risk). Patients’ health indicator scores from the prior two years are plotted for comparison to demonstrate whether or not they are making the necessary adjustments in their fitness, nutrition, and lifestyle choices. Additionally, comparing cores provides a base for personalized health education. Each officer’s composite score is also compared with the aggregate scores of his or her peers (with individual confidentiality strictly maintained). This trending and comparative data has often proven the greatest motivator for behavioral change among patients by providing both a visual reminder and a concrete target. In addition to undergoing the thorough risk assessment described, a number of ERHC patients are also eligible to participate in cutting-edge arterial scans hosted by the Saint Alphonsus Research Institute in Boise. Because a heart attack can be the first—and final—signal of underlying heart disease in as many as one-third of cardiac arrest fatalities, cardiologists are seeking better tools to predict, detect, and reverse heart conditions at the earliest possible stage.4 The role of “traditional” risk factors (e.g., hypertension, cholesterol, family history, tobacco) as a primary cause of heart attacks is well understood; however, these indicators alone do not explain the increased propensity for CAD-related death among on-duty police officers. Non-traditional risk factors, including inflammation-boosting chronic stress; issues related to shift work (e.g., endocrine dysfunction, circadian rhythm sleep disorders); and the combination of extreme exertion, hyperthermia, and inhalational exposures of toxic fumes and particles must also be considered. In 2013, the author was invited to collaborate with Steven Writer, MD; Pennie Seibert, PhD; and the Saint Alphonsus Regional Medical Center on an ongoing study to determine (a) if CT scans to detect arterial calcium plaque could serve as effective predictors of CAD and heart attack in first responders; (b) whether this plaque burden could be reversed through nutrition, fitness, and lifestyle changes; and (c) if first responders’ increased awareness of their personal risk would increase their adherence to healthy choices, leading to improved health status.5 Following eventual completion of the study, the team hopes to address all three primary study questions while measuring the prevalence and severity of CAD among police officers as an under-recognized, high-risk population.6 The ERHC has worked to continually refine its service delivery over the past 10 years and currently is working to further enhance the care of first responders by integrating a clinic dietitian, sports physical therapist, and health coach, as well as working to build a fitness testing and injury prevention program. The health center’s success can be replicated in other communities committed to giving back to their police officers and other first responders. With an emphasis on preventative medicine and advanced screenings based on specific occupational risk, the ERHC approach has not only served first responder patients well; it is highly consistent with the evolution of health care toward the specialized management of populations and the avoidance of hospitalizations and emergency room (ER) visits in the first place. In time, the methodology refined through the ERHC and similar clinics is likely to be highly applicable to the mainstream population. By taking bold steps to improve their own wellness, police officers and other first responders will be modeling healthy choices—protecting their citizens in yet another way. ♦