NORTH GREENVILLE FITNESS

Published in Carolina Fire Rescue EMS Journal, Winter Issue by: Charles F. Turner, R.N., President/Owner North Greenville Fitness & Cardiac Rehabilitation Clinic, Inc.

 

        The concept of graded exercise testing is not new in screening for coronary artery disease/heart disease. The actual testing has gone from a V5, or one-lead, test in the 1960’s and 1970’s to a 12-17 lead EKG test as 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 is the only answer. Heart rate and blood pressure protocols are not medically acceptable in screening for heart disease. This is some of the reason the Gerkin protocol is called the “pickle” protocol. This protocol 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, according to research for screening.

 

1. The method of testing while being EKG monitored is the issue.

2. The second issue is if the testing is being performed by qualified personnel who are academically and medically qualified to perform the tests.

3. The monitoring physician is not qualified for graded exercise testing just because he/she has an “M.D.” or “D.O.” after his/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 graded exercise tests. Their practices are not such that they perform these tests. This is the critical point in asking if the personnel running the tests are academically and medically qualified to perform these tests. Specifically, if they Advanced Cardiac Life Support (ACLS) certified and is the physician trained and versed to perform he screenings and has experience in graded exercise testing.

 

        Remember, this is your program, so ask the questions. You won’t go to a family practice physician for major surgery, so do not accept a physician who is not qualified to perform tests. Again, this is not to be critical of any physician or physician groups.

 

        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 services. It makes no difference how you get the heart into the proper heart rate range (bike, treadmill, arm, step), but that the 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 a test.

 

        The use of a protocol which takes the firefighter to exhaustion or symptom limited, per research, 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 also should be performed for diagnostic purposes only and in an inside clinical setting.

 

        Health screenings cannot be confined to cardiovascular testing, but 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 the thyroid screening. With the amount of thyroid disease in the fire services, 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 of diabetes mellitus.

• Iron should also be included, as it applies to anemia as well as to other diseases.

 

        This is cursory look at blood panels and will be a topic for future discussion.

 

        The purpose of this article is for educational purposes. The better trained and better educated the fire service is, the more lives can be saved.

 

 

*BASIC PROGRAM PROPOSAL*

 

Session #1:            BLOOD DRAW:  12 hour fasting blood work panel.  A copy of the                                   results is provided for each participant.

                               

                                PHYSIOLOGICAL TESTS AND HEALTH SCREENING:  We will                                           provide the equipment and staff to administer the following                                         tests:  up to 30-35 people/day (7per/hr)

               

                1.             Comprehensive health history questionnaire and cardiovascular                                 risk factor assessment.

                2.             Resting blood pressure

                3.             Body composition evaluation; includes height, weight and skin                                     fold

                                measurements to obtain body fat percentage.

                4.             Resting (12- lead) electrocardiogram

                5.             Pulmonary function assessment

                6.             Sub maximal ergometer (bike) graded exercise Stress Test (with                                 12- lead EKG and blood pressure monitoring)

                7.             Basic hearing and vision screening

                8.             A supervising board certified physician will briefly review all test                                 results with the participant.

 

Session #2:            POST TEST CONSULTATION:  Copies of all test results, profiles                                     and individualized exercise prescriptions are provided for each                                   participant in an individual report packet.  A consultation session                                 is set up about 2 to 3 weeks after initial health screening where                                   this report is reviewed and explained to the participants.

 

                               A statistical annual summary report is provided for the                                                  department that lists the averages and ranges for different                                          health characteristics found within the population tested.  This                                    can be used as a progress tool to chart the health of the group as                                a whole.

 

                               -  A fire brigade clearance form is provided for each structural                                      fire fighter.

                               -  A respirator clearance form is provided for individuals who are                                  assigned to tasks which require use of a respirator.

                               - Any abnormalities detected during the screening and evaluation                                  are discussed with the individual, if he/she is referred to their                                      personal physician.