The UK fire service has specific and rigorous requirements for fitness to practice as a firefighter. These requirements are clearly defined in the Medical and Occupational Evidence for Recruitment and Retention in the Fire and Rescue Service’ document.1 During the recruitment process, candidates undergo a medical assessment, along with a test of aerobic fitness and strength, to assess physical and mental endurance of combat fatigue. Once recruited and trained, firefighters’ aerobic fitness and general health status are regularly reviewed.
A firefighter has three roles: the first and most visible is to respond to emergencies, including fires, road, rail or air accidents, floods, bomb incidents, and chemical or biological spills. A firefighter may need to run out fire hoses, carry and use heavy cutting equipment, climb ladders, enter smoke-filled buildings and crawl around in confined spaces while wearing breathing apparatus.
The second role is fire prevention, through giving presentations or inspecting and advising on fire safety for new or existing buildings, to ensure that fire safety standards are met. It is also their duty to inspect and clean equipment, practice drills to maintain competency, and maintain fitness to remain operational.2
The firefighter role requires the ability to work in a team, follow commands, combat fatigue to perform effectively in an emergency environment, and be ready to deliver firefighting duties day or night.
Before the 2004 recruitment and retention documents were introduced, the available guidance was clear that firefighters with epilepsy were unfit for role. In October 2004, the consultation documents about the new recruitment and retention guidance included provisions for the Disability Discrimination Act (DDA) to cover firefighting. They state that decisions on fitness to work are based on an individual assessment.3
The role of occupational health (OH) can often bring interesting and rewarding health cases to the fore. This is the case with a firefighter with epilepsy who wishes to return to a full operational firefighting role. It demonstrates the contribution OH can make to the decision-making process.
‘Robert’ is a 38-year-old operational firefighter who has worked for the fire service for seven years. He was referred to OH by the station manager to discuss his health and assess his fitness to work. On the referral form the station manager said he was reviewing Robert’s risk assessment to ascertain whether he would be fit to commence his full operational role.
Robert has had epilepsy since 2003 and has been operational since 2006, with restricted duties involving working at height, using breathing apparatus and working alone. He has worked a regular shift pattern of two days and two nights without any adverse health effect reported, and annual review has allowed this to continue. He is not a group 2 LGV driver for the fire service.
The referral asked the OH service:
- Is the employee fit to undertake the full operational role?
- What is the likelihood of an epileptic seizure affecting Robert while he is undertaking the role of an operational firefighter?
- How will this likelihood change with time?
- What control measures are possible – for example, medication, sufficient sleep, adjusted duties and so forth?
- Are there any types of duty that Robert should not undertake on medical grounds?
Epilepsy is usually diagnosed after two or more seizures have occurred. A seizure occurs where there is a sudden burst of intense electrical activity in the brain. This electrical activity temporarily disrupts normal messages between brain cells and the messages become confused or stop altogether.4 It is different for each person, with varying symptoms depending on where the excess electrical activity started in the brain. After a seizure most people recover fully. For six out of 10 sufferers, there is no known cause. There is a higher incidence in males, although the reason for this is not fully understood.
When interviewed, Robert was keen to know whether he would be fit to commence his full operational firefighter role. He explained how he came to be diagnosed with epilepsy after his wife was woken by him shaking violently and foaming at the mouth one night in 2003. A few weeks later he had a further seizure at night, and was subsequently diagnosed with epilepsy and commenced on Carbamazepine, 200mg twice daily.
His health records contained several reports from neurologists who had carried out extensive medical investigations during 2003. The results had revealed no identified cause for the seizures, nor clinical features that would predict further seizures. The neurologists had indicated that up to 80% of patients would be fully controlled on one drug, although 20% were at risk of further seizures over the next two years. Robert had remained seizure-free for the past six years and was discharged from specialist care in 2005.
Robert’s outlook on his epilepsy, risk perception and therefore compliance with self-care routines, was explored. Determining the attitude to the health issue gives an indication of whether a patient may be inclined towards risky behaviours, such as failing to take prescribed medication. Such behaviours would then affect the health outcome and fitness for work, so is a valuable part of the risk assessment process.5
Robert is a non-smoker, does not consume alcohol, is compliant with his medication, and is careful to have sufficient sleep and rest. He follows a fitness programme, including a mixture of cardiovascular and strength exercises in the fire station gym, and he passed his six-monthly fire service fitness test. Robert says he enjoys his work, has good working relationships with his crew, likes the fire service and has no untoward pressures at work or at home.
In 2005, Robert appealed against a decision to discharge him from the fire service on medical grounds, so with his permission, the appeal notes were obtained from HR. The attempted medical discharge was based on the diagnosis of epilepsy and a recommendation for ill-health retirement. His appeal was upheld as it was not possible to say at that time whether the incapacity was permanent, and a risk assessment with regular review was recommended.
The content of the preliminary OH report was discussed with Robert. The report summarised the known history of the epilepsy, of prescribed medications, of good sleep and fitness routines, of discharge from specialist care in 2005, and being seizure-free for six years. The report indicated that the health condition may fall within the scope of the DDA, although it acknowledged that this could only be confirmed by a legal expert. A medical report was obtained from Robert’s GP that confirmed his understanding of treatments and medical details since his discharge from specialist care and his compliance with medication routines.
The station manager agreed that a full exploration of fitness to work would require a multidisciplinary approach for a decision to be reached. A multidisciplinary team would likely include OH, HR, his station manager, and members of the senior management team.
The station manager requested a meeting with OH to discuss health issues and the risk assessment process, the focus being whether the three current restrictions could be lifted, or whether suitable control measures could be identified. The station manager was supportive of Robert’s request for review.
Robert was aware that this meeting was being convened and allowed OH to prepare a summary of dates and findings from the health records and notes of the appeal as appropriate. Each of the three activities of breathing apparatus work, working at height and lone working was then discussed.
Breathing apparatus (BA) equipment consists of a face mask, visor, hoses and valves connecting to a cylinder that delivers a positive pressure supply of compressed air with an approximate working duration of 40 minutes. BA wearers work in crews of two or three to enter toxic, hot and humid environments commonly found at fires in buildings and forests, or where exposed to chemicals.6
In these situations, BA wearers have entry control procedures employed to ensure their safety when entering an environment where visibility is often limited. This includes handing their ‘tally’ or personal alarm key to the entry control officer before entering a building. This personal alarm is automatically activated if the BA wearer remains inactive for more than 90 seconds, or can be manually activated if they require assistance.
On entering the building, the BA wearer will employ specific search procedures to navigate safely, often by touch, by reference points they find in the room such as doorways and furniture, and by frequent communications to team members. By sweeping with hands and feet as they go they check that the area is clear of injured people or the source of fire before moving on to the next room. They can use a personal safety line connected between them if needed.
Each BA crew will continually check remaining air supply and search until a judgement is made about remaining cylinder contents. Upon exiting the risk area, the BA crew will debrief and pass on information to the next BA crew, and so on until the building or area is clear.
The risks of a seizure occurring while in BA kit with unprotected airway, unable to communicate and becoming isolated from other team members was explored – the risk of becoming a casualty who then needs to be rescued themselves, as was the impact on manpower to continue the search and rescue operation. A further question was then raised about how likely all these factors were to occur simultaneously.
Working at height
Working at height is described as an activity where there is a risk of a fall that can cause personal injury or death.7 For the fire service, the activity may include working below ground level, down railway or road embankments, in manholes or trenches, as well as the familiar activity of using ladders. The regulations8 describe a hierarchy of risk at which appropriate equipment should be selected.
Where a fall cannot be eliminated, then equipment or other measures should focus on minimizing the distance or the consequences of a fall should this occur. The fire service employs various fall arrest systems or locking devices which are added to the harness and lines and arrest the fall quickly, safely and reasonably comfortably.
Risks considered here are falls from height if working up a ladder or hanging from a harness at the moment of a seizure. The consideration again was how likely was a seizure to occur when working at height.
The discussion moved on to the third restricted duty, lone working. The fire service policy is that an employee below the level of station manager would never be at the station on their own. When a fire call is received, all crew members leave the station together. Each crew on an appliance will work as a team whose whereabouts is always known through constant communications as the response to the situation unfolds.
Apart from when out on a fire call, all firefighters remain at their fire stations. The lone working restriction was not further discussed at this time, other than to note that at the fire station, individuals could be alone if sleeping in the dorms even if their whereabouts is known. At other times, firefighters will be assigned time to attend the gym, update their NVQ information in the training room, or relax in the mess room, with no opportunity for lengthy periods alone.
- Where the risk is considered to be low, it may be safe to undertake operational firefighting duties.
- Individuals should be seizure-free for at least one year.
- The question that remained was whether the risk for Robert was sufficiently low enough to allow him to commence full operational duty.
- Referral and case conference
- It was felt that a current opinion was needed on the likelihood of further seizures, so Robert was referred to a neurologist who was asked:
- Are the statistics of 80% of patients being fully controlled on one drug and 20% risk of further seizures over the next two years still in line with current thinking?
- Is there a percentage sliding scale of risk over the years or beyond the two years? If so, what is the risk percentage after being six years seizure-free in May 2009?
- Is there any medical indication of situations where a seizure is more likely to occur?
The specialist replied that the statistics are still current, although there is lack of good long-term follow-up studies to provide an individual risk assessment. He said that the 20% risk of seizure would fall with the passage of time – the best predictor is the length of time without seizure, and Robert is at the good end of the prognostic range. The specialist concluded that the chance of further seizures, although small, remains at a significant level for a sudden unpredictable incapacitation.
Robert was informed of the findings of the specialist report and a further summary report was provided to the manager who was then able to initiate the risk assessment process which looked at the three restricted duties and the controls necessary to protect Robert.
The case conference included the station manager, HR, OH, health and safety and two senior management team members. The risk assessment was discussed to ensure that responsibilities to Robert, his colleagues and the public had been fully considered based on the HSEs ‘Five Steps to Risk Assessment’. The conference explored the controls in detail. These details will be passed to the director of service delivery for final approval.
Regulations, guidance and opinions change, so it is of utmost importance that there is regular case management review with managers and HR. Employees in hazardous occupations need to be regularly monitored by OH, and specialist opinions should be sought to assist with this process.
Where there is no clear outcome of fitness to work, a risk assessment must be undertaken, with understanding of the control measures that need to be in place for the likelihood of a sudden incapacity. Where control measures cannot be implemented, then that work should be restricted.9 However, this case study would indicate that where reasonable adjustments are achievable in complex and hazardous working environments such as the fire service, then these should be more easily achievable in less hazardous work environments.
For management to take appropriate action on health-related issues, the OH service should be appropriately qualified, experienced and have sufficient working knowledge of the role and function of serving fire service personnel. However, the final decision on employment and the capacity in which someone should work rests entirely with the organisation.
Mel Wyatt is an occupational health manager who works part-time with Premier Occupational Healthcare, located at fire service premises. She is also an independent OH nurse consultant at Well Aware Occupational Health Services.
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3 Office of the Deputy Prime Minister Fire and Rescue Service Circular 16/2004
5 Palmer, K, Cox, R, Brown, I (2007) Fitness for Work. The medical aspects. Oxford University Press
7,8 HSE Work at Height (Amendment) Regulations 2007
9 Palmer, K, Cox, R, Brown, I (2007) Fitness for Work. The medical aspects. Oxford University Press