The fire service continually strives to protect the communities we serve through training, innovative technologies and techniques, and a constant desire to do a better job. Although many of the components that make up the fire service have improved, we still continue to perish at an alarmingly high rate.
In the past 25 years, the fire service has done many things to attempt to protect our personnel and give them the tools to perform their jobs in the safest possible environment. The days of rubber fire coats and day boots have given way to turnout gear and Nomex hoods. Many fire departments have developed fitness programs to help their personnel be as prepared as possible physically. New standards and policies have brought about things such as incident management systems and critical incident stress management teams. Unfortunately, in looking at the statistics from these 25 years, it appears that we as an industry may have missed an important point.
In comparing the numbers of injuries and deaths over this same time period, it is clear that we are making a difference. In 1987, 57,755 fireground injuries were reported. By 1996, this number had been reduced to 45,725.1 Unfortunately, the number of deaths didn’t show as dramatic a decrease. After a high of 171 in 1978, there was a downward trend to a low of 77 in 1992. Since that time, the number of deaths annually has remained at approximately 100 firefighters. This takes into account the 343 members of the Fire Department of New York who perished in the attacks of September 11, 2001.
If you continue to look at the numbers, another alarming trend is that although cardiac-related problems account for less than 1 percent of all injuries, in all years except 2002 they accounted for approximately half of all deaths. (1, p. 8)
It is not burns or falls or collapse that is killing responders. It is a combination of heat and cardiac stress.
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Theories relative to the reasons for this abound. Among them are heat stress inside turnout gear and increased physical demands caused by decreased staffing. One of the most interesting theories involves the amount of oxygen being made available to the body’s cells while working.
A study by the Illinois Fire Service Institute at the University of Illinois showed that as the body began to work harder, the efficiency of the cardiovascular system and its ability to circulate oxygenated blood throughout the body actually decreased. Initially, the heart responded to the increased workload by beating faster, but, after a slight increase, the cardiac output actually decreased as the work continued. This resulted in less blood being circulated and thus less oxygen being available to the cells.
The study involved a group of firefighters in week five of a Firefighter II program who performed three sets of four exercises that were similar to tasks that would be required of them on the fireground. By the end of the last set of exercises, the heart was actually pumping 30 percent less efficiently.2 This is because as the heart beats faster and faster, it loses the preload (because there is not enough time between contractions for the heart to refill) and does not move the blood through the body as easily. The heart can also lose some of the force of the contraction as electrolyte levels change because of fluid shifts within the body.
THE BODY’S COOLING MECHANISM
The next area to look at is the body’s cooling mechanism. We dispose of excess heat by the process in which sweat evaporates from our skin surface. Encasing all of our skin within the “protective envelope” greatly hinders the body’s ability to cool itself. The body works harder to cool itself, and it does so less effectively. The blood vessels near the skin surface dilate, trying to get blood closer to the surface to allow it to cool. This causes the blood pressure to drop even further, causing the heart to again work harder.
It is important that everyone on the fireground recognize these processes for several reasons. The incident commander (IC) must realize that we need to look at rehabilitation earlier at incidents that may become extended events. It may be tough to convince an IC who is already short of staffing to take crews out of service and rotate them into the rehab group. Allowing crews to stay fresh lets them remain a productive part of an incident scene for a longer time.
The incident safety officer and the company officer must be familiar with the early signs and symptoms of heat stress or cardiac compromise. Company officers are very important in this scenario since they probably work most closely with the individual responders and may notice the subtle changes earlier. This can be difficult, though, because the signs and symptoms of cardiac compromise are similar to the effects fighting a fire has on many firefighters, but to a lesser degree.
Firefighters themselves must be educated and constantly reminded to maintain proper hydration and nutrition to ensure their readiness to serve when duty calls. Off-duty activities such as sports or other activities in the sun and heat can greatly affect a firefighter’s ability to perform in extreme conditions. It is much easier and more effective to maintain hydration than to try to rehydrate a responder during an incident.
The earliest signs and symptoms of dehydration do not present a large risk for most people under normal circumstances. These include impaired judgment, changes in the body’s ability to control its temperature, and reduced muscle strength and endurance. The problem is that when we put firefighters in life-and-death situations, where they must perform at the top of their game both physically and mentally, they are by the nature of the business at great personal risk. If their signs and symptoms are not recognized and treated early, dehydration can quickly lead to heat exhaustion and heat stroke. The latter, characterized by hot, dry skin caused by the body’s inability to produce sweat, can include coma and death. (It should be noted that it might be difficult to determine that someone is no longer sweating, as the skin may be moist from the residual moisture present in the protective clothing.)
Firefighters need to be informed about the causes of dehydration and the methods that can ensure that they are at their peak when responding to emergencies. By educating our people, we can hope to change habits and enhance performance.
The problem with this idea is that many of the things we should avoid are “staples” in the fire station-such as caffeinated and carbonated beverages. The caffeine in coffee acts as a diuretic, or a substance that causes an increase in urine output, causing a direct and negative impact on hydration. Sodas and soft drinks also contain large amounts of the same caffeine and put us at a fluid deficit before we even leave the fire station. Add this to the fact that most people do not have a sufficient fluid intake on a daily basis to begin with, and it quickly becomes clear that we are putting ourselves at risk before the bells even ring. Coming from a shift that always had the coffee pot brewing and a table littered with soft drink cans, I can attest to the fact that when my shift made a conscious effort to avoid these drinks and to drink more water, there was a marked change. Every individual on my shift, from the two-year probie to the 32-year veteran, has stated that they feel more energetic, feel less fatigued, and have fewer aches and pains. All of this is on a daily basis, during day-to-day duties.
It is also important for people to realize that what they do outside of the fire station greatly impacts their hydration status. Nonduty activities may also greatly hinder on-the-job performance. Alcohol consumption, strenuous activities, and even certain medications may affect the body’s ability to maintain a proper level of hydration. Although it may be easy for the career responder to regulate some of these activities to nonduty cycles, the majority of responders across the United States are volunteers who cannot predict when the next call will come.
Recognizing these facts makes it easier to understand why it is so important to consider the rehab needs of responders early in an incident. It is not only at the calls that extend hour after hour but also at most calls that extend beyond a simple investigation.
NFPA STANDARDS
Several National Fire Protection Association (NFPA) standards address the rehabilitation of responders.
NFPA 1584, Recommended Practice on the Rehabilitation for Mem-bers Operating at Incident Scene Operations and Training Exercises, was issued in Spring 2003. It was written to encompass the issue of the rehabilitation of members and went much further than previous NFPA standards. It took information from several other NFPA standards and for the first time put them into one area. It includes information about setting up SOPs/SOGs, setting up a rehab area at an incident, and medical monitoring,
All of the following are also now included in NFPA 1584:
• NFPA 1500, Standard on Occupational Safety and Health Program, requires two things. It states that the fire department will establish a standard operating guideline (SOG) that addresses the rehab of members and that this rehab shall be performed in accordance with the department’s SOG and with the provisions of NFPA 1561, Standard on Emergency Services Incident Management System. NFPA 1500 also says that rehab should include providing medical care at least at the basic life support level. With recent advances in cardiac care and the high number of problems related to cardiac stress and overexertion, this should include oxygen and an automated external defibrillator where allowed by local protocols. NFPA 1561 also states that responders assigned to rehab should be tracked within the accountability system set up by the department.
• NFPA 1403, Standard on Live Fire Training Evolutions, goes even more in depth by stating:
The instructor-in-charge shall consider the circumstances of each training session and make suitable provisions for the rest and rehabilitation of members operating at the scene. These considerations shall include medical evaluation and treatment, food and fluid replacement, and relief from climatic conditions, in accordance with the training session.
It is important for instructors to note that the responsibility for rehab now falls on the instructor, not the fire officer or official.
ESTABLISHING THE REHAB GROUP
The location of the rehab group is important. Several things must be considered. First, although rehab must be easily accessible and allow responders to rotate in and out of “the fight,” it should also be remote from the scene. It is important to treat the personnel emotionally as well as physically. If they are in sight of the incident scene, it is nearly impossible to bring them down from the emotional high, or adrenaline rush, they are experiencing. Removing them from the stressors of the fight allows their bodies to relax and replenish more easily. Isolating the rehab area also makes it easier for the responders to resist the urge to reenter the operations area prior to the rehab officer’s releasing them. One disadvantage to moving the rehab group away from the scene is that in jurisdictions with limited resources, a second vehicle may be needed to provide generators, lighting, and equipment. Command staff is also less likely to rotate through rehab if it is remotely located.
Wherever rehab is located, there are certain conditions that must be considered. The area should not be in direct view of the public or the media. The object of rehab is to protect the health and safety of responders; protecting them from the eyes of the public allows them to concentrate on the tasks at hand. Provisions must also be made to protect the firefighters from the climate. This means not only from the heat but also from the cold, rain, snow, and wind. One way to do this is to preplan with fixed facilities in your response areas. Often, occupancies such as churches, schools, and municipal buildings are willing to open their doors after a presentation on how they can assist in meeting the needs of the responders in their communities. The added advantage of a fixed facility is that restrooms and kitchen equipment are also available.
If a fixed facility is not used, there are alternatives. Some departments are buying larger and larger rescue trucks with climate-controlled bodies. Although they offer some protection, they can accommodate only a limited number of people and make treatment and evaluation difficult. Ambulances offer large amounts of equipment but even less room. Many departments are adding to the space offered by these vehicles by adding awnings at the sides. Note: If the vehicle is going to remain running, there is the risk of high carbon monoxide levels as well as diesel or gasoline exhaust coming from the apparatus. This is also true when using gas-powered ventilation fans for air movement. If fans are used, they should be electric. An even better alternative would be the misting fans designed specifically for rehab. A fine water mist can cool the ambient temperature by 10°F to 20°F.
Some large municipalities have extensive resources assigned to rehabilitation, but others accomplish the same objective using other means. Two examples are Phoenix, Arizona, and Yates County, New York. The Phoenix Fire Department has several rehab units that were designed specifically for rehab. They are staffed by personnel assigned to the units and by paramedics from advanced life support units dispatched to an incident. All of the personnel work under guidelines developed by the fire department’s physician working through the Phoenix Fire Department Health Center.
Yates County, in the southwestern part of the Finger Lakes in upstate New York, on the other hand, has taken a different approach. Ten volunteer fire departments cover a population of approximately 25,000 people. After identifying a need for some type of equipment and vehicle to provide rehab services to its fire departments, sheriff’s department, and other responders in the area, Yates County Fire Coordinator Glenn Miller decided to go a different route. A trailer was obtained and funding was sought from different sources, including the Yates County Ladies Auxiliary. For about $9,000, the county was able to obtain a fully equipped trailer, including awnings, tents, a generator, tables, EMS equipment, and food and beverage supplies. The trailer is available for rapid deployment anywhere in the communities they serve, as well as surrounding jurisdictions. They also have a creative solution for providing restroom facilities. Recognizing that there is not always a bathroom where one is needed most, especially in a rural community, they mounted a portable toilet onto a utility trailer. An agreement with the Porta-John company allows it to be serviced at a reasonable price. It has proved invaluable at emergency incidents and is available to the local departments for other functions.
The coordinator’s staff brings both trailers to incidents when requested or when specified by county SOGs.
DUTIES OF THE REHAB GROUP
The duties performed by the rehab group depend on the type of incident. In many instances, the assignment is simply fluid replacement. In most cases, it should also include some type of medical evaluation, starting with the taking of vital signs. An efficient way to do this is to set up a firefighter-evaluation area near the SCBA bottle refill/exchange area. As firefighters come out to exchange bottles, they must enter rehab. Remember that in hot conditions, firefighters must be removed from their turnout gear to aid the body in the cooling process. Remember also that the body cools itself by the process of sweat evaporating from the skin surface. The body is unable to do this while still covered in protective clothing. Laying down a large tarp will allow firefighters to remove their boots and pants without having to walk around on bare ground. The firefighters should then have their vital signs taken. This will give the rehab personnel a good idea of the firefighters’ status.
From here, the individuals should be sent to one of two areas. If the vital signs are within normal limits, the firefighters should be sent to an area where they can receive food and fluids (which we will discuss later). If their vital signs indicate any of the risks of cardiac compromise, they should be sent to a separate area for further treatment and continued monitoring. Any firefighters identified as having a condition or an injury that may hinder performance or may become worse with further work should be removed from service.
Anyone experiencing nausea or vomiting should not receive oral fluids. The body’s reaction to the stress it is under is causing it to shunt blood away from the gastrointestinal tract and to the more vital organs, causing the nausea. This is important for two reasons. The first is that this causes the process of digestion to shut down. When this happens, the body tries to get rid of any food it has in the stomach through vomiting. We don’t want to add to this problem by giving more fluids or food. The second reason is that as the body becomes stressed to this degree, the individual needs to receive more extensive rehab in the form of intravenous (IV) fluids. If someone receives IV fluids, he should be immediately removed from duty for the remainder of the incident. In many jurisdictions, the administration of IV fluids is also a trigger for the individual’s being transported to a medical facility for further medical evaluation.
FLUID REPLACEMENT AND NUTRITIONAL NEEDS
There are many opinions concerning firefighters’ fluid replacement needs. Some say that water should be used; others advocate sports drinks. Still others say that sports drinks are too concentrated and should be mixed half strength or diluted with water. I am presenting below background information on all three perspectives, since each is correct in its own way.
Water accounts for about 48 percent of the total blood volume. Furthermore, it is 92 percent of the blood plasma, or the liquid part of the blood. It accounts for approximately 60 percent of an individual’s body weight. When the body becomes overheated, it sweats to try and protect itself.
When the body sweats, it loses not only fluids but also electrolytes. These electrolytes are essential for the body’s performance, as different tissues and systems use them. Many are key for proper cardiac function. Others are used for the transmission of nerve impulses in muscle tissue. Without them, or in some cases with too much of them, body performance suffers. We need to remember that as an incident becomes longer and more intensive, we need to think about replacing these electrolytes as well as the fluid volume.
Another substance we use up very quickly is glucose. Glucose is the simplest form of sugar in the body, where it is metabolized as fuel for the cells. The body cannot store glucose except in the blood supply as an immediate but limited source of energy for intensive physical demands. It needs to store it as glycogen in the liver and localized muscle tissue. Glycogen must then be broken down into the simpler form of glucose. This takes time, and when we are overworking our body, we need simple sugars (glucose) for the quick form of energy.
This is similar to what happens in a diabetic patient, although on a lesser scale. EMTs may recognize a problem in that glucose is metabolized and used very quickly. This is evident by the fact that if we give D50 (50 percent dextrose-another simple sugar) to diabetic patients suffering from low blood sugar levels, they will respond very well. Many times, their orientation improves immediately, and they want to refuse further treatment. The risk is that the dextrose will be used up quickly and they could quickly fall back into a coma. We need to ensure that they eat complex sugar, or carbohydrates, to maintain the blood sugar for the long term. The reason we give dextrose is that it can be readily used and is the quick fix. The complex sugars need to be broken down into simple sugars to be used, so they do not have an immediate effect, but they last longer.
The same applies to our firefighters who are physically stressed at an incident. This is very important to remember in early-morning incidents, especially when dealing with volunteer responders. Many have been home in bed all night and have not eaten since early the evening before. Their sugar levels may be at the lower end of the normal range to begin with and may drop to dangerously low levels very quickly. The earliest signs of low blood sugar levels are changes in mental status and possibly the decision-making process. The affected responder may exhibit bizarre behavior, begin to sweat more, and experience an increased heart rate. These signs and symptoms are common when the body is working harder and overheating.
After we have taken all of this into account, we can begin to look at what constitutes effective replenishment for the body. First, we will look at the fluids used for replacement.
Many times agencies will use water. For many incidents, water is ideal. The main point is that we are losing fluid volume in the blood, which inhibits our cooling. By replacing the water lost from the blood, we are replacing that cooling capacity and are also making it easier for the body to maintain blood pressure. Water is easy to obtain, store, and dispense. Water is palatable to most responders, and we don’t have to figure out what brand and flavor everyone on our scenes prefer.
Where we may want to think about something other than water is at incidents that extend beyond one to three hours or through a normal mealtime. In these cases, also consider fluids that contain electrolytes.
Many sports drinks are on the market. They all have benefits and drawbacks. All have some amount of electrolytes and sugar, but many differ in the amount and type of sugar or carbohydrates they contain. Some have artificial colors and dyes, some are designed as a replacement drink, and others recently on the market are marketed as “fitness water.”
When looking at sugars that are in these beverages, we have to go back to simple and complex sugars. The drinks should ideally have a combination of both. Remember that the simple sugars offer the quick form of energy and the complex sugars offer a more sustained source. Of the major brands on the market, about half contain only simple sugars (glucose, sucrose, dextrose, and fructose). Some beverages offer these in combination with complex sugars. They most likely will list a glucose polymer (complex sugar) or maltodextrin on their label.
When looking at carbohydrate content, take into account that we may burn up to 300 to 600 calories per hour. This loosely translates into the need for about 100 grams of carbohydrates. If you look at the nutritional information on the labels, you will see that the drinks provide only approximately 15 to 20 grams of carbohydrates and 50 to 70 calories. The new “fitness waters” are even worse, at 3 grams of carbs and 10 calories. Looking more closely, the manufacturers say that these fitness waters are not marketed as a replacement drink but as a maintenance beverage. Their main use in the fire service would be to encourage personnel who do not like the plain taste of water to drink these while on duty.
The discussion of whether or not to provide sports drinks at full strength comes from looking at their concentrations and osmolarity (in laymen’s terms, a measure of how thick or concentrated a fluid is). A beverage with too high an osmolarity may actually draw fluids out of the cells in an effort to make it less concentrated. We are looking for an osmolarity value of less than 350 mOsm/liter. This value is not listed on the labels, but it should be available from the manufacturers. The sports drinks on the market are all in the neighborhood of this 350-mOsm/liter value.
The other value to look at is the percentage of carbohydrates in a beverage. Ideally, a drink should contain 2 to 5 percent carbohydrates. This information is available on the labels. Again, sports beverages on the market today are at the upper end of this range. If either of these values (osmolarity or percentage of carbohydrates) is above the recommended limits, the common thought is to lower the values by diluting them with water.
The last thing to look at is the other ingredients in the sports drinks. Most contain artificial dyes and artificial flavors. A walk down the beverage aisle of your local supermarket makes this evident. There are several colors in the sports drink section that I don’t think I have ever seen in nature. Tasting them is another clue. Many people I know also mix their drinks 50/50 with water to weaken the flavor in the drinks, as they can be overbearing. I know of at least one sports drink on the market that has neither artificial dyes nor flavors. The drink may not look as impressive on the shelf, but the flavors are actually recognizable and there are no artificial ingredients.
When looking at nutrients, much less information is available. There are three main areas of concern: carbohydrate replacement as a source of energy, protein to supply the essential amino acids, and small amounts of fat for the necessary fatty acids.
 1 Yates County (NY) Fire & Emergency Management¿s solution to long-term incidents: (1) firefighter rehab trailer and (2) mounted Porta-John. (Photos by author.) |
Looking at each individually, carbohydrates are the most important for rehabilitation. They are the source of the sugars we need as a source of energy and are easily metabolized. The molecules are quickly broken down into a form that can be used by the body.
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Proteins, on the other hand, are large molecules, which require more time and an expenditure of energy by the body to break them down into a form we can use. We still need them but in a smaller quantity. They are broken down into amino acids, which are important as we try to maintain essential bodily functions. Proteins are involved in growth and healing, water balance in the blood, and the transport of oxygen, among other things.
Fats and fatty acids are similar to proteins in that the body needs time and energy to use them. The essential fatty acids are available only through diet; the body cannot produce them. They are key in the function of the cardiovascular, reproductive, immune, and nervous systems.
With that in mind, what we provide to our responders becomes important. As an incident extends in duration, especially if it crosses through a regular mealtime, food becomes important. That food should be high in carbohydrates and yet still have protein and some fat. The limiting factors tend to be what facilities are available for preparing and distributing food. Hot food must be maintained warm and cold food kept cool for safety reasons. It should be easy to serve and easy to eat. In talking to members of the New York State Regional Response Team-1 after its response to the World Trade Center site, they talked about food and beverages being plentiful but not easy to eat on the site because responders had to decontaminate and clean up. There is also the issue of what to do with the containers in which the food is served.
The food we serve also needs to be appealing to the people who need to eat it. Energy and sports bars are easy to maintain and store, but they are not the best tasting foods to many people. Avoid spicy foods; they cause heartburn-like discomfort in many people. These effects could mimic the signs or symptoms of cardiac compromise and will make it difficult to assess responders’ health. Fruit is a good source of simple sugars and has the added benefit of a high water content, but it is perishable and does not last in storage. Avoid foods high in sugar or salt because they could have an adverse effect on the body.
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The fire service continues to change and evolve every day. New technology, equipment, and training methods have made the job very different than it was even five years ago. These changes have been for the better.
Unfortunately, economics and society have also changed. Fire chiefs are being asked to do more with less. In most communities, paid and volunteer alike, we are providing more services with fewer people. This means that the firefighters we have are working harder. This makes it all the more important that we educate everyone in the fire service in the everyday risks we face and the methods we can use to decrease those risks. Unfortunately, this is probably going to be a slow change. Many look at rehab as an EMS function, and even though we do not like to admit it, firefighters in many places in the country are reluctant to admit that EMS is part of the fire service. They are also afraid that if they start to use a rehab group on their emergency scenes that it will be viewed as a weakness. Look back 10 to 15 years. You may remember similar arguments about incident command and critical incident stress management. Both have found their place in the fire service today, and it is time that rehab does as well. How much longer must our firefighters continue to die? ■
References
1. Dickinson, Edward T., MD, & Michael A. Wieder. Emergency Incident Rehabilitation; Upper Saddle River, N.J.: Brady/Prentice Hall Inc, 2000, 12.
2. Smith, Denise L., PhD, “Hot Under the Turnout,” Fire Chief, Aug. 2001, 82-88.
