EMS OPERATIONS ON THE FIREGROUND
FIRE SERVICE EMS
Emergency medical services are included as a routine element of most dispatch assignments for fire responses. Unfortunately, most fireground operational plans relegate the EMS crews to “standing by” in case of civilian or firefighter injury. This is a waste of an important fireground resource and overlooks the need to address an important firefighter safety and health issue.
The physical and mental demands associated with firefighting and other emergency operations, coupled with the environmental dangers of extreme heat and humidity or extreme cold, create conditions that can have an adverse impact on the safety and health of the individual emergency responder. Members who are not provided with adequate rest and rehydration during emergency operations or training exercises are at increased risk for illness or injury and may jeopardize the safety of others on the incident scene. When emergency responders become fatigued, their ability to operate safely is impaired. As a result, their reaction time is reduced and their ability to make critical decisions diminishes. Rehabilitation is an essential element on the incident scene to prevent more serious conditions such as heal exhaustion or heat stroke or even death from occurring.
The perfect mix of these two situations is to have the EMS responders establish a rehab area and work toward preventing injuries to firefighters and other emergency responders rather than waiting for them to happen. The EMS personnel become an integral part of the incident operations, and a secondary benefit is improved relations between fire and EMS personnel.
THE NEED FOR REHAB
Recent studies have concluded that a properly implemented fireground rehabilitation program will result in fewer accidents and injuries to firefighters. One such study, conducted by the National Institute for Occupational Safety and Health, came as the result of the heat stroke death of a firefighter in Sedgwick County, Kansas, in 1990. Other studies have shown that responders who are given prompt and adequate time to rest and rehydrate may safely reenter the operational scene, which may reduce the requirement for additional staffing at an incident.
The need for an emergency incident rehabilitation program is also cited in several national standards. NFPA 1500. Standard on Fire Department Occupational Safety and Health Programs, and NFPA 1561. Standard on Fire Department Incident Management Systems, address the need for appropriate rehabilitation during emergency operations.
The need for rehabilitation at a specific incident should be considered by staff officers when developing an incident action plan. However, the climatic or environmental conditions of the emergency scene should not be the sole justification for establishing a rehab area. Any activity/incident that is large in siz.e. long in duration, and/or labor-intensive will rapidly deplete the energy and strength of personnel and therefore merits consideration for rehabilitation.
A climatic or environmental condition that indicates the need to establish a rehab area is a heat stress index above 90“F (according to a heat index chart) or a windchill index below 10″F (according to a windchill chart).
DEVELOPING A REHAB PROGRAM
Developing an emergency incident rehab program for a department is relatively easy and can be done very inexpensively. It is important for your members, but remember that most departments have automatic or mutual-aid agreements and respond regularly with other departments. Therefore, it is also important to work with neighboring departments when planning for rehab and when establishing procedures and guidelines to be used at emergency operations and training evolutions. Remember, when the “chips are down.” it is too late to just be figuring out how to do rehab. The procedures must be in place, the equipment ready, and the people trained.
So, how does a department develop a rehab program? The United States Fire Administration (USFA), in an effort to reduce the incidence of emergency responder injury and death, has developed a sample Emergency Incident Rehabilitation Standard Operating Procedure (SOP). This SOP outlines the responsibilities of incident commanders, supervisors, and personnel: identifies the components of rehab area establishmerit: and provides rehabilitation guidelines. A sample Emergency Incident Rehabilitation Report form, as well as a heat index chart and windchill chart, are also included. Much of the information in this article was derived from the USFA rehab SOP.
(Photo courtesy of Phoenix Fire Department.)
(Photos courtesy of Longmeadow Fire Department.)
(Photo courtesy of Phoenix Fire Department.)
SETTING UP A REHAB AREA
Rehab needs to be considered at all emergency operations and training exercises where strenuous physical activity or exposure to heat or cold exists. These can include structure, vehicle, and wildland fires; mass casualty or other major EMS incidents; lengthy or labor-intensive extrications; hazardous-materials incidents; and all types of training evolutions. These might occur in rural, suburban, or urban areas anywhere in the country.
The incident commander must consider the circumstances of each incident and make adequate provisions early in the incident for rest and rehabilitation for all members operating at the scene. These provisions should include medical evaluation, treatment and monitoring, food and fluid replenishment, mental rest, and relief from extreme climatic conditions and the other environmental parameters of the incident.
The incident commander should establish a rehabilitation sector or group when conditions indicate that rest and rehabilitation are needed for personnel operating at an incident scene or training evolution. A member, to be called the rehab officer, will be placed in charge of the sector/group. This can (and perhaps should) be the person in charge of the EMS crew.
The rehabilitation area should include dedicated EMS personnel at the basic life support level or higher: a separate EMS unit should stand by in case of injuries at the scene. Some departments assign one ambulance and its crew to the rehab area and another to the fireground: others assign a crew of EMS-trained firefighters to rehab, while the ambulance and crew assist them as they stand by in case of fireground injuries.
The location of the rehab area normally is designated by the incident commander. Otherwise. the rehab officer should select an appropriate location based on site characteristics. The site should
- be in a location that will provide physical rest by allowing the body to recuperate from the demands and hazards of the emergency operation or training evolution;
- be far enough away from the scene that members may safely remove their turnout gear and SCBA and be afforded mental rest from the stress and pressure of the emergency operation or training evolution;
- provide suitable protection from the prevailing environmental conditions. During hot weather, it should be in a cool, shaded area. During cold weather, it should be in a warm, dry area;
- enable members to be free of exhaust fumes from apparatus, vehicles, or equipment (including those involved in the rehab sector/group operations):
- be large enough to accommodate multiple crews, based on the size of the incident:
- be easily accessible by EMS units; and
- allow prompt reentry back into the emergency operation upon complete recuperation.
The rehab area itself can lx in just about any type of setting, such as
- a nearby garage, building lobby, or other structure;
- several floors below a fire in a high-rise building;
- in a school bus. municipal bus, or bookmobile;
- in fire apparatus, ambulance, or other emergency vehicles at the scene or called to the scene; or
- perhaps most commonly, in an open area in which a rehab area can be created using tarps, fans, etc.
In some departments, a retired piece of fire apparatus or a surplus government vehicle has been renovated as a rehab unit. This unit responds on request or is dispatched during certain weather conditions.
Once the location of the rehab area has been determined, the rehab officer should secure all necessary resources required to adequately staff and supply the rehab area. The equipment and supplies should include
- fluids—water, activity beverage, oral electrolyte solutions, cups, and ice:
- medical equipment—blood pressure cuffs, stethoscopes, oxygen administration devices, cardiac monitors, intravenous solutions. and thermometers;
- other supplies and equipment—awnings, fans, tarps. smoke ejectors, heaters, dry clothing, extra equipment, floodlights, blankets and towels, traffic cones and fireline tape (to identify the entrance and exit of the rehab area), and chairs or five-gallon pails with shelfboards or backboards (to sit on); and
- food, such as broths or soups, and fresh fruit also may be needed for long-term incidents or those that will extend past a regular mealtime.
FLUIDS AND FOOD
A critical factor in the prevention of heat injury is the maintenance of water and electrolytes. Water must be replaced during exercise periods and at emergency incidents. During heat stress, the member should consume at least one quart of water per hour. The rehydration solution should be a 50/50 mixture of water and a commercially prepared activity beverage and administered at about 40‘T. Rehydration is important even during cold weather operations where, despite the outside temperature, heat stress may occur during firefighting or other strenuous activity when protective equipment is worn. Avoid alcohol and caffeine beverages before and during heat stress because both interfere with the body’s water-conservation mechanisms. Avoid carbonated beverages as well.
The department should provide food at the scene of an extended incident when units are engaged for three or more hours. A cup of soup, broth, or stew is highly recommended because it is digested much faster than sandwiches and fast food products. In addition, foods such as apples, oranges, and bananas provide supplemental forms of energy replacement. Avoid fatty and/or salty foods.
WORK-T0-REST RATIO
The “two-air-bottle rule,” or 45 minutes of worktime, is recommended as an acceptable level prior to mandatory rehabilitation. Members should rehydrate (at least eight ounces) while SCBA cylinders are being changed. Firefighters having worked for two full 30-minute-rated bottles, or 45 minutes, should be immediately placed in rehab for rest and evaluation. In all cases, the objective evaluation of a member’s fatigue level should be the criterion for rehab time. Rest should not be less than 10 minutes and may exceed an hour as determined by the rehab officer. Fresh crews, or crews released from the rehab area, should be available in the staging area to ensure that fatigued members are not required to return to duty before they are rested, evaluated, and released by the rehab officer.
Members in the rehab area should maintain a high level of hydration. Members should not be moved from a hot environment directly into art air-conditioned area because the body ‘s cooling system can shut down in response to the external cooling. An air-conditioned environment is acceptable after a cool-down period at ambient temperature with sufficient air movement. Certain drugs impair the body’s ability to sweat, so members who have taken antihistamines, such as Actifed® or Benadryl®; diuretics; or stimulants should use extreme caution.
EMS REHAB GUIDELINES
EMS in the rehab area should be provided and staffed by the most highly trained and qualified EMS personnel on the scene (at a minimum of BLS level). They should evaluate vital signs, examine members, and make proper disposition (such as return to duty, continued rehabilitation, or medical treatment and transport to a medical facility). Remember, these members are being evaluated in a preventative manner, so they aren’t considered patients unless they indicate signs and/or symptoms of a medical problem. (Think of it as taking a citizen’s blood pressure at the station.) Provide medical treatment in accordance with local medical control procedures for members whose signs and/or symptoms indicate potential problems. EMS personnel should be assertive in an effort to find potential medical problems early.
Criteria for EMS personnel to use when evaluating members in the rehab area are heart rate and temperature. The heart rate should be measured for 30 seconds as early as possible in the rest period. If a member’s heart rate exceeds 110 beats per minute, take an oral temperature. If the member’s temperature exceeds 100.6‘-F, do not allow him to wear protective equipment. If it is below I00.6″F and the heart rate remains above 110 beats per minute, increase rehabilitation time. If the heart rate is less than 110 beats per minute, the chance of heat stress is negligible.
Record all medical evaluations on standard forms, along with the member’s name and complaints, if any. The rehab officer or a designee must sign. date, and note the time on the form.
ENSURING ACCOUNTABILITY
To ensure proper accountability, members sent to rehab should enter and exit the rehab area as a crew. The rehab officer or a designee should document the crew designation. number of crew members, and times of entry to and exit from the rehab area on the company check-in/out sheet. Crews should not leave the rehab area until authorized to do so by the rehab officer.
PUBLIC PERCEPTIONS
One concern often expressed by chief officers is the impression that a rehab area may make on the public. One way to ensure that the public won’t get the wrong idea about “all the firefighters sitting around while the building bums’” is to address it up front by educating the public about rehab. Let the media highlight your rehab program when you implement it or the first time you use it at an incident
EMS personnel should not be a wasted commodity by being a “stand-by” element at a fire scene. While having EMS personnel available in case of a civilian or firefighter injury is important, preventing these injuries is just as important. EMS personnel assigned to the incident are in a perfect position to serve in this role.
An emergency incident rehabilitation program can be established in any department with minimal impact on human, fiscal, and equipment-related resources. A successful rehabilitation program will improve the morale of the department and increase the level of productivity. It fits into the framework of the incident management systems used by most fire departments, emergency medical services, hazardous-materials response teams, and special rescue teams across the country. Most important, it increases the level of safety provided to emergency responders.
The views expressed in this column are strictly those of the author and do not necessarily reflect those of the US. Fire Administration or the Fairfield Community Fire Company.
All of this information on rehab is spelled out in the USFA publication Emergency Incident Rehabilitation. To get a copy free of charge, send a request on department letterhead, asking for USFA publication #FA-114. to;
USFA Publications Post Office Box 70274 Washington. DC 20472
