There's a new standard that you need to become familiar with. It's National Fire Protection Association (NFPA) Standard 1584, theStandard on the Rehabilitation Process for Members During Emergency Operations and Training Exercises. The result of years of work by NFPA, it's designed to complement the other standards it has published relating to our safety, fitness and health. The document also reflects the efforts of many fire-service leaders in understanding the physical stress of fire and rescue work, and the leadership of the U.S. Fire Administration (USFA), which recognized the benefit of on-scene recovery of fire personnel and publishedEmergency Incident Rehabilitation in July 1992.
But the adoption of this standard by fire andEMS agencies is more than just acceptance of a standard. It's a department's commitment to developing a safer emergency incident environment and ensuring long careers for its personnel. Incident rehab isn't just about operating safely at a certain scene, but doing so at every physically and environmentally challenging incident throughout the shift.
Establishing Your Rehab Program
There are several types of departments, and every department's operating guidelines must be planned to match relevant hazards with the proper resources to manage them. This planning is typically not an expensive or resource-consuming part of operations. Preplans must include when to implement rehab, where the resources will come from, who will oversee and provide services, and how the paperwork will be managed. The program must be aligned with the scene-management priorities at each type of incident, and the operating guidelines should align rehab with the other elements of incident command.
For smaller departments, implementation of a rehab program is an opportunity for positive mutual aid interaction with neighboringEMS agencies and fire departments. This arrangement will allow adequate resources to be available for all departments in the region. For those departments that don't have internal EMS resources, an interagency agreement with the localEMS provider is another way to develop the program.
The rehab process, protocols and paperwork can be standardized and the necessary equipment and ˙propsÓ purchased and positioned for timely deployment. Some communities have used regional grant sources to assist in the funding of rehab programs, with an assurance that the funding supports safety of the firefighters and service to the community.
Whatever the organization of the resources for the rehab program, the final pathway to implementation is pre-incident training. Appropriate members of the operations leadership team will define when the rehab program is to be initiated on scene. NFPA 1584 suggests this should occur ˙when emergency operations pose the risk of members exceeding a safe level of physical or mental endurance.Ó Although a large number of physical hazards can be addressed for personnel operating at an incident, there's universal concern about the dangers of heat and cold. Therefore, the standard mandates training of those operating the rehab area in the recognition and management of these hazards. Training will need to include the use of equipment and documentation appropriate for the rehab operation.
In establishing your rehab program, it's critical for your agency to also note the need for appropriate rehab during training exercises. The physical dangers are just as acute at training evolutions as with live operations. The staff overseeing training exercises should be particularly skilled at recognizing signs and symptoms of heat and cold stress, and prepared to intervene to prevent a tragedy.
Incident command or other personnel will have authorization to initiate rehab, in line with the department standard operating procedures (SOP). The basis for this operation is contained in another set of NFPA standardsƒNFPA 1500,Standard on Fire Department Occupational Safety and Health Program, and NFPA 1561,Standard on Emergency Services Incident Management System. Under these standards, your personnel can be empowered to initiate rehab when there's recognition that the operation poses a safety or health risk to members. Some fire departments also recognize the use of SCBA as the initiation point for rehab operations, especially if the environment is unusually hot or cold.
The rehab operation is typically overseen by a member of the fire department responsible for the incident. The leadership position can certainly be delegated to other individuals, depending on the nature, length and scope of the incident. This leadership designation must be clear because that individual must have the authority to release or retain members in the rehab area, or even order transport to a hospital for further evaluation. Your preplan should outline decision elements for this responsibility.
There's an important interface with the safety officer at dangerous operations. The rehab process at an incident provides essential personnel safety support by evaluating every working member at the scene and ensuring their physical capability to perform duties. If a rehab officer is ensuring personnel aren't dangerously fatigued, dehydrated or poisoned by carbon monoxide, the safety officer can then focus on the many other hazards at the scene.
The preplan process should include resource needs to set up and manage your rehab area. Many resources can be placed on front-line apparatus. But some pieces of equipment, particularly for large-scale incidents, are better placed in a vehicle that can store and transport them to emergency sites. This equipment includes tents, shelters, chairs, portable heaters, misting fans, and spare clothing and gear.
Incidents that will require days to manage will need to have a rehab area that can be supplied by contracted resources, such as portable toilets, larger tents or shelters, generators and potable water sources. Therefore, it's beneficial to have short-term rental arrangements or pre-arranged purchase orders in place to obtain these assets when they're needed.
A key resource at most emergency incidents is water. It's needed for drinking, cooling and cleaning. It's usually an advantage to use domestic water for operations, if local residents or businesses will supply it. Water from tanks on fire equipment shouldn't be considered safe for drinking, and may be too warm or too cold for other needs. Domestic water, obtained through a simple garden hose, is a better resource.
Once the rehab area is set up, personnel should immediately work on meeting the key objectives of NFPA 1584:
> Relief from climate conditions;
> Rest and recovery;
> Active and/or passive cooling or warming as needed for incident types and climate conditions;
> Calorie and electrolyte replacement, as appropriate, for longer duration incidents;
> Medical monitoring;
> Member accountability; and
> Release from rehab to return to duty.
Warm conditions generate the need for extra hydration, shelter from sun, prevention of burns due to hot asphalt, and cooling therapies. Hot weather conditions often reduce firefighters' appetites and make turnout gear feel like a furnace. On the positive side, smoke often lifts better in warm air, as does vehicle exhaust.
In a brush or wildfire, cooling capabilities are often needed. Shaded areas and sun block are necessary in prolonged sunshine, as are the protective measures against insect stings, poison ivy and falls.
Cold weather, especially when mixed with precipitation, such as snow, rain or sleet, creates some of the most dangerous firefighting conditions. Cold-weather operations produce the need for wind shelter, relatively smaller amounts of fluid, more calories, and thawing heaters for gear. Rehab must be located away from vehicle exhaust, because low temperatures tend to keep exhaust close to the ground.
Medical monitoring at prolonged incidents involving cold weather should include frostbite checks. Cold conditions in humans create a physiologic response that results in increased urination. So, during long operations in the cold, don't forget to arrange for bathroom facilities.
Key rehab support equipment may include dry socks and boots. Walking areas around the scene must have a continual evaluation for ice. Slips and falls are a high risk, with a real potential for broken limbs and serious back injuries. Salt or sand to treat walking surfaces is an essential supply. When you see public works crews using ice-dissolving or retardant material to prevent roadway crashes, think of the need for the same material on the ground around your incident scene.
Departments may benefit from the development of simple decision worksheets for those who will oversee rehab (seeTable 1 pg 109).
NFPA 1584 calls for a minimum of BLS care available at incident scenes, and resources for transport if they're needed. Personnel performing the medical monitoring should evaluate all working members for symptoms suggestive of a health or safety concern at two pointsƒwhen they enter the rehab process and prior to releaseƒto ensure there are no obvious indications that they aren't capable of performing full-duty activities.
The standard also specifies thatEMS personnel performing medical monitoring should assess for:
> Chest pain, dizziness, shortness of breath, weakness, nausea or headache;
> General complaints such as cramps or aches and pains;
> Symptoms of heat or cold-related stress;
> Changes in gait, speech or behavior;
> Alertness and orientation to person, place and time; and
> Abnormal vital signsƒthe specific vital signs and what defines abnormal is to be defined by the department medical authorities. The appendix lists the vital signs that typically are used in assessingEMS patients or athletesƒtemperature, heart rate, respiratory rate, blood pressure, pulse oximetry and carbon-monoxide levels.
You can remember the necessary elements of the medical monitoring through use of the mnemonic ˙Vital Aches.Ó
>Altered mental status
>Carbon monoxide (assessed using either an exhaled breath CO monitor or a pulse CO-oximeter)
>Heat or cold stress
>Stroke-like symptoms (changes in gait, speech or behavior)
If you conduct regular physicals on your personnel or offer physical training programs, it's possible to utilize the parameters obtained from stress testing to assist in rehab. Integration of existing physiologic data on the individual EMT or firefighter, particularly how their heart rate and blood pressure respond during exercise, will allow the member and EMS providers to understand that particular individual's level of exhaustion, and the potential for them to do further work. Not all departments will have this data, but those that do can customize the work evaluation based on known elements of the person's physiology.
Because hot climates lead to particularly dangerous conditions for firefighters and other emergency personnel, NFPA 1584 has recommendations in the appendices related to recognition of heat dangers, including new methods of calculating heat stress. It may be beneficial for departments to develop specific guidelines for rehab operations during hot conditions (seeTable 2, p 115).
The rehab branch will need to utilize the department's accountability system for tracking members entering and leaving the area. The responsibility for release resides withEMS rehab personnel. The standard dictates use of a time-in/time-out documentation process for crews or individual members, and offers samples of these simple documents for departments to use as a template.
A more complex set of operations will take place when members are injured or ill and require further assessment and treatment. When this occurs, the department's standard medical protocols will be followed and care for the individual will occur and be documented appropriately.
When a person in rehab becomes a patient, it's the responsibility of the manager of the area to ensure adequate care and mobilize transportation resources. The appendix to the standard suggests ALS care be available, if possible. For high-risk operations, where hazmat operations will be conducted and/or ongoing risks to the public are presented, it's appropriate to have ALS resources participating in rehab operations, keeping some ALS personnel available to manage other ALS needs on scene.
Initial assignedEMS crews have multiple duties, such as to triage civilian casualties, transport injured or ill civilians, assist the public information officer in developing community messages and help establish the rehab area.
All personnel who receive medical care will need a patient-care report completed for their employee health record, as well as for their health-care providers. Other documentation necessary upon completion of rehab operations includes:
> A report that verifies that the medical monitoring process was conducted;
> Verification reports that rehab supplies were used;
> Any forms required by incident command; and
> Verification that rehab supplies were restocked for the next incident.
It may be appropriate to notify command or company officers about the needs for members to continue re-warming, drinking fluids, or cleaning and drying equipment before returning their unit to full service.
The Future of Rehab
Structured rehab programs are a big step to preventing acute injuries and the fatigue or thirst that causes judgment errors. NFPA 1584 will change the nature of managing fire incident personnel and increase the safety of firefighters and other emergency responders who work at an incident. It presents a prime opportunity for us to develop important practices in our departments that will produce healthy retirees.
The scientific evidence behind the standard will continue to increase. Some departments are developing research programs to investigate physiologic responses to fireground activities. These will add to our knowledge of safe incident practices, improved methods for rest and revitalization, and reductions in injuries related to scene operations. We need these elements to build research programs for lifelong safety and member health improvements.
All agencies should post a copy of the 32-page standard in their station and use the appendix for sample guidelines, heat index and wind-chill charts, and training materials. You can purchase the document atwww.nfpa.org.
James J. Augustine, MD, FACEP,serves as medical director for many fire services in the Atlanta area, including the Atlanta Fire-Rescue Department and Airport Division of Atlanta Fire at Hartsfield Jackson Atlanta International Airport. He's a clinical assistant professor of emergency medicine at Wright State University in Dayton, Ohio. His firefighting and EMT-A experience extends back 27 years. He's also on the editorial board forJEMS.Resources
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