Once in a while, fate knocks us off our feet when we realize we may have dodged a bullet. Successfully managed large-scale incidents, like the crash of United Flight 232 in„Sioux City,„Iowa, come to mind. Emergency responders in the„Sioux City region had practiced and prepared for major aircraft disasters only months prior to that incident. Their timing couldn't have been better, and their training and quick actions helped save 185 lives.
Smaller-scale incidents can have a similar lasting effect on a local area. On an unseasonably hot day in 2005, a major downtown fire broke out in the small community of„Vinton,„Iowa. The primary„EMS response agency had struggled to convince some responders of the need for firefighter rehab operations for more than a year. Luckily, their preparation and training paid off on this day and undoubtedly assisted in saving lives and property.
Vinton has a population of roughly 5,500. It's the county seat and largest city in„Benton„County, which has a total population of approximately 25,000. The Vinton Fire Department (VFD) consists of 25 well-trained volunteers who respond to approximately 80Ï90 emergency calls annually, which are primarily structure and grass fires, and motor vehicle collisions.
North Benton Ambulance is a non-fire-based ambulance service with a private, non-profit status. Founded in 1970, the agency consists of 25 volunteers and one full-time director/paramedic. The volunteers are a combination of EMT-basics, EMT-intermediates and paramedics. The agency operates two ambulances and serves as the primary transport service for Vinton and several smaller communities within a 200-square-mile response area.„North Benton typically responds to approximately 700 calls each year.
The Birth of a Rehab Program
For many years, North Benton Ambulance automatically responded as standby to all structure fires within the VFD's district as a safety precaution. However, firefighter rehab operations weren't conducted unless a firefighter experienced severe fatigue or injury.
Historically, the VFD Auxiliary had consisted of firefighter spouses who provided canteen services to the department. Around 2002, the Auxiliary dissolved and was no longer a regular part of the fire department's response effort.
During a four-hour, cold weather house fire in October 2003, North Benton and Vinton Fire personnel began to realize the full potential and need for regular rehab operations at major incidents. So North Benton Ambulance staff began researching the topic and developed a rehab procedure that was approved and adopted by both agencies.
North Benton also assembled a rehab kit. The kit included additional O regulators, non-rebreather masks, cups, fruit snacks, granola bars, sports drink mix, hot and cold packs, and a three-ring binder that included rehab log sheets, guidelines and procedures.
North Benton personnel also procured water coolers, folding chairs, bottled water, and a portable shelter for use during rehab operations, and began to obtain and maintain records of baseline vitals for all Vinton Fire personnel.
After the 2003 incident,„North Benton began providing formal rehab services for VFD and other agencies, and conducted rehab at 10Ï12 incidents over the next two years. During these smaller, two- to four-hour incidents,„EMS crews practiced their operations as they conducted rehab along the street, in the back of an ambulance or in residential garages. Some firefighters were initially slow to accept the need for rehab services, particularly those who were denied permission to re-enter the fire scene after assessment by„EMS revealed vital signs outside normal limits.
In May 2005, North Benton Ambulance hosted its first formal firefighter rehab training. Chief Mike Nesslage, FF/EMT-P, of the Hiawatha (Iowa) Fire Department, conducted the class. Nesslage gave„North Benton personnel high marks on the steps they had taken to establish a rehab program and also provided them with additional ideas for improvement, particularly regarding patient assessment. As it turned out, this formal training was received just in time.
And So It Begins
On Friday, Sept. 9, 2005, the American Legion Post 57, located in downtown Vinton, was preparing for an annual fish fry. Like many„Iowa towns, downtown Vinton consists of numerous buildings constructed circa 1900 and built adjacent to each other. The temperature was around 86_F with a south-southeast wind.
At approximately 3 p.m., a grease fire started in the kitchen of the Legion Hall and quickly spread throughout the old building. Legion members made a call to 9-1-1, and the VFD, Vinton Police Department and North Benton Ambulance were dispatched.
When the call came in, VFD was understaffed due to the time of day and the attendance of several members at a state firefighter convention. Fortunately, fire command personnel quickly recognized the severity of the situation and requested mutual aid. Nine area fire departments were dispatched to help VFD, including two aerial trucks from departments 30 miles away.
Command personnel from all disciplines believed losing an entire city block of downtown Vinton was a likely possibility. An estimated 2,000 onlookers crowded the streets and sidewalks, and business owners rushed to salvage items from adjacent stores and offices.
The first North Benton EMS unit to arrive on scene carried an EMT-B and a paramedic. This crew quickly realized the potential scope of the incident and requested their second ambulance be dispatched. At 3:34, an ˙all callÓ page was put out for all available„North Benton personnel to respond and assist the two units on scene.
Dr. Mark Dearden,„North Benton's medical director, and the Benton County Emergency Management Agency also responded to assist at the scene. The area chapter of the Red Cross responded, although their support was somewhat hampered by ongoing Hurricane Katrina response efforts.
Rehabilitation & Canteen
Due to the size of the incident area,„North Benton personnel established two separate rehab areas. Rehab Area One was located approximately one block southwest of the fire scene, and Rehab Area Two was located one block southeast. At the height of the incident, each rehab area was handling 10Ï15 firefighters. Personnel were assessed; vitals were taken; treatment was provided when necessary; food, water and sports drinks were supplied; and wet towels were distributed to lower the temperature of overheated firefighters.
The rehab areas initially consisted of only two personnel. Area One was eventually commanded by the service director/paramedic and included three EMTs, two additional paramedics and several civilian volunteers. Area Two was eventually commanded by an EMT and was ultimately staffed by three EMTs, two paramedics, five civilian volunteers and five support personnel from other agencies.
Civilians provided an invaluable service to each rehab area, particularly during the early stages of the incident when additional„North Benton personnel were in short supply. Civilians primarily performed recordkeeping and fluid and towel distribution.
While„EMS personnel were focusing on rehab, the community responded without request, providing food, drinks and supplies to keep the personnel functioning. Grocery and convenience stores donated bags of ice, bottled water and sports drinks. Restaurants provided countless pizzas, hamburgers, sandwiches and chicken dinners. Some citizens provided home-baked goods, such as cookies and breads, as well as tables and chairs for the rehab areas.
Despite the nearly 150 emergency responders and 2,000 onlookers on scene, only two patients were treated for illness or injuries. One firefighter collapsed from fatigue and heat exhaustion. The second patient was a civilian volunteer who had also succumbed to heat exhaustion after spending three to four hours moving around and distributing water, ice and towels to firefighters in the rehab area. Both patients were rapidly assessed and treated by„North Benton paramedics and the medical director/physician. The patients never lost consciousness, and each refused transport.
Many fire personnel on scene from other departments had little, if any, previous knowledge or experience with personnel rehabilitation and were slow to rotate crews out of service. At the height of the incident, one exhausted firefighter, known to suffer from high blood pressure, was operating pump controls and refused to leave his engine in order to rehab. When„North Benton personnel became aware of his condition, two EMTs took rehab equipment to his location, monitored vitals and convinced him to sit and rest at his engine until his vital signs normalized.
The Final Numbers
As the fire operation continued, the fire and associated damage was contained primarily to the Legion Hall, which was a total loss. By the time the fire was out, the City of„Vinton had only about 45 minutes of water left in its water system, and crews were preparing to draw directly from a nearby river. All personnel and apparatus were back in service by 9:30 p.m., despite the early prediction that the incident would continue through the night.
By the end of this incident, at least nine fire departments were on scene with an estimated 125 firefighters. Two law enforcement agencies provided seven police officers. Representatives of at least five EMS agencies were on scene, with an estimated staff of 25„EMS personnel.
During the initial stages of the incident, recordkeeping of rehab operations was poor until the areas were well established with adequate personnel. Crew members estimated 80Ï90 firefighters were processed through rehab; however, some firefighters were processed multiple times during this six-and-a-half hour incident.
In addition to fire personnel, civilian volunteers and„EMS personnel were also rotated out of service for short breaks and fluid/food replenishment. Law enforcement personnel were unable to leave their positions at key intersections, so civilian volunteers were directed to take food and water to them.
The„EMS response to this incident was deemed an overall success by those involved. Senior officials from all disciplines agreed the rehab operation was an invaluable part of the response and kept personnel safe and alert, thereby helping to save additional property from destruction.
Many fire departments that assisted at this major incident had never experienced a dedicated rehab sector in operation. As a result of this incident, many began instituting their own rehab response to incidents and received training on the topic. Additional discussions have included the possible creation of a countywide incident rehab response capability, including a dedicated vehicle and expanded rehab equipment.
In the months that followed, several areas were identified that worked well or needed improvement in the overall response to this incident.
What Worked Well
Basic training and understanding of rehab operations:„EMS and the local fire department had trained and practiced rehab operations.
Incident command:„ Each discipline was well organized and well commanded.
Rehab command personnel of lower certification levels:„ Lower certifications were capable of handling command responsibilities, freeing paramedics for assessment and care.
Medical director/physician on scene:„ These personnel added to our assessment capabilities.
Rehab of the ˙rehabÓ crews:„ On-scene personnel realized the rehab staff also needed rest and rehydration.
What Needed Improvement
A more unified incident command:„ A centralized command post might have resolved some failures in communication between disciplines operating at three different locations.
Crowd and traffic control:„ Crowds were often within 50 yards of the fire and interfered with operations, which may have been resolved with a greater law enforcement presence.
Training:„ The need for additional incident command and rehab training for some agencies was apparent. Fire commanders and individual firefighters need to be responsible for rotating crews to rehab.
Separation of EMS and rehab sectors:„EMS can assist in the rehab area, but they must be designated and available for personnel emergencies, so they're not trapped into staffing the rehab area.
Mutual aid:„ This could have been requested for rehab support.
Freelancing personnel:„ Non-dispatched agencies responded. A few„EMS personnel knowingly and unnecessarily put themselves in dangerous areas without the use of proper PPE.
Food/water/supplies:„ Preplanning for supplying food, water and other necessary provisions would help reduce the dependence on citizen support. Food should consist of soup and other easily digestible items. Personnel should prepare for the possibility of multiple simultaneous rehab operationsƒurban or rural, in cold or hot temperatures, rain or shine. Preplanning must also actively include other support organizations, such as fire auxiliaries.
Firefighters and other responders aren't typically as fit as professional athletes, but they often believe they're capable of physical activity even beyond that of professional athletes. Athletes train several days a week in both physical fitness and job-specific skills. They have a set schedule of games and can mentally and physically prepare for months ahead of time. They eat right, get a good night's sleep and stretch thoroughly before a game. The team's doctors and trainers constantly look out for their health and ensure they hydrate regularly. And they spend only 60 minutes in actual play.
On the other hand, firefighters and other emergency responders are often in poor to average physical condition, don't train daily and are never certain what day or time they may have a call. They often eat poorly, don't get enough sleep and have no time to stretch before beginning physical exertion. And a call can last for hours as they operate in dangerous conditions where lives hang in the balance. With this in mind, all emergency response agencies should support the establishment and operation of rehab sectors at major incidents.Too often in public safety, personnel and administrators believe they responded well simply because no one was hurt or exhibited ill effects. These shortsighted individuals fail to examine their tactics and learn from their mistakes. Eventually, fate catches up with them, and someone gets hurt needlessly. For North Benton Ambulance, Vinton Fire Department and numerous other agencies, this incident was a reality check that convinced many of the value of a quality personnel rehabilitation program.