EMERGENCY INCIDENT REHABILITATION

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EMERGENCY INCIDENT REHABILITATION

• Mason County Emergency Medical Services
• Douglas Richardson, EMT-P

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Objectives

• Define rehabilitation in context to emergency
  workers.
  
• Discuss the importance of rehabilitation to the
  fire and emergency services.
  
• Understand situations warranting, and criteria
  for initiating rehabilitation.
  

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Objectives

• Discuss the impact of Heat Stress on emergency
  workers.
  
• Discuss the impact of Wind Chill on emergency
  workers.
  
• List criteria for the appropriate placement of a
  rehabilitation area.

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Objectives

• List five (5) reasons to send emergency workers
  for medical evaluation.
  
• List four (4) criteria that should be meet before
  emergency workers are allowed to return to duty.
  

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Objectives

• List two (2) reasons for not allowing injured
  emergency workers to return to active duty.
  
• List ten (10) reasons to transport emergency
  workers to an appropriate hospital for further
  evaluation.

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Objectives

• Discuss the physiological consequences of fluid
  loss.
  
• Define osmolarity and discuss the importance of
  osmolarity in the rehydration of fire / rescue
  personnel.

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What is Rehab and Why Do We Need It?
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Background To Rehab

• For many years the fire service has treated the
  element of job-related danger as a badge of
  courage, worn with pride. Firefighters would
  boast of this element of danger when discussing
  the merits of various occupations.

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Background To Rehab

• In the last 20 years or so, however, the attitude
  of the fire service toward safety has changed
  dramatically. Firefighters and department
  officials began to realize that needless deaths
  and injuries of firefighters were not badges of
  courage but indicators of problems.

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Background To Rehab

• If firefighters are extended beyond their safe
  operating periods, the results may be
  
• Stress- or fatigue-related illness or injury
• The Firefighter, although uninjured, will be
  fatigued to a point at which he/she is unable to
  continue in the operation
  
• The mentally and/or physically fatigued
  firefighter may make poor decisions in a
  high-risk environment

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What Is Rehab?

• In the Emergency Services, rehabilitation, or
  rehab, describes the process of providing rest,
  rehydration, nourishment, and medical evaluation
  to responders who are involved in extended and/or
  extreme incident scene operations.

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What Is Rehab?

• Note that Rehab operations are not limited to
  emergency scenes. Other type of activities that
  might necessitate Rehab include
  
• Training exercises
• Athletic events
• Parade or event standbys

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Why Do We Need Rehab

• Over 50 of all firefighter deaths are to some
  extent, directly attributed to stress and
  overexertion.

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The Functions Of A Rehab Operation

• Physical assessment
• Revitalization (rest, rehydration, and
  nutritional support)
  
• Medical evaluation and treatment
• Continual monitoring of physical condition
• Transportation for those requiring treatment at a
  hospital

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The Functions Of A Rehab Operation

• Initial critical incident stress assessment and
  support.
  
• Reassignment

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The Functions Of A Rehab Operation
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Physical Assessment

• General physical assessment
• Basic vital signs
• Medical evaluation
• Revitalization
• Reassignment

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Revitalization

• Rest
• An adequate amount of time for core temp and
  vital signs to return to normal.
  
• Fluid replenishment
• Provided with appropriate fluid to replace those
  lost
  
• Nutrition
• Should receive nutritionally sound food

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Medical Evaluation and Treatment

• Firefighters who appear ill or injured should be
  assigned to personnel in the medical
  evaluation/treatment area for rehab
  
• This should not be delayed by providing with
  drinks/food unless the medical evaluation shows
  this to be a priority.

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Continual Monitoring of Physical Condition

• Firefighters in the rehab area should have their
  condition continual monitored.
  
• Firefighters who meet the criteria for release
  from rehab should be reassigned or released from
  care
  
• Firefighters who do not respond to rest or
  medical attention may require more intensive
  interventions.

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Continual Monitoring of Physical Condition

• No one should be released from rehab until he/she
  is medically sound or,
  
• Is transported to a medical facility for further
  treatment.

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Knowing When To Establish Rehab
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Knowing When To Establish Rehab

• The goal of emergency incident rehab operations
  is to lessen the risks of injury that may result
  from extended operations, which are sometimes
  carried out in adverse conditions, involving
  weather and other factors.

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Knowing When To Establish Rehab

• Ideally, rehab operations should commence
  whenever emergency operations pose a risk of
  pushing personnel beyond a safe level of physical
  and mental endurance.

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Knowing When To Establish Rehab

• Extended fire incidents
• Hazardous Material Incidents
• Prolonged rescue/recoveries
• Adverse weather conditions
• Crime scene/standoffs
• Search activities

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Extended Fire Incidents

• Structure Fires
• High-rise structural fires
• Wildland fires

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Weather Conditions

• Hot-Weather
• Ambient temperature
• Relative Humidity
• Direct Sunlight
• Cold-Weather
• Ambient temperature
• Wind chill factor

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Hot-Weather

• Even under the ideal climatic conditions,
  fires, hazmat incidents, and rescue operations
  place a variety of thermal stresses on the
  responders operating at them.

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Hot-Weather

• Emergency responders must frequently perform
  heavy physical labor in heated atmospheres, while
  wearing bulky protective clothing. In those
  ideal conditions when the responders have
  completed their assignments they go to a safe
  area such as rehab to remove their clothing and
  cool down.

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Hot-Weather
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Hot-Weather

• Ambient air temperature and relative humidity can
  be factored together to create what is often
  referred to as a Heat Index
  
• Working in direct sunlight can add 10ºF to the
  heat index.
  
• Working in full turn-out gear can add an
  additional 10ºF to the heat index.

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Injuries Associated with Heat Stress Index
Conditions
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Heat Stress Index

• The USFA (United States Fire Administration)
  recommends that rehab operations be initiated
  whenever the heat stress index exceeds 90 ºF (32
  ºC).

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Cold-Weather Conditions

• Often overlooked when determining the need for
  rehab operations are the effects of cold weather
  on responders who must operate in low-temperature
  conditions for long periods of time.

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Cold-Weather Conditions

• Cold weather poses different rehab challenges to
  emergency responders then the warm-weather
  scenarios talked about earlier. The potential
  threat to the well-being of the emergency workers
  from them, however is just as great.

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Cold-Weather Conditions

• An emergency worker insufficiently protected
  against the cold may have his/her bodys core
  temperature lowered to dangerous levels under
  extreme circumstances. This condition is referred
  to as hypothermia.

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Cold-Weather Conditions

• The most common cold-weather related injuries
  among emergency responders are localized cold
  injuries, commonly called frostnip or frostbite.
  These injuries occur when particular parts of the
  body are exposed to extreme cold for extended
  periods of time.

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Wind Chill

• Just as heat and humidity combine to increase the
  impact of heat, cold and wind combine to impact
  the effects of cold upon the human body.
  
• The combined effect of cold and wind is referred
  to as the Wind Chill Factor.

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Wind Chill Factor

• The USFA (United States Fire Administration)
  recommends initiating rehab operations whenever
  the wind chill factor drops to 10ºF (-12º C) or
  lower.

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Other Situations Where Rehab May Be Necessary

• Crime scene/standoffs
• Search activities
• Public events
• Training events

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Crime Scene / Standoffs

• Bomb squad members who have been operating for
  long periods of time in heavy protective
  clothing.
  
• Police tactical unit teams who have been
  operation in forward positions for a long period
  of time.

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Search Activities

• Large area searches for person(s) who have
  wandered away from their home.
  
• Urban search and rescue (USAR) incidents
  following a natural or manmade disaster, such as
  a structural collapse.
  
• Searches for climbers, hikers, or others involved
  in sports or recreation activities.
  

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Public Events

• Fairs, carnivals or other festivals
• Auto Races
• Parades
• Concerts
• Major sporting events
• Political rallies
• Large-scale religious ceremonies

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Establishing and Managing A Rehab Area

• The first five minutes of an incident can dictate
  the outcome of the next five hours.

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Establishing and Managing A Rehab Area

• Once the need for a rehab has been established
  the most important decision and one that must be
  made almost immediately is where to locate the
  rehab operations.
• Making a good initial choice for the location of
  rehab is vital. Trying to relocate rehab later in
  the incident can be very difficult to nearly
  impossible.

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Locating the Rehab

• Close to Incident Command
• More easily keep track of who is in rehab
• Easier to anticipate when people will be ready
• More efficient use of equipment
• Away from Incident Command
• Easier for the personal to relax
• Fewer distractions

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Site Characteristics

• The site for the Rehab must be selected on
  several criteria
  
• The estimated number of people that will need to
  be rehabbed
  
• The weather at the time of the incident
• The duration of the incident

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Site Characteristics

• The site should be outside, uphill and upwind of
  the operational hazard area.
  
• The site should permit prompt reentry into
  emergency operations when personnel have
  completed rehab.
  
• The site should provide maximum protection from
  environmental extremes.

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Site Characteristics

• The site should be large enough to accommodate
  all those that need rehab.
  
• The site should be free of vehicle exhaust.
• The site should be as quite as possible.
• Access to the site by the media should
  restricted.
  
• The site should provide SCBA replenishment/refill.

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Site Characteristics

• The site should have easy entrance and exit
  routes for ambulances.
  
• The site should have a supply of running and
  drinking water.
  
• It is helpful if restroom facilities are part of
  the rehab.

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Site Characteristics

• If the incident involves the recovery of
  fatalities, the rehab site should be out of view
  of the work area.

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Staffing of The Rehab Area

• The most highly trained and qualified EMS
  personnel on the scene should provide medical
  evaluation and treatment in the Rehab area.

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Roles of the Rehab Staff

• EMTs must assure that the sector provides a safe
  area in which fire and rescue crews can rest and
  receive rehydration.
  
• EMTs must identify fire and rescue personnel
  entering the rehab who are at risk for heat- and
  stress-related illness or injury.

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Roles of the Rehab Staff

• EMTs should have an AED readily available in the
  unlikely, but statistically important, event that
  a fire or rescue personnel experiences cardiac
  arrest.
• EMTs must assure accountability for fire and
  rescue personnel who enter and exit the rehab

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Roles of the Rehab Staff

• EMTs must medically monitor crews to determine
  whether they
  
• Are fit to return to active fire/rescue duty.
• Require additional hydration and rest.
• Require transport to an ED for further.
  evaluation and medical treatment.

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Roles of the Rehab Staff

• EMTs must give regular reports/updates to the
  Safety Officer or the Incident Commander.

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Rehab

• The amount of time that a responder will require
  in rehab will vary depending on a variety of
  conditions
  
• The responders level of physical conditioning.
• The atmospheric conditions.
• The nature of the activities the responder was
  performing prior to entering rehab.
  
• The time needed for adequate rehydration.

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Rehab - Rest

• It is recommended that departments establish a
  minimum amount of time that fire/rescue personal
  spend in rehab. This will vary with the
  atmospheric conditions and the number of personal
  available but a good rule of thumb is that each
  person spend at least 20 minutes in rehab.

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Rehab - Rehydration

• The hydration that occurs in the rehab is very
  important to a responders recovery.
  
• Personnel who perform heavy work under stressful
  conditions, while wearing heavy personal
  protective clothing are subject to excessive
  fluid loss.

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Rehab - Rehydration

• While fluid loss is obvious in hot weather
  conditions, do not overlook the fact that
  dehydration also occurs in cold climates.
  
• Maintaining sufficient levels of water and
  electrolytes in the body can greatly aid in the
  prevention of heat- or stress-related illness or
  injury.

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Osmolarity

• Osmolarity can be roughly defined as the
  thickness of a fluid as determined by the
  electrolyte and carbohydrate content of the
  beverage.
• The higher the osmolarity the longer the time it
  will take to absorb the fluid.
  
• In general it is recommended that rehydration
  solutions do not exceed an osmolarity of
  350mOsm/liter.

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Rehab - Rehydration

• Assure that the rehydration solutions have an
  osmolarity of less than 350 mOsm/liter.
  
• Assure that rehydration solutions are
  administered in reasonable rather than excessive
  amounts.
  
• Assure that rehydration solutions are not
  carbonated.

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Medical Evaluation

• On entry into the Rehab each fire/rescue personal
  should be triaged to determine if medical
  treatment or transport is necessary.

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Medical Evaluation

• On entry any rescue fire personal with any of the
  following should be sent immediately to the
  treatment area of rehab
  
• A heart rate of greater the 120 BPM
• A systolic BP of greater then 200 mm/Hg
• A systolic BP of less then 90 mm/Hg
• A diastolic BP of greater then 110 mm/Hg
• Any Traumatic injury

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Medical Evaluation

• No fire/rescue personal should be returned to
  active duty if after 20 minutes of rest if he/she
  presents with
  
• A pulse of greater than 100 BPM
• A systolic BP of greater than 160 mm/Hg
• A systolic BP of less than 100 mm/Hg
• A diastolic BP of greater than 90 mm/Hg

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Medical Evaluation

• No fire/rescue personal should be returned to
  active duty if he/she presents with
  
• An injury that may be worsened by a return to
  duty.
  
• An injury that might in any way impair the
  performance of his/her duty.

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Medical Evaluation

• Any fire/rescue personal should be considered for
  transport to the hospital if he/she presents
  with
  
• Chest pain
• Shortness of breath
• Altered mental status
• Skin that is hot and either moist or dry
• Irregular pulse

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Medical Evaluation

• Any fire/rescue personal should be considered for
  transport to the hospital if he/she presents
  with
  
• Oral temp of greater than 101ºF
• Pulse of more than 150 BPM at any time
• Pulse of more than 140 BPM after cool down

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Medical Evaluation

• Any fire/rescue personal should be considered for
  transport to the hospital if he/she presents
  with
  
• Systolic BP of greater than 200 mm/Hg after cool
  down
  
• Diastolic BP of greater than 130mm/Hg at any time

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Medical Evaluation

• Any emergency worker should be considered for
  transport to the hospital if he/she is unable to
  orally rehydrate due to nausea and vomiting.

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Application

• Define rehabilitation in context to emergency
  workers.
  
• Discuss the importance of rehabilitation to the
  fire and emergency services.
  
• Understand situations warranting, and criteria
  for initiating rehabilitation.

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Application

• Discuss the impact of Heat Stress on emergency
  workers.
  
• Discuss the impact of Wind Chill on emergency
  workers.
  
• List criteria for the appropriate placement of a
  rehabilitation area.

79
Application

• List five (5) reasons to send emergency workers
  for medical evaluation.
  
• List four (4) criteria that should be meet before
  emergency workers are allowed to return to duty.
  

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Application

• List two (2) reasons for not allowing an injured
  emergency workers to return to active duty.
  
• List ten (10) reasons to transport emergency
  workers to an appropriate hospital for further
  evaluation.

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Application

• Discuss the physiological consequences of fluid
  loss.
  
• Define osmolarity and discuss the importance of
  osmolarity in the rehydration of fire / rescue
  personnel.

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Summary

• Deciding when and if to initiate rehab, and
  deciding where to set up rehab are decisions that
  must be made early on in an incident.
  
• Rehydration and constant monitoring of fire
  /rescue personnel is of the utmost importance.
  

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Summary

• Following accepted guidelines for returning
  emergency workers to duty, will aid in both
  returning fit workers to duty while at the same
  time keep stressed/injured workers from the risk
  of causing further harm to themselves.

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Bibliography

• The material presented in this course was
  compiled using Emergency Incident Rehabilitation,
  Edward T. Dickson, MD, NREMT-P, FACEP and Michael
  A Wieder, MS, CFPS, Brady publishing,
  International Fire Service Training Institute.
• Photos by Julie Richardson and Kim Wheat