Emergency Incident Rehabilitation
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Emergency Incident Rehabilitation. Amy Gutman MD EMS Medical Director Tobey Emergency Associates prehospitalmd@gmail.com. Objectives. Define Emergency Incident R ehabilitation (EIR) Discuss importance of EIR Understand which situations warrant EIR Impact of weather conditions

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Amy Gutman MD EMS Medical Director Tobey Emergency Associates prehospitalmd@gmail.com

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Emergency Incident Rehabilitation

Amy Gutman MD

EMS Medical Director Tobey Emergency Associates

prehospitalmd@gmail.com


Objectives

  • Define Emergency Incident Rehabilitation (EIR)

  • Discuss importance of EIR

  • Understand which situations warrant EIR

  • Impact of weather conditions

  • Criteria for EIR location

  • Criteria for return to duty vs hospital evaluation


Background

  • Job-related danger historically a “badge of courage”

    • Resting is sign of weakness

    • Firefighters often boast of element of danger

  • Firefighter deaths & injuries are not badges of courage but indicators of problems


High Risk Profession

  • If firefighting extended beyond safe operating periods, may result in:

    • Stress or fatigue related illness or injury

    • Though firefighter may be uninjured, they are often fatigued to a point where unable to continue working

    • The mentally & / or physically fatigued firefighter may make poor decisions in a high-risk environment


Process & Function of EIR

  • The process of providingrest, rehydration & nourishment

  • Medical evaluation & treatment

    • Initial evaluation

    • Continual monitoring of physical condition

  • Transportation for those requiring treatment at a hospital


What Is Emergency Incident Rehabilitation (EIR)?

  • Rehab operations not limited to emergency scenes

  • Other activities potentially requiring EIR include:

    • Training exercises

    • Athletic events

    • Parade or event standbys


Why Do We Need EIR?

  • Over 50% firefighter deaths directly attributed to stress & overexertion

  • Unknown how many deaths & long-term illness indirectly related to cardiovascular stressors


Breakdown of Firefighter Deaths *2006 NFPA's Fire Incident Data Organization (FIDO)

Cause of Injury Percent

Exertion/Stress/Other42.7%

Struck by Object31.5%

Entrapment22.5%

Fall1.1%

Electrocuted1.1%

Extreme Weather1.1%

Nature of Injury Percent

Cardiac Arrest38.2%

Trauma29.2%

Asphyxiation10.1%

Burns10.1%

Crushing3.4%

CVA3.4%

Drowning2.2%

Electrocution1.1%

Arrythmia or Seizure1.1%

Sepsis1.1%


The Functions Of A EIR Operation


R1: Rest

  • Adequate time for core temp & vitals to return to “normal”

    • “Normal” yet to be established in firefighters

    • “Normal” currently based upon physiological norms set for healthy, active male athletes & military personnel

  • 10-30 min time frame is based upon time thought necessary to exchange cylinders, obtain refreshment & have vitals return to “normal”

    • Not based in evidence


R2: Rehydration

  • Can lose 1-3 lbs of body weight for every 30 minutes in full gear in a working structure fire in “moderate” temperatures

  • Special hydration liquids are generally overpriced & underdeliver

  • Best bet – 8 oz Gatorade with ¼ teaspoon added salt, popsicles, Special K protein water + salt, KoolAid + salt


Rehydration

  • Hydration important to recovery

  • Personnel who perform heavy work under stressful conditions while wearing heavy personal protective clothing are subject to excessive fluid loss

  • While fluid loss obvious in hot weather conditions, do not overlook that dehydration occurs in cold climates

  • Maintaining sufficient levels of water & electrolytes aids in prevention of heat or stress-related illness or injury


R3: Restoration of Core Temp

  • How many in this room have had a rectal temp performed prior to gearing up & entering a house fire?

    • Really? No one?

  • Theoretically, this means “normalization” of core temp to 98.6F, with cessation of either shivering or sweating due to adequate revitalization


R4: Rx (Treatment)

  • Injuries

    • Obvious & “non-obvious”

  • Dehydration

  • Heat Exhaustion

  • Hypothermia

  • Seemingly minor complaints may lead to immediate or delayed cardiovascular abnormalities


R5: Climate Relief

  • Personal climate

  • Environmental climate

  • Case climate

A little something for the ladies


R6: Calorie Refueling

  • Aside from liquid hydration & calories

  • Healthy, nutritious & easily digestible

  • “FireBar” is one such product

    • Don’t waste your money…Snickers are a better bet for less money (yes…Snickers)


Physical Assessment

  • General Assessment

  • Vitals

  • Medical evaluation

  • Revitalization

  • Reassignment


Revitalization

  • Rest

    • Adequate time for core temp & vitals to return to normal

  • Fluid replenishment

    • Provide appropriate fluids to replace losses

  • Nutrition

    • Nourishing & nutritionally sound food


Medical Evaluation &Treatment

  • Firefighters appearing ill or injured are assigned to personnel in medical evaluation area

  • Injured personnel have priority over those simply requiring simply drinks/food, unless that is a medical priority

    • i.e. hypoglycemia or dehydration


Continual Monitoring

  • Continual monitoring throughout EIR

  • Firefighters meeting criteria for release may go back to original assignment (“Medically Sound”) or reassigned to less strenuous activities

  • Firefighters who do not respond to rest or medical attention may require more intensive interventions

    • Transported to a medical facility for further treatment


Establishing EIR


Goal of EIR Operations

  • Lessen risks of injury resulting from extended or intense operations

    • i.e. adverse conditions - specifically foul weather

  • Rehab necessary when emergency operations pose a risk of pushing personnel beyond a safe level of physical & mental capabilities


When To Establish EIR

  • Extended fire incidents

    • Multiple alarm fires, wildfires

  • Hazardous Material Incidents

  • Prolonged rescue/recoveries

  • Adverse weather conditions

  • Crime scene/standoffs

  • Search & Rescue


Weather Conditions

  • Hot Weather

    • Ambient temperature

    • Relative Humidity

    • Direct Sunlight

  • Cold Weather

    • Ambient temperature

    • Wind chill factor


Hot Weather

  • Personnel perform heavy physical labor in hot atmospheres while wearing bulky protective clothing

  • Often cannot break from assignment to go to rehab, remove gear & cool down

  • USFA recommends EIR initiated when heat stress index exceeds 90 ºF (32 ºC)


Heat Index

  • Ambient air temperature & relative humidity factored together to create a “Heat Index”

  • Working in direct sunlight adds 10ºF to heat index

  • Working in full turn-out gear adds additional 10ºF to heat index


Injuries Associated with Heat Stress Index Conditions


Cold Weather Conditions

  • Often overlooked when determining the need for rehab operations

  • Effects of cold weather on responders who operate in low temp conditions for long periods of time are significant


Cold Weather Rehab Challenges

  • Hypothermia

    • Insufficient clothing protection against the cold

    • Allows decrease in body temperature

  • Frostbite

    • Isolated body part freezing


Wind Chill

  • Just as heat & humidity combine to increase the impact of heat, cold & wind combine to impact the effects of cold

  • Combined effect of cold + wind = Wind Chill Factor

  • USFA recommends initiating rehab operations when wind chill drops below 10ºF (-12º C)


Other Situations Where EIR Necessary

  • Crime scene/standoffs

  • Search activities

  • Public events

  • Training events


Crime Scene / Standoffs

  • Bomb squad & tactical / SWAT team members

    • Operate for long periods of time in heavy protective clothing

    • Heat & Cold effects

    • High stress situations


USAR Activities

  • Large area searches for missing person(s)

  • USAR activities follow natural or manmade disasters such as structural collapses

  • Searches for climbers, hikers or others involved in sports or recreation activities


Public Events

  • Fairs, carnivals, festivals

  • Auto Races

  • Parades

  • Concerts

  • Sporting events

  • Political rallies

  • Large-scale religious ceremonies


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

Establishing & Managing EIR


Establishing & Managing A Rehab Area

  • Location is one of the most important decisions

  • Relocation of rehab late in incident often confusion

  • The safety of Rehab site is paramount


Rehab Location

  • Close to Incident Command...

    • Easy tracking of personnel

    • Easy to track progress of those in rehab

    • Efficient use of equipment

  • But…Far enough away

    • Easier for the personnel to relax

    • Fewer distractions


Site Characteristics

  • Estimated number of people needed to run EIR?

  • Weather conditions?

    • Need for shelters or buses?

  • Length of time rehab required?

  • Is site large enough?

  • Is site free of vehicle exhaust?


Site Characteristics

  • Restricted media access

  • Adjacent to SCBA refill

  • Easy ambulance entrance & exit

  • Ideally has both running & drinking water

  • Restroom facilities

  • If involves fatalities, site should be out of view of work area


Additional Resources

  • Metro Bus

  • Salvation Army &/ or Red Cross

  • BLS or ALS Engines

  • Additional Ambulance or Rescue Units

  • Medical Director (s)


EIR Staffing

  • The most highly trained & qualified EMS personnel on scene should provide medical evaluation & treatment in Rehab

  • Highest ranking medical officer should command EIR if possible


Roles of the EIR Staff

  • EIR personnel must assure the sector provides a safe area in which rescue crews can rest & receive treatment & rehydration

  • EIR personnel must identify personnel entering rehab at risk for heat & stress-related illness or injury

  • Rehab Sector commander must give regular updates to the Safety Officer or Incident Commander


Roles of the EIR Staff

  • Rehab area should be equipped to handle a myriad of medical situations

  • Required Equipment:

    • Cardiac monitor/ defibrillator

    • Airway bag

    • Drug box & IV supplies

    • Suction

    • Trauma supplies

  • Rehab personnel must assure accountability for fire & rescue personnel who enter & exit rehab


Roles of the EIR Staff

  • Rehab personnel must medically monitor crews to determine whether they:

    • Are fit to return to active fire/rescue duty

    • Require additional hydration & rest

    • Require transport to an ED for further evaluation and medical treatment


EIR Time Frame

  • The amount of time a responder requires in EIR varies depending on a variety of conditions:

    • Responders level of physical conditioning

    • Atmospheric conditions

    • Nature of the activities the responder was performing

    • The time needed for adequate rehydration

  • A good rule of thumb is 20 minutes per visit

    • Equates to change-out time for oxygen cylinders


Medical Evaluation

  • Immediately on entry assess for injury

    • If no injury, then onto full assessment

  • Vitals

    • BP, RR, HR, SaO2, Temp – obtain and document

  • Personnel with abnormal VS should be sent for treatment

    • HR > 120 BPM

    • SBP > 160 mm/Hg or < 90 mm/Hg

    • DBP > 110 mm/Hg


Medical Evaluation

  • No personal should return to active duty if after 20 minutes of rest if:

    • HR > 100 BPM

    • SBP > 160 mm/Hg or < 100 mm/Hg

    • DBP > 90 mm/Hg

    • Injury that may worsen or impairs performance

    • Inability to hold down water

  • My personal marker – tell personnel that they cannot leave until they pee…if not adequately hydrated, they will not be able to urinate


Hospital Transport

  • Serious symptoms:

    • Chest pain, SOB, AMS

    • Heat exaustion

  • Irregular, persistent HR > 150 bpm

  • Oral temp > 105ºF

  • SBP > 200 mm/Hg post cool down

  • DBP > 130mm/Hg at any time


Summary

  • Deciding when & if to initiate EIR

  • Planning a EIR location

  • Understanding importance of early decision-making

  • Rehydration & constant monitoring is of the utmost importance

  • Following guidelines for returning emergency workers to duty aids in both returning fit workers to duty & preventing further harm to ill or injured personnel


Questions?prehospitalmd@gmail.com


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