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Emergency Incident Rehabilitation
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Emergency Incident Rehabilitation. Amy Gutman MD EMS Medical Director Tobey Emergency Associates 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

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Amy gutman md ems medical director tobey emergency associates prehospitalmd gmail com

Emergency Incident Rehabilitation

Amy Gutman MD

EMS Medical Director Tobey Emergency Associates



  • 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



  • 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

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

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 rehab ilitation eir

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

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

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

Cause of Injury Percent


Struck by Object31.5%




Extreme Weather1.1%

Nature of Injury Percent

Cardiac Arrest38.2%








Arrythmia or Seizure1.1%


The functions of a eir operation

The Functions Of A EIR Operation

R1 rest

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

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



  • 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

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

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

R5: Climate Relief

  • Personal climate

  • Environmental climate

  • Case climate

A little something for the ladies

R6 calorie refueling

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

Physical Assessment

  • General Assessment

  • Vitals

  • Medical evaluation

  • Revitalization

  • Reassignment



  • 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

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

  • 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

E stablishing eir

Establishing EIR

Goal of eir operations

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

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

Weather Conditions

  • Hot Weather

    • Ambient temperature

    • Relative Humidity

    • Direct Sunlight

  • Cold Weather

    • Ambient temperature

    • Wind chill factor

Hot weather

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

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

Injuries Associated with Heat Stress Index Conditions

Cold weather 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

Cold Weather Rehab Challenges

  • Hypothermia

    • Insufficient clothing protection against the cold

    • Allows decrease in body temperature

  • Frostbite

    • Isolated body part freezing

Wind chill

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

Other Situations Where EIR Necessary

  • Crime scene/standoffs

  • Search activities

  • Public events

  • Training events

Crime scene standoffs

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

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

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

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

Establishing & Managing EIR

Establishing managing a rehab area

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

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

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 characteristics1

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

Additional Resources

  • Metro Bus

  • Salvation Army &/ or Red Cross

  • BLS or ALS Engines

  • Additional Ambulance or Rescue Units

  • Medical Director (s)

Eir staffing

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

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 staff1

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 staff2

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

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

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 evaluation1

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

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



  • 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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