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Emergency Incident Rehabilitation. Amy Gutman MD EMS Medical Director Tobey Emergency Associates [email protected] Objectives. Define Emergency Incident R ehabilitation (EIR) Discuss importance of EIR Understand which situations warrant EIR Impact of weather conditions

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Emergency Incident Rehabilitation

Amy Gutman MD

EMS Medical Director Tobey Emergency Associates

[email protected]

  • 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

Exertion/Stress/Other 42.7%

Struck by Object 31.5%

Entrapment 22.5%

Fall 1.1%

Electrocuted 1.1%

Extreme Weather 1.1%

Nature of Injury Percent

Cardiac Arrest 38.2%

Trauma 29.2%

Asphyxiation 10.1%

Burns 10.1%

Crushing 3.4%

CVA 3.4%

Drowning 2.2%

Electrocution 1.1%

Arrythmia or Seizure 1.1%

Sepsis 1.1%

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
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
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
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