Incident Rehabilitation for Response Personnel

1. Incident Rehabilitation for Response Personnel Capt. W Michael Collins, NREMT-P

2. Session Objectives • Identify the legal requirements for establishing the Rehab Group. • Describe the “9 Elements of Rehab”. • Describe the fireground medical assessment. • Describe how the Incident Commander uses the Rehab Group in the incident management process.

3. Legal Requirements • Occupational Safety and Health Administration (OSHA) • National Institute for Occupational Safety and Health (NIOSH) • National Fire Protection Association (NFPA)

4. Just what is “rehab” • Defined as : An attempt to restore (a person) to normal physical functioning • Sustain or restore work capacity • Improve performance • Decrease injuries • Prevent deaths

5. Nine Key elements to Rehab • Relief from climatic conditions • Rest and recovery • Cooling or rewarming • Re-hydration • Calorie and electrolyte replacement • Medical Monitoring • EMS tx according to local protocols • Member accountability • Release

6. 1. Relief from climatic conditions • Most common use is the Ride-On Bus • There are some positives • There are some negatives • Consider some our resources • Decon units • Other structures / facilities

7. Pegler’s Rehab Axiom • Communications (Children) • Hydration • Location • Oxygenation • Relaxation • Inspiration • Nutration • Evaluation

8. 2. Rest and Recovery • 10 minutes of rest • Removed form stress and noise • Must have an area where FF can sit down • Out of contaminated environments

9. 3. Cooling and Rewarming

10. Cooling • Heat Stress • Internal • Exertion • External • Environmental conditions (Fire floor) • Trapped heat (PPE) • Heat Strain • Body reacts to heat stress

11. Cooling • Passive • Simple evaporation • Water changing from liquid to vapor • The higher the humidity the more difficult to change

12. Cooling • Active – Convection • Movement of air reduces heat • NOTE: • When to ambient air temperature is above 98o F this has a warming effect.

13. Cooling • Active- Radiation • Loosing heat to a cooler environment • Examples: • Shade • Shelter • A facility with ac • Are the guys to the right really cooling off?

14. Cooling • Active –Conduction • Skin contact with a cooler object • Cold water • Cold ground • Most of us hate it when all of our gear is soaking wet. Is it still operational?

15. Cooling Methods

16. Cooling Methods • Forearm immersion • Canadian study found one of the fastest way to decrease body temp • Requires a commercially available chair

17. Cooling Methods • 3 Bucket Cold Towel Technique • Bucket 1 (Sanitizing) • ¼ cup of bleach • Fill with water • Bucket 2 (Rinse) • Removes bleach • Fill with clean water • Bucket 3 (Rejuvenation) • Fill bucket with ice and water • 3 buckets/20 towels = 60 members per hour

18. 4. Re-hydration • During extreme exertion we may lose as much as 1 qt of sweat per hour • Will require 12 to 32 oz to replace the lost water. • Does not end in the Rehab Area

19. 5. Calorie and Electrolyte Replacement • Fruits, meal replacement bars, carbohydrate drinks… • 30-60 grams carbohydrate per hour • High fat foods inappropriate

20. 6. Medical Monitoring Specifies minimum 6 conditions be screened: • CP, dizzy, SOB, weakness, nausea, h/a • General c/o (cramps, aches, pains…) • Symptoms of heat or cold-related stress • Changes in gait, speech, behavior • Alertness and orientation x 3 • Any VS considered abnormal locally

21. 6. Medical Monitoring in Rehab Local (FD) medical monitoring protocols: • Immediate EMS treatment and transport • Close monitoring in rehab area • Release

22. 6. Medical Monitoring in Rehab • Vital signs per FD protocol • Options suggested: • Temperature • Pulse • Respiration • Blood pressure • Pulse oximetry • CO assessment (pulse CO-oximetry)

23. Vital Signs • Many departments do not measure • No evidence or published studies: • Determine when treatment necessary • Predict type or duration of rehab needed • Vitals may help set parameters for monitoring, treatment, transport, release • Must be evaluated in context

24. Temperature • Core temp most accurate • NL = 98.6-100.6°F (37-38.1°C) • Best measured rectally or temp transmitter • Oral or tympanic used in field • Oral 1°F (0.55°C), tympanic 2°F (1.1°C) less • Multiple user & environmental potentials for error

25. Temperature • Elevated temps by measurement or touch suggest possible heat related illness • NOTE: normal oralor tympanic tempsdo not exclude heatillness!

26. Pulse • NL = 60-80, many influences. • Very important to interpret in context of individual. • Recovery rate may be more significant than actual heart rate. • If > 100 after 20 min rest, further eval needed before release • Pulse ox offers accurate measure

27. Respiratory Rate • NL = 12 – 20, should  with fever and exercise • Should return to normal with rest

28. Blood Pressure • Most measured • Least understood • Very contextual • Tremendous potential for error

29. Blood Pressure Sources of error: • Cuff size • Arm placement • NIBP Potential for cross contamination: • Need to decon between each use

30. Blood Pressure • NFPA suggests members with SBP > 160 or DBP > 100 not be released from rehab. • Oddly, hypotension (SBP < 80) is probably of far greater concern than high blood pressure…

31. Pulse Oximetry • Non-invasive measurementof oxygen and blood flow • NL = 95-100% • Most oximeters cannotdifferentiate oxyhemoglobinfrom carboxyhemoglobin • Members with SpO2 < 92% should not be released from rehab

32. CO Assessment • Carbon monoxide is present at all fires and a leading cause of death • NFPA suggests any member exposed to CO or with CO s/s be assessed for CO poisoning • Exhaled CO meter or pulse CO-Oximeter are two detection devices

33. CO Poisoning Assessment

34. CO Poisoning Assessment

35. CO levels • Non-smokers = 0 – 5% • Smokers 5 – 10% • If > 15%, treat with high flow O2 • Between 10 – 15%, assess for s/s, treat if necessary • Release from rehab requires normal CO level per local protocol

36. Cyanide • Consider at all fire scenes • All patients in cardiac arrest • Any patient in shock, especially if low CO level • Treat with cyanide antidote kit

37. 7. Transport per Protocol • Advise IC as soon as treatment begins • FF Name and Unit assignment • Possible condition and treatment provided • Receiving hospital

38. 8. Accountability • Rehab is an assignment like fire attack or venting • Our Incident Commanders are taught to establish the Rehab Group early on • It is the Rehab Group Supervisor responsibility to track units/personnel in the Rehab Area and resources assigned to that area. • The Rehab Group Supervisor must keep Command advised of progress and what units are in the Rehab Area

41. 9. Release • Personnel are ready to return to work • The Rehab Group Supervisor must inform Command when Units are ready • There will be times that Rehab may fell like a staging area, and it might just be. • Forward your Rehab Forms to the EMS Office with any MAIS Forms.

42. MCFRS Policy

43. MCFRS Policy

44. MCFRS Policy

46. Summary • Just do it! • It’s Command’s job to establish the Rehab Group • Define who will do what • Medical Monitoring • Emergency Care • Bring supplies • Record keeping • Accountability

47. Information for this session came from • Emergency Incident Rehabilitation FEMA FA-314 (July 2008) • The Elephant on the Fire Ground: Secrets of NFPA 1584 Compliant Rehab Mike McEvoy, PhD, REMT-P, RN, CCRN • http://www.firerehab.com/