Amy Gutman MDEMS Medical Director Tobey Emergency Associates

prehospitalmd@gmail.com

Emergency Incident Rehabilitation

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 weaknessFirefighters 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 providing rest, rehydration & nourishment

Medical evaluation & treatmentInitial evaluationContinual 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 exercisesAthletic eventsParade 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 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%

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 replenishmentProvide appropriate fluids to replace losses

NutritionNourishing & 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 priorityi.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 WeatherAmbient temperatureRelative HumidityDirect Sunlight

Cold WeatherAmbient temperatureWind 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

Heat Stress Index Relative Humidity Temp ˚F 10% 20% 30% 40% 50% 60% 70% 80% 90% 104 98 104 110 120 132 102 97 101 108 117 125 100 95 99 105 110 120 132 98 93 97 101 106 110 125 96 91 95 98 104 108 120 128 94 89 93 95 100 105 111 122 92 87 90 92 96 100 106 115 122 90 85 88 90 92 96 100 106 114 122 88 82 86 87 89 93 95 100 106 115 86 80 84 85 87 90 92 96 100 109 82 77 79 80 81 84 86 89 91 95 80 75 77 78 79 81 83 85 86 89 78 72 75 77 78 79 80 81 83 85 76 70 72 75 76 77 77 77 78 79 74 68 70 73 74 75 75 75 76 77 Note: Add 10˚ when protective clothing is worn and add 10˚ when in direct sunlight.

Injuries Associated with Heat Stress Index ConditionsHeat Index, °F Danger Category Injury Threat

Below 60° None Little to no danger under normal circumstances80° to 90° Caution Fatigue possible if exposure is prolonged and there is

prolonged physical activity90° to 105° Extreme Caution Heat cramps and heat exhaustion possible if exposure is

prolonged and there is physical activity105° to 130° Danger Heat cramps and heat exhaustion likely and heat stroke

possible if exposure is prolonged and there is physicalactivity

above 130° Extreme Danger Heat stroke is imminent

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 coldAllows 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)

Wind Chill Factor IndexTemperature, °F

Wind Speed MPH 45 40 35 30 25 20 15 10 5 0 -5 -10 -15

5 43 37 32 27 22 16 11 6 0 -5 -10 -15 -2110 34 28 22 16 10 3 -3 -9 -15 -22 -27 -34 -4015 29 23 16 9 2 -5 -11 -18 -25 -31 -38 -45 -5120 26 19 12 4 -3 -10 -17 -24 -31 -39 -46 -53 -6025 23 16 8 1 -7 -15 -22 -29 -36 -44 -51 -59 -6630 21 13 6 -2 -10 -18 -25 -33 -41 -49 -56 -64 -7135 20 12 4 -4 -12 -20 -27 -35 -43 -52 -58 -67 -7540 19 11 3 -5 -13 -21 -29 -37 -45 -53 -60 -69 -7645 18 10 2 -6 -14 -22 -30 -38 -46 -54 -62 -70 -78

Wind Chill Temperature, °F Danger

Above 25 °F Little danger for properly clothed person25°F to -70°F Increasing danger, flesh may freezeBelow -70°F Great danger, flesh may freeze in 30 seconds

Other Situations Where EIR Necessary

Crime scene/standoffs

Search activities

Public events

Training events

Crime Scene / Standoffs

Bomb squad & tactical / SWAT team membersOperate for long periods of

time in heavy protective clothing

Heat & Cold effectsHigh 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

ESTABLISHING & MANAGING EIR

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

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 rehabEfficient use of equipment

But…Far enough away Easier for the personnel to relaxFewer 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/ defibrillatorAirway bagDrug box & IV suppliesSuctionTrauma 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 conditioningAtmospheric conditionsNature of the activities the responder was performingThe time needed for adequate rehydration

A good rule of thumb is 20 minutes per visitEquates to change-out time for oxygen cylinders

Medical Evaluation Immediately on entry assess for injury

If no injury, then onto full assessment

VitalsBP, RR, HR, SaO2, Temp – obtain and

document

Personnel with abnormal VS should be sent for treatmentHR > 120 BPMSBP > 160 mm/Hg or < 90 mm/HgDBP > 110 mm/Hg

Medical Evaluation No personal should return to active duty if

after 20 minutes of rest if:

HR > 100 BPMSBP > 160 mm/Hg or < 100 mm/HgDBP > 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, AMSHeat 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