Analysis of firefighter rehab and respiratory protection ...

Analysis of firefighter 1

Running head: ANALYSIS OF FIREFIGHTER REHAB AND RESPIRATORY

Analysis of Firefighter Rehab and Respiratory Protection during Fireground Operations

Barry G. McLamb

Chapel Hill Fire Department

Chapel Hill, North Carolina

May 2007


CERTIFICATION STATEMENT

I hereby certify that this paper constitutes my own product, that where the language of others is

set forth, quotation marks so indicate, and that appropriate credit is given where I have use the

language, ideas, expressions, or writings of another.

Signed: __________________________________


Abstract

The Chapel Hill Fire Department was operating at incident scenes without formal policies

to support firefighter rehab, and operated with procedures for respiratory protection that were

potentially harmful for firefighters. The purpose of the research was to describe current

practices, procedures, and cultural issues related to rehab and respiratory protection within the

department, and to seek out benchmarks and areas for improvement. Descriptive research

methods were used for analysis. Questionnaires were constructed to develop internal data on

cultural and compliance issues, and external data for program benchmarks. Recommendations

were made for various improvements to policy and procedure, as well as careful implementation

of any changes due to the significant cultural influences.


Table of Contents

Certification Statement 2

Abstract 3

Table of Contents 4

Introduction 6

Background and Significance 7

Literature Review 10

Procedures 17

Results 19

Discussion 25

Recommendations 27

Reference List 28

Appendix A 30

Appendix B 31


List of Tables

Table 1 20

Table 2 21

Table 3 23


Analysis of Firefighter Rehab and Respiratory Protection during Fireground Operations

Introduction

The hazardous nature of firefighting operations is a universally recognized fact that even

the general public can comprehend and appreciate. However, firefighters and fireground

commanders often fail to follow the best risk management principles which can lead to

firefighter death and injury resulting from exposure to workplace hazards. Often, exposure to the

hazards does not inflict immediate or significant damage, nor produce recognizable symptoms;

but the repeated exposure, over time, can lead to substantial consequences for firefighter health.

Additionally, while the potential for fireground exposure has increased, our use of tools and

techniques to reduce the risk has not kept pace. Over the last two decades, there have been

rampant changes in building construction, materials, and contents, but very often, fire

departments are still operating with the same practices for firefighter rehabilitation and

respiratory protection that were in place 20 years ago. In order to maximize the health and safety

of firefighters, the fire service must put in place policies and practices that minimize the risk to

firefighters working in the fireground operations workplace.

Within the Chapel Hill Fire Department (CHFD), the problem faced by the organization

is that personnel on the fireground have the potential to be exposed to hazards and yet, the

policies and practices regarding firefighter rehabilitation (rehab) and respiratory protection may

not be enough to adequately protect our members. The purpose of this research is to first,

describe the current practices, procedures, and cultural issues related to respiratory protection,


and second, to determine benchmarks for improvement including the National Fire Protection

Association (NFPA) recommended practice for firefighter rehabilitation.

To examine how the organization can respond, current issues and trends regarding

firefighter rehab and respiratory protection will be investigated through a literature review.

The existing practices and policies governing rehab and respiratory protection will be analyzed

through policy review and the impact of the organizational culture through questionnaires. A

survey of other organization’s practices will help establish how the CHFD is doing in

comparison. Finally, CHFD practices will be examined against the recommend practices

established in NFPA 1584.

Background and Significance

The Chapel Hill Fire Department provides fire, rescue and medical first responder

services to a growing and diverse population in the central North Carolina piedmont. Comprised

of 92 employees, the fire department operates 5 stations, 6 front-line apparatus, and 3

reserve/support apparatus. The organization is configured in a paramilitary hierarchy typical of

most fire departments and is divided into three divisions: Administration, Life Safety, and

Emergency Operations. The town is also home to the University of North Carolina, and both are

undergoing a significant period of growth and change. Located in the metropolitan area known

as the Triangle, so named for the cities of Raleigh, Durham, and Chapel Hill, the department

participates in multiple mutual aid and regional efforts. Despite being one of the smaller career

departments in the metro area, Chapel Hill often exceeds its neighbor departments in terms of

services delivered to our customers.

The organization has long struggled with meeting service demands and its own high

standards with what can only be described as grossly inadequate staffing when compared to the


number of initiatives that the department is involved. Only in the last two years has staffing been

added to the operations division baseline, which has made some improvement in personnel safety

and response capability. During the same time period, the department was finally able to add

one staff position, a full-time Training and Safety officer.

The addition of the Training and Safety Chief in October, 2003 was a milestone for the

organization because previously there had not been any one individual responsible for

implementing training and safety programs for the department. Instead, the tasks associated with

the position were split up as additional duties among various staff members, each with his or her

own responsibilities and agendas. Consequently, neither safety nor training received the priority

commiserate with the importance of either, given the impact of both on the organization.

However, the training and safety programs are still in developmental stages, due in part to

personnel changes and the re-emergence of academy training. Safety, in particular, is not a fully

functional program, but holds the promise to be able to address many of the issues raised in this

research.

Another prevalent issue is the safety climate in the organization. As with any fire

department, Chapel Hill posses its own unique culture in addition to the aspects of fire service

culture that are nearly universal. The organizational stance on safety is evident in the mission

statement of the department:

The mission of the Chapel Hill Fire Department is to protect lives, property and the

community environment from the destructive effects of fire, disaster or other life hazards

through public education, incident prevention and emergency response services. Our

Priorities are: Safety, Service and Morale. (Chapel Hill Fire Department [CHFD],

2004, p. 1)


Since its inception, the Fire Chief has ensured all members participate in the annual Safety Stand

Down that was initially sponsored by the International Association of Fire Chiefs (IAFC) and

Fire Chief Magazine. This represents a positive trend that continues to develop new ideas and

challenge old ways of doing business.

Despite the organizational posture and the commitment of the leadership to safe

practices, there are still areas for improvement in the department. Among these are mitigating

the impact of incident stressors and hazards through more proactive incident scene rehabilitation

and better respiratory protection policy and practices. According to a report by the United States

Fire Administration (USFA) and the National Fire Data Center (2004), stress and overexertion

continues to be the leading cause of firefighter fatalities. Additionally, younger firefighters are

more subject to smoke inhalation injuries and older firefighters are prone to sprains and strains;

injuries directly related to overexertion (United States Fire Administration / National Fire Data

Center).

This applied research project is directly related to the USFA Operational Objectives. The

third USFA objective is to reduce the loss of life from fire of firefighters; this project is directly

related to firefighter health and safety. The fifth USFA operational objective is to respond

appropriately in a timely manner to emerging issues. Firefighter health and safety and

particularly, incident scene rehabilitation, are emerging issues in the fire service today. This

study is also directly related to the course material in the Executive Analysis of Fire Service

Operations in Emergency Management as this research looks at an important consideration in

emergency response operations.


Literature Review

There is a fire service axiom that says: “take care of yourself first, take care of

your team second, and take care of the people at the incident third”, because if you do not take

care of yourself, you cannot take care of anything else. This is the premise behind incident scene

rehabilitation or rehab. Much emphasis is placed on proper rehab in the modern training

environment because of the physically demanding work of firefighting. Instructors keep an eye

on students to ensure they are not pushing too hard nor getting enough rest. At emergency

scenes, crew chiefs, safety officers and incident commanders are responsible for ensuring the

welfare of responders. Rehabilitation is essential on emergency responses and in training to

ensure safe and effective fire operations. Tired firefighters are more injury prone and caring for

injured firefighters diverts limited resources away from mitigating the incident. (National Fire

Protection Association / International Association of Fire Chiefs [NFPA/IAFC], 2004, 590-591)

According to one study, the majority of firefighter injuries in the 2002 study period

occurred on the fireground and the largest percentage of those injuries were strains, sprains, and

muscle pain directly related to overexertion (TriData Corporation [TriData], 2004). While the

overall trend in firefighter injuries fell 20 percent over the previous 10 year period (TriData), the

number of structure fires only fell 13 percent in the seven years prior to 2002 (Federal

Emergency Management Agency [FEMA], 2006). Although, the injury trend is getting better,

the TriData (2004) study included several recommendations to improve firefighter injuries

related to this study.

Among the recommendations were to research ways to instill safety awareness and

change the behavior of firefighters because, “the degree to which firefighters behave without

regard to their safety, and to standard procedures, affects that safety” (TriData, 2004, p. 52).


Improving training was another recommendation because improved training reduces risk through

increasing experience levels, and that is critical to safety-related fireground decisions. The study

also advocated the use of various technologies to improve the situational awareness of incident

commanders that will provide them better data and lead to safer operations. Finally, improving

firefighter fitness was a suggested solution that relates to this study. (TriData)

In the Fundamentals of Firefighter Skills, respiratory protection is listed as one of the

most critical elements of PPE. “When protecting your lungs, good is not enough” is the sage

advice found on respiratory protection (NFPA/IAFC, 2004, p. 804). A recent theory involving

respiratory protection suggests that the hidden danger lurking on the fireground is cyanide

poisoning. Cyanide is a by-product of burning wool, silk, leather, and most plastics, and

continues to be produced as long as the combustible product is off-gassing (Lee, 2007).

According to the Centers for Disease Control, the most likely route for cyanide is through

inhalation and in the blood stream, cyanide prevents cells from using oxygen which leads to cell

death (Centers for Disease Control [CDC], 2004). Because cyanide interrupts cellular

respiration, the symptoms of cyanide poisoning can mimic other conditions, such as exhaustion,

carbon monoxide poisoning, or even a heart attack (Lee). The problem is that cyanide poisoning

is difficult to diagnose and the symptoms are often hard to differentiate. Fortunately, the

solution is simple: if post-fire fuels are off-gassing, firefighters must remain on SCBA while

performing overhaul (Lee).

In a presentation to the Chapel Hill Fire Academy, Dr. Preston Rich, Chief of Trauma

and Critical Care at the University of North Carolina Hospital, discussed the increased risk of

heart attack for firefighters, specifically relating information from the recent study that revealed

the abnormally high number of firefighter heart attack deaths that occurred during fire


suppression. Dr. Rich relayed information from the study showing that the odds of dying of a

heart attack while performing fire suppression were between 10 and 100 times greater than

would be statistically predictable. However, the overall risk of a fatal heart attack in firefighters

is only 90 percent of the general population. Dr. Rich postulates that a primary cause of the

dramatic increase in firefighting coronary death is from the “perfect storm of cellular oxygen

starvation” that is a result of the “additional and unique risks” that firefighters face on the

fireground. That perfect storm is brought on by inhalation exposure to carbon monoxide and

cyanide. (Rich, 2007)

In reviewing departmental SOPs, a weakness against the inhalation hazards posed by

carbon monoxide and cyanide quickly emerges. SOP 300-1 stipulates Protective Clothing

Requirement for firefighters in various types of duty. Under the category ‘overhaul and salvage’,

the following items are listed: “boots, pants, gloves and helmets. SCBA until thoroughly

ventilated.” (CHFD, 1990, p. 1). The problem lies in the definition of ‘thoroughly ventilated’.

The common practice for many in the fire service is to use the Occupational Safety and Health

Administration (OSHA) permissible exposure limit (PEL) for carbon monoxide to determine if it

is safe to remove SCBA.

As illustrated by Lee (2007) and Rich (2007), this practice may be leading to a more

hazardous exposure than is assumed and can include exposure to cyanide gas, which is not

monitored the same as carbon monoxide and is more difficult to detect through blood analysis.

In his article, Lee cites a National Institute of Standards and Technology (NIST) study that found

that nearly all of the 100 deaths from the tragic Station nightclub fire in Rhode Island were

caused by cyanide poisoning resulting from the burning plastics, used to enhance acoustics, on

the walls.


In 2002, the SOP on SCBA performance and operation was updated to address current

practices and policies. SOP 500-3.10 states that “it is not acceptable to remove SCBA during

overhaul when the smoke clears – residual harmful vapors may be present” (CHFD, 2002, p. 5).

It goes on to say that it is acceptable to remove SCBA when approved by command, operations,

safety; when the atmosphere has been determined with testing and monitoring; and when the unit

prevents escape from a dangerous condition (CHFD, 2002). Unfortunately, the update does not

address all of the issues emerging concerning respiratory protection.

According to the NFPA recommended practice on rehabilitation, standard operating

procedures (SOPs) should be developed that include the following elements: medical evaluation

and treatment, food and fluid replenishment, and crew rotation and relief. Additionally, the

Emergency Medical Service (EMS) protocols should be developed in collaboration with the

EMS medical director, the fire department physician, and the fire chief. NFPA 1584 also

recommends that all members are trained to recognize the symptoms or heat and cold stress.

Finally, SOPs should ensure that rehab operations are put in place whenever an incident escalates

beyond the normal limits of physical or mental endurance. (National Fire Protection Association

[NFPA], 2003, chap. 4)

NFPA 1584 also stipulates that proper hydration and nutrition are essential prior to an

incident. Daily hydration should include six to eight ounces of water every six hours in addition

to fluid intake at meals. Furthermore, in pre-incident and training situations, firefighters should

include an additional sixteen ounces of fluids within two hours prior. If the incident or training

is projected to last longer than an hour, then sports drinks are preferred for pre-hydration. Proper

nutrition should consist of smaller, more frequent meals that are comprised mostly of

carbohydrates with smaller portions fat and protein. Food and beverages to avoid consist of:


caffeinated and high-sugar/fructose drinks, high fat and/or high protein foods, any alcohol within

eight hours of duty, and finally, excessive fluid intake. (NFPA, 2003, chap. 4)

There are numerous site considerations that the incident commander (IC) should include.

First, ICs must ensure that rehab is set up in area that is capable of conducting rehab operations

and is also sheltered from any weather extremes. In the event of hot weather, the area should be

shaded or equipped with tents, fans, and misters, or air conditioning if inside a facility.

Firefighters should also have the ability to sit and remove gear. For extremes of cold and wet,

the area or facility should be dry and provide warmth and dry clothing. In large or

geographically separated incidents, more than one rehab area may be necessary. (NFPA, 2003)

Other site considerations include either keeping the rehab area far enough away or

separated from the incident or training, so that personnel can remove their personal protective

equipment (PPE) and also be shielded from the noise and stress of the event. The area should

also be protected from exhaust fumes from vehicles as well as any products from the incident.

Prior to entering the designated rehab area, firefighters should have the ability to remove and

leave their PPE and self-contained breathing apparatus (SCBA). Medical personnel or the

medical sector should have easy access to the rehab area. Finally, the area should be close and

accessible enough that firefighters can quickly return to the incident (NFPA, 2003).

EMS at a minimum of Basic Life Support (BLS) level should be provided for firefighters

and EMS personnel should be included within the tactical level of the incident management

systems (IMS). Advanced Life Support (ALS) level care is preferred when available. EMS

personnel should question firefighters arriving at rehab to determine illness, injury, and exertion.

Questions and observations should be used to reveal symptoms of dehydration, heat or cold

stress, exhaustion, irregular heart rhythms, as well as mental or emotional stress and exhaustion.


The Rating of Perceived Exertion (RPE) scale should be used to determine the level of physical

output. Upon entering the rehab area, the following criteria from each firefighter should be

evaluated: 1 -10 on the RPE scale, blood pressure, temperature, and heart rate. Local EMS

protocols and department SOPs should always be utilized in the triage and treatment of

firefighters. Firefighters meeting or exceeding any triage parameter should be evaluated after

twenty minutes. If, after rest, the firefighter is still within an unacceptable range in any one

parameter, the firefighter should be taken for medical treatment. (NFPA, 2003)

Assignment to and out of rehab is a function of the IMS and members must be tracked

through a personnel accountability system. Upon entering rehab, firefighters should have the

resources to add or remove clothing in order to regain body temperature, eat food to replace the

calories expended in the operation, and drink water or sports drinks to return the body’s fluid and

electrolyte balance. The fluid goal during a 20-minute rehab period is 12-32 ounces, in addition

to the recommended 2-4 ounces every 20 minutes taken in during the incident. A recommended

practice is keeping water available on the truck and near bottle changing stations so that

firefighters can re-hydrate while their SCBA cylinder is serviced. (NFPA, 2003)

A key feature found in the NFPA recommended practice is the work-rest cycle. The

work-rest cycle establishes the following guidelines for personnel engaged in various types of

work:

Up to one 30-minute SCBA cylinder or 20 minutes of intense work without SCBA to at

least 10 minutes of self-rehabilitation (rest with hydration) as a company or crew. The

company officer or crew leader should ensure that all members in the company or crew

seem fit to return to duty. Up to two 30-minute SCBA cylinders or one 45-minute or 60-

minute SCBA cylinder when encapsulating chemical protective clothing is worn or 40


minutes of work without SCBA to at least 20 minutes of rest (with hydration) in a

rehabilitation area. (NFPA, 2003, chap. 6)

NFPA goes on to say that following the formal establishment of rehab, no one should be

allowed to return to duty until after resting and re-hydrating for a minimum of 10 minutes and

being medically evaluated and cleared by EMS personnel. Also, firefighters should not be in an

operational role at a scene for 12 or more hours without a multi-hour break away from the scene.

(NFPA, 2003)

If one or more crew members are determined to be unfit for duty, the other members of

the crew may remain on duty and be reassigned with certain considerations due the decreased

number. However, if a member or members of the crew are seriously injured or killed, the entire

crew should be relieved of duty immediately. The department should then implement critical

incident stress management protocols to assist the crew members. (NFPA, 2003)

There are additional considerations during and after the incident. Documentation during

the incident is critical. The time entering and leaving rehab should be recorded for all personnel.

Any medical evaluation done should be documented on a rehab evaluation report. If any medical

treatment is performed, the required EMS forms as well as injury reports and workers

compensation forms must be accomplished. Following the incident, firefighters should look for

signs and symptoms of dehydration and report any incident related illness or injury that is

discovered after leaving the scene. Also, firefighters should follow the same nutritional

guidelines as pre-incident and avoid high-fat foods, caffeine, foods with excessive calories, and

carbonated beverages. (NFPA, 2003)

An additional rehab tool and technique not addressed by NFPA 1584 involves the

concept of active cooling. Research conducted by Defense Research and Development Canada


(DRDC) demonstrated a remarkable improvement in recovery times using the technique. The

research compared active cooling, comprised of forearm immersion, the use of a mister for

cooling, and passive cooling, which was the control. The active cooling revealed a dramatic

differential over the other cooling methods. As a result of the research, manufacturers are now

producing specialized rehab chairs that allow firefighters to immerse their forearms in water for

active cooling in the rehab sector. (Selkirk, McLellan, & Wong, 2004)

In addition to describing the elements of the NFPA recommended standard, the literature

review has highlighted the injury problem as it relates to rehab, identified other issues and trends

regarding rehab and respiratory protection. The two department policies that relate to respiratory

protection have also been identified and the relevant sections outlined. The review has clearly

revealed problems facing the department as well as potential solutions.

Procedures

Descriptive research was the primary method for analysis of the problems with firefighter

rehab and respiratory protection. The process originally evolved after seeing two presentations:

one on firefighter rehab, and another on the firefighter heart attack risk. The decision was then

made to investigate what impact the information might have on the Chapel Hill Fire Department

to improve processes related to firefighter rehab and respiratory protection.

The literature review consisted of information developed out of web searches and the

information gathered or retained following the presentation. Web searches with the keywords

firefighter rehab and firefighter respiratory protection yielded results, as did the resources

available through the USFA web site. The NFPA web site was used to access NFPA 1584.

Finally, books from the author’s library and organization’s reference materials were used to

round out the literature review.


Two questionnaires were developed to gather data from internal and external sources. An

internal survey was used to determine the level of understanding, the common practices, and the

attitudes towards firefighter rehab and respiratory protection, and the external questionnaire was

used to gauge the department against a variety of organizations throughout the state.

The internal questionnaire was distributed to operations personnel at the level of engine

company officer and below. Firefighters hired within the last year and life safety division

personnel were excluded. For the internal sample, the population of the group was 54 at the time

the survey was distributed. A sample of 51 was needed to ensure a 95 percent confidence level

and 53 surveys were returned. The survey, included in Appendix A, contained 9 questions that

were designed to illicit responses regarding comprehension of policies (questions 2, 3, 6, 8),

management involvement (question 1), attitudes regarding rehab (questions 4-5, 9), and current

practices (question 7).

The external questionnaire was distributed to conference attendees at the North Carolina

instructor’s conference. The primary audience is training officers, but some respondents were

company level officers and at least one chief officer of the department. The sample of 86

required a response of 82 for 95 percent compliance. The number of attendees and the rate of the

return both fell short of projections. The questionnaire, included in Appendix B, contained eight

questions designed to gather data on the respondents’ knowledge and understanding of their

organization’s policies (questions 1, 5), the practices of their department (questions 2-4, 6), and

the make-up and jurisdictional demographic of their organization (question 7, 8).

Finally, the NFPA 1584 recommended practice was used as a comparison tool to identify

areas for improvement. The proposals in NFPA 1584 were organized through the literature

review and examined in terms of full compliance, partial compliance, and non-compliant.


Limitations

The major limitation was the insufficient number of questionnaires returned for the

external survey. Another mechanism should have been used to access a better sample. Also, the

internal questionnaire could have been better constructed to gather more data regarding the effect

of cultural attitudes rehab and respiratory protection, and should have been followed by a short

test to determine how accurate their responses really were.

Definitions

Rating of Perceived Exertion (RPE) Scale: The original chart for RPE was created by Dr.

Gunnar Borg, and is often referred to as the Borg scale. This scale started at 6 and

ended at 20. Borg originally created this scale to correspond to heart rates, so that

a 6 would be equal to a heart rate of 60 beats per minute and, most individuals

would rate between 12 and 16 during maximum exertion. A new chart has

replaced the Borg scale that ranges from 1–10, with 10 being hardest. Most

individuals rate between 4 and 7 at maximum exertion on the new RPE scale, and

that correlates with 60 percent to 85 percent of maximum heart rate. (NFPA,

2003)

Results

The literature review analysis of current research and reporting in the areas of fireground

rehab and respiratory protection yielded significant results. Although the trends cited in the

TriData study and affirmed through USFA structure fire statistics seem to point in positive

direction, the information revealed by Dr. Rich and Chief Lee casts a pall of doubt over the trend

toward decreasing injuries. However, armed with the knowledge of the silent killers lurking on


the fireground, departments can easily mitigate the hazards. The concept of active cooling was

also revealed through the literature review.

The current situation in the department was done through the analysis of policies in the

literature review and through the internal questionnaire. The policy review yielded two results

and both contained only limited information on respiratory protection. There was no policy

found on rehabilitation, although it is practiced on almost all scenes and follows many of the

NFPA 1584 recommendations. The results of the internal questionnaire are included in Table 1.

Table 1

Responses to Internal Questionnaire

Question: 1 2 3 4 5

1. My supervisor stresses the importance of rehab on fireground scenes

0 7 13 23 10

2. I fully understand rehab SOPs and protocols 3 3 8 28 10

3. I am allowed to work as long as I want on the fireground without being sent for rehab

5 22 14 9 3

4. I have been criticized for going to or spending too much time in rehab or I have felt pressure to work past my limits

25 16 6 6 0

5. I have been critical of others for going to or spending too much time in rehab

14 9 13 15 2

6. I fully understand respiratory protection policies and protocols related to fireground operations

2 0 3 25 23

7. I have performed overhaul without an SCBA while there were products of combustion (off-gassing or smoke), to which I was exposed

10 16 8 17 2

8. It is OK to work in smoky atmospheres without SCBA as long as the air has been monitored and the CO levels are within acceptable limits

17 17 4 10 5

9. The only time medical monitoring is necessary is when someone has physiological symptoms that need to be examined

20 20 7 5 1


For the first question, my supervisor stresses the importance of rehab on fireground

scenes, the majority at 43 percent, agreed, with the next highest percentage, 24.5, rated as

neutral. The overwhelming majority of over 54 percent felt they fully understood rehab SOPs

and protocols. A little over 11 percent disagreed or strongly disagreed with question 2. A clear

majority of over 77 percent either disagreed or strongly disagreed that they had been criticized

for spending too much time in rehab, while a smaller majority of 43 percent either disagree or

strongly disagreed that they had been critical of others for spending too much time in rehab.

Over 88 percent responded that they either agreed or strongly agreed that they fully understood

respiratory protection policies and protocols. Almost half the respondents strongly disagreed or

disagreed in regards to performing overhaul without an SCBA, and only 36 percent either agreed

or strongly agreed. More than 64 percent disagreed or strongly disagreed that CO levels alone

was an acceptable monitoring standard, with 28 percent agreeing or strongly agreeing that it was

OK to work without SCBA in a CO monitored, but smoky atmosphere. The vast majority

disagreed with the statement that only symptomatic personnel require medical evaluation.

In the external survey, the desired goal was to identify what other organizations are doing

in terms of firefighter rehab and respiratory protection. The results are included in Table 2.

Table 2

Responses to External Questionnaire

1. Does your department have an SOP / SOG that governs fireground rehabilitation?

• Yes 16

• No 11

• Not Sure 1


2. Is it standard procedure in your department to establish a formal rehab sector?

• Yes 18

• No 8

• Not Sure 2

3. Does your department utilize specialized rehab equipment, such as mister fans and tents,

rehab / cool down chairs, rehab trucks or trailers?

• Yes 19: 8 mister fans, 5 tents, 3 active cooling chairs, 6 trucks

or

Trailers, and 3 fans

• No 9

4. Does your department mandate medical monitoring of firefighters at structure fires when

entering and leaving rehab?

• Yes 10

• No – but EMS is available if needed 13

• No – EMS only responds if called 5

5. Does your department have a specific respiratory protection policy?

• Yes 24

• No 3

• Not Sure 0

6. What method does your department use to clear an atmosphere to allow firefighters to

work without an SCBA?

• Monitor atmosphere for safe Carbon Monoxide level 8

• Use positive pressure ventilation to clear structure 3

• No policy – Judgment call of the Incident Commander 8

• Not allowed – Policy mandates wear of SCBA in any

hazardous atmosphere 5

• Other: monitor and use positive pressure 3

7. What is the composition of your department?

• All Paid 9

• All Volunteer 3

• Combination 14


8. What population level does your jurisdiction serve?

• Less than 10,000 9

• 10,000 – 50,000 12

• 50,000 – 100.000 1

• Over 100,000 4

Over 57 percent of the respondents reported their organization did have an SOP for

fireground rehab and over 64 percent had a procedure to establish a formal rehab sector. Almost

68 percent used some type of specialized equipment to support rehab. A majority of

departments, 46 percent, did not require medical monitoring, but did have EMS available.

Nearly 86 percent said they had a respiratory protection policy. Clearing the atmosphere was

split at 25 percent each for monitor for carbon monoxide and no policy. The next highest

response was mandated SCBA wear with almost 18 percent. Over half the respondents

represented combination departments and the majority of departments served populations less

than 50,000.

The final procedure involved analyzing the current practices of the department as

compared to the NFPA 1584 standard and those results are displayed in Table 3.

Table 3

Comparison of CHFD practices to the NFPA 1584 recommended practice

Criteria: F = full compliance, P = partial, N = non-compliant F P N

Standard Operating Procedures (SOPs) should be developed that include the following elements: medical evaluation and treatment, food and fluid replenishment, and crew rotation and relief.

X

Emergency Medical Service (EMS) protocols should be developed in collaboration with the EMS medical director, the fire department physician, and the fire chief.

X

All members are trained to recognize the symptoms or heat and cold stress.

X


SOPs should ensure that rehab operations are put in place whenever an incident escalates beyond the normal limits of physical or mental endurance.

X

Personnel are trained in proper hydration and nutrition X

ICs must ensure that rehab is set up in area that is capable of conducting rehab operations and is also sheltered from any weather extremes

X

In the event of hot weather, the area should be shaded or equipped with tents, fans, and misters, or air conditioning if inside a facility. X

Firefighters should also have the ability to sit and remove gear X

For extremes of cold and wet, the area or facility should be dry and provide warmth and dry clothing. X

EMS at a minimum of Basic Life Support (BLS) level should be provided for firefighters and EMS personnel should be included within the tactical level of the incident management systems

X

EMS personnel should question firefighters arriving at rehab to determine illness, injury, and exertion. X

Upon entering the rehab area, the following criteria from each firefighter should be evaluated: 1 -10 on the RPE scale, blood pressure, temperature, and heart rate.

X

Local EMS protocols and department SOPs should always be utilized in the triage and treatment of firefighters. X

Firefighters meeting or exceeding any triage parameter should be evaluated after twenty minutes. If, after rest, the firefighter is still within an unacceptable range in any one parameter, the firefighter should be taken for medical treatment. (NFPA, 2003)

X

Assignment to and out of rehab is a function of the IMS and members must be tracked through a personnel accountability system

X

Upon entering rehab, firefighters should have the resources to add or remove clothing in order to regain body temperature, eat food to replace the calories expended in the operation, and drink water or sports drinks to return the body’s fluid and electrolyte balance

X

Work-rest cycles are established for personnel engaged in various types of work. X

Following the formal establishment of rehab, no one should be allowed to return to duty until after resting and re-hydrating for a minimum of 10 minutes and being medically evaluated and cleared by EMS personnel

X

Firefighters should not be in an operational role at a scene for 12 or more hours without a multi-hour break away from the scene. X

If a member or members of the crew are seriously injured or killed, the entire crew is relieved of duty immediately. The department then implements critical incident stress management protocols

X


The time entering and leaving rehab should be recorded for all personnel. X

Medical evaluation done should be documented on a rehab evaluation report. X

If any medical treatment is performed, the required EMS forms as well as injury reports and workers compensation forms must be accomplished.

X

Discussion

The importance of understanding the underlying cause and the significant hazards of

exposure to carbon monoxide and cyanide cannot be overstated. That is one of the single most

important elements that resulted from this study. Especially since cyanide is such a common by

product in fires due to the plastics and other materials found in the modern built environment

(Lee, 2007). Equally troubling is the high potential for lethality and the short half-life in the

body that makes it so difficult to diagnose and treat, especially since it mimics other symptoms

so well (Lee). The encouraging news is the advent of experimental therapies that can be given

post exposure that chemically combines with the cyanide to form a harmless B vitamin (Rich,

2007). Additionally, armed with the knowledge that the silent killers are lurking on the

fireground, departments can easily mitigate the hazard by ensuring firefighters only remove their

SCBA when there in zero off-gassing of post-fire fuels. This should become policy and practice

in every department in America.

The review of the department policies was not surprising. SOP 300-1 is in need of an

update and SOP 500-3.10 does not establish an unequivocal benchmark for when it is safe to

remove SCBA (CHFD, 2002). Having served in each of the identified command roles,

command, operations, and safety, the author can attest that it is standard practice to allow

firefighters to enter post-fire buildings when there is off-gassing of fuels taking place, so long as

the carbon monoxide benchmark is met. Having been one of the firefighters, the desire to get out


of the SCBA is normally much stronger than the perceived harm, and therein lies the problem:

the hazards present in today’s fire are more hazardous than ever, but the perception is that a little

smoke will not hurt you. In order to ensure the health and safety of our personnel, we must

provide the necessary education to change attitudes and behaviors.

Clearly, there exists a need for a comprehensive respiratory protection policy where all

the required information can be accessed by everyone. The responses to the questionnaires in

regards to policies and practices are also somewhat bewildering. The vast majority of personnel

responded that they understood rehab SOPs and protocols, yet there is no SOP that covers rehab.

A positive note from the internal survey was the recognition among a sizable portion that

it was not OK to work in smoky atmospheres, and that medical monitoring is not just for the

symptomatic. Another positive was that only a small group felt that their supervisor did not

stress the importance of rehab, and a majority also has neither criticized others nor been

criticized for going to rehab.

There were few surprises in the external survey. The results of the medical monitoring

and atmosphere clearing questions were somewhat troubling, but the majority did have an SOP

for rehab as well as a respiratory protection policy. A large majority employ specialized

equipment to support rehab.

Another key element of the study was the information on active cooling. The forearm

immersion study conducted by the DRDC was nothing less than astounding (Selkirk et al.,

2004). The use of the active cooling concept needs to be widely communicated and others in the

marketplace need to develop new equipment and tools utilizing the concept.

The use of the NFPA 1584 standard as a process benchmark served to identify areas for

improvement in the departments rehab program. Not surprising, there were many areas were full


or partial compliance were already present. The identification of avenues for process

improvement is a good first step towards change.

Recommendations

The first recommendation is to complete an overhaul of SOP 300-1 and 500-3.10. In

addition to or in place of, there needs to be a comprehensive respiratory protection SOP that

provides all the information needed for a successful program and includes it all in one place.

Additionally, a new SOP governing rehab needs to be developed. The new rehab SOP should

follow the guidelines established in NFPA 1584 as closely as possible.

All personnel need training on the new and revised policies to ensure there are no

assumptions of what the SOPs and policies are. The information regarding the carbon monoxide

and cyanide poisoning needs to be communicated to each member and followed up with

recurring training to ensure everyone understands the significant threat that those hazards posses.

Finally, in order to take advantage of the phenomenal concept of active cooling, the

department should implement it as soon as possible. Investigate the purchase of rehab chairs

and/or adapt equipment for use in active cooling. The better a firefighter recovers, the more

work can be accomplished and the incident of injury reduced. Investing in equipment that helps

firefighters rehab more effectively and reduces the potential for exhaustion and injury is

definitely an acquisition worth pursuing.


References

Centers for Disease Control (2004, January 27). Facts about cyanide. Retrieved April 14, 2007,

from http://www.bt.cdc.gov/agent/cyanide/basics/facts/asp

Chapel Hill Fire Department (1990). Standard Operating Procedure No. 300-1. In D. L. Jones

(Ed.), Chapel Hill Fire Department: Standard Operating Procedures (pp. 1-2). Chapel

Hill, NC: Author.

Chapel Hill Fire Department (2002). SOP 500.3.10. In D. L. Jones (Ed.), Chapel Hill Fire

Department: Standard Operating Procedures (pp. 1-7). Chapel Hill, NC: Author.

Chapel Hill Fire Department (2004). Rules, regulations and policies of the Chapel Hill Fire

Department. Chapel Hill, NC: Author.

Federal Emergency Management Agency (2006, December 28). U.S. Structure Fire Loss: 1996-

2005. Retrieved April 5, 2007, from http://www.usfa.dhs.gov/statistics/national/

all_structures.shtm

Lee, M. (2007, April 11). Cyanide poisoning poses hidden threat. Firerehab.com, 3, pp. 1-3.

Retrieved April 14, 2007, from http://www.firerehab.com/news/283219

National Fire Protection Association (2003). Recommended practice on the rehabilitation of

members operating at incident scenes operations and training exercises (2003 ed.).

Quincy, MA: Author.

National Fire Protection Association / International Association of Fire Chiefs (2004).

Fundamentals of firefighter skills (1st ed.). Sudbury, MA: Jones and Bartlett.

Rich, P. B. (2007, March 26). The heart, hemoglobin, and the firefighter. Paper presented at the

Chapel Hill Fire Academy, Chapel Hill, NC.


Selkirk, G. A., McLellan, T. M., & Wong, J. (2004, August). Active versus passive cooling

during work in warm envrionments while wearing firefighter protective clothing.

Retrieved April 17, 2007, from http://cradpdf.drdc.gc.ca/PDFS/unc48/p523427.pdf

TriData Corporation (2004). The economic consequences of firefighter injuries and their

prevention. Gaithersburg, MD: National Institute of Standards and Technology.

United States Fire Administration / National Fire Data Center (2004). Fire in the United States:

1992-2001 (13th ed.). Emmitsburg, MD: Author.


Appendix A

CHFD Rehab Questionnaire

Please evaluate the following questions in terms of your personal opinion and perspective. All responses are anonymous and confidential. All responses should be given within the context of your position at the CHAPEL HILL FIRE DEPARTMENT ONLY. Each item is rated in terms of how strongly you agree or disagree with each statement on a five point scale: 1 = Strongly Disagree, 2 = Disagree, 3 = Neutral, 4 = Agree, 5 = Strongly Agree. Only rate a question neutral if you have no opinion or no information on which to base an answer. Place an X in the block that most represents your point of view.

Strongly – Disagree – Neutral – Agree – Strongly Disagree Agree

Question: 1 2 3 4 5 1. My supervisor stresses the importance of rehab on fireground scenes

2. I fully understand rehab SOPs and protocols

3. I am allowed to work as long as I want on the fireground without being sent for rehab

4. I have been criticized for going to or spending too much time in rehab or I have felt pressure to work past my limits

5. I have been critical of others for going to or spending too much time in rehab

6. I fully understand respiratory protection policies and protocols related to fireground operations

7. I have performed overhaul without an SCBA while there were products of combustion (off-gassing or smoke), to which I was exposed

8. It is OK to work in smoky atmospheres without SCBA as long as the air has been monitored and the CO levels are within acceptable limits

9. The only time medical monitoring is necessary is when someone has physiological symptoms that need to be examined


Appendix B

Fireground Rehab and Respiratory Protection Questionnaire

This is a research project survey to determine how organizations are managing firefighter rehabilitation and respiratory protection on the fireground.

9. Does your department have an SOP / SOG that governs fireground rehabilitation?

• Yes

• No

• Not Sure

10. Is it standard procedure in your department to establish a formal rehab sector?

• Yes

• No

• Not Sure

11. Does your department utilize specialized rehab equipment, such as mister fans and tents,

rehab / cool down chairs, rehab trucks or trailers?

• Yes Please

specify:_______________________________________________

• No

12. Does your department mandate medical monitoring of firefighters at structure fires when

entering and leaving rehab?

• Yes

• No – but EMS is available if needed

• No – EMS only responds if called

13. Does your department have a specific respiratory protection policy?

• Yes

• No

• Not Sure


14. What method does your department use to clear an atmosphere to allow firefighters to

work without an SCBA?

• Monitor atmosphere for safe Carbon Monoxide level

• Use positive pressure ventilation to clear structure

• No policy – Judgment call of the Incident Commander

• Not allowed – Policy mandates wear of SCBA in any hazardous atmosphere

• Other:

____________________________________________________________

15. What is the composition of your department?

• All Paid

• All Volunteer

• Combination

16. What population level does your jurisdiction serve?

• Less than 10,000

• 10,000 – 50,000

• 50,000 – 100.000

• Over 100,000

17. Please list your organization. All information collected will remain confidential and this

information is only being collected to avoid duplication.

Thank You!

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