Emergency Incident Rehabilitation1 EMERGENCY INCIDENT REHABILITATION Mason County Emergency Medical...

Emergency Incident Rehabilitation 1

EMERGENCY INCIDENT REHABILITATION

Mason County Emergency Medical Services

Douglas Richardson, EMT-P


Objectives

• Define rehabilitation in context to emergency workers.

• Discuss the importance of rehabilitation to the fire and emergency services.

• Understand situations warranting, and criteria for initiating rehabilitation.


Objectives

• Discuss the impact of Heat Stress on emergency workers.

• Discuss the impact of Wind Chill on emergency workers.

• List criteria for the appropriate placement of a rehabilitation area.


Objectives

• List five (5) reasons to send emergency workers for medical evaluation.

• List four (4) criteria that should be meet before emergency workers are allowed to return to duty.


Objectives

• List two (2) reasons for not allowing injured emergency workers to return to active duty.

• List ten (10) reasons to transport emergency workers to an appropriate hospital for further evaluation.


Objectives

• Discuss the physiological consequences of fluid loss.

• Define osmolarity and discuss the importance of osmolarity in the rehydration of fire / rescue personnel.


What is Rehab and Why Do We Need It?


Background To Rehab

For many years the fire service has treated the element of job-related danger as a badge of courage, worn with pride. Firefighters would boast of this element of danger when discussing the merits of various occupations.


Background To Rehab

In the last 20 years or so, however, the attitude of the fire service toward safety has changed dramatically. Firefighters and department officials began to realize that needless deaths and injuries of firefighters were not badges of courage but indicators of problems.


Background To Rehab

• If firefighters are extended beyond their safe operating periods, the results may be:– Stress- or fatigue-related illness or injury– The Firefighter, although uninjured, will be

fatigued to a point at which he/she is unable to continue in the operation

– The mentally and/or physically fatigued firefighter may make poor decisions in a high-risk environment


What Is Rehab?

In the Emergency Services, rehabilitation, or rehab, describes the process of providing rest, rehydration, nourishment, and medical evaluation to responders who are involved in extended and/or extreme incident scene operations.


What Is Rehab?

• Note that Rehab operations are not limited to emergency scenes. Other type of activities that might necessitate Rehab include:– Training exercises– Athletic events– Parade or event standbys


Why Do We Need Rehab

• Over 50% of all firefighter deaths are to some extent, directly attributed to stress and overexertion.


The Functions Of A Rehab Operation

• Physical assessment

• Revitalization (rest, rehydration, and nutritional support)

• Medical evaluation and treatment

• Continual monitoring of physical condition

• Transportation for those requiring treatment at a hospital



• Initial critical incident stress assessment and support.

• Reassignment


Physical Assessment

• General physical assessment

• Basic vital signs

• Medical evaluation

• Revitalization

• Reassignment


Revitalization

• Rest– An adequate amount of time for core temp and

vital signs to return to normal.

• Fluid replenishment– Provided with appropriate fluid to replace those

lost

• Nutrition– Should receive nutritionally sound food


Medical Evaluation and Treatment

• Firefighters who appear ill or injured should be assigned to personnel in the medical evaluation/treatment area for rehab

• This should not be delayed by providing with drinks/food unless the medical evaluation shows this to be a priority.


Continual Monitoring of Physical Condition

• Firefighters in the rehab area should have their condition continual monitored.

• Firefighters who meet the criteria for release from rehab should be reassigned or released from care

• Firefighters who do not respond to rest or medical attention may require more intensive interventions.


Continual Monitoring of Physical Condition

• No one should be released from rehab until he/she is medically sound or,

• Is transported to a medical facility for further treatment.


Knowing When To Establish Rehab



The goal of emergency incident rehab operations is to lessen the risks of injury that may result from extended operations, which are sometimes carried out in adverse conditions, involving weather and other factors.



Ideally, rehab operations should commence whenever emergency operations pose a risk of pushing personnel beyond a safe level of physical and mental endurance.



• Extended fire incidents

• Hazardous Material Incidents

• Prolonged rescue/recoveries

• Adverse weather conditions

• Crime scene/standoff’s

• Search activities


Extended Fire Incidents

• Structure Fires• High-rise structural

fires• Wildland fires


Weather Conditions

• Hot-Weather– Ambient temperature

– Relative Humidity

– Direct Sunlight

• Cold-Weather– Ambient temperature

– Wind chill factor


Hot-Weather

Even under the “ideal” climatic conditions, fires, hazmat incidents, and rescue operations place a variety of thermal stresses on the responders operating at them.


Hot-Weather

Emergency responders must frequently perform heavy physical labor in heated atmospheres, while wearing bulky protective clothing. In those “ideal” conditions when the responders have completed their assignments they go to a safe area such as rehab to remove their clothing and cool down.


Hot-Weather


Hot-Weather

• Ambient air temperature and relative humidity can be factored together to create what is often referred to as a “Heat IndexHeat Index”

• Working in direct sunlight can add 10ºF to the heat index.

• Working in full turn-out gear can add an additional 10ºF to the heat index.


Heat Stress IndexRelative Humidity

Temp °F 10% 20% 30% 40% 50% 60% 70% 80% 90%

104 98 104 110 120 132102 97 101 108 117 125100 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 77Note: 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


Heat Stress Index

• The USFA (United States Fire Administration) recommends that rehab operations be initiated whenever the heat stress index exceeds 90 ºF (32 ºC).


Cold-Weather Conditions

Often overlooked when determining the need for rehab operations are the effects of cold weather on responders who must operate in low-temperature conditions for long periods of time.



Cold weather poses different rehab challenges to emergency responders then the warm-weather scenarios talked about earlier. The potential threat to the well-being of the emergency workers from them, however is just as great.



An emergency worker insufficiently protected against the cold may have his/her body’s core temperature lowered to dangerous levels under extreme circumstances. This condition is referred to as hypothermia.hypothermia.



The most common cold-weather related injuries among emergency responders are localized cold injuries, commonly called frostnip frostnip or frostbite. frostbite. These injuries occur when particular parts of the body are exposed to extreme cold for extended periods of time.


Wind Chill

Just as heat and humidity combine to increase the impact of heat, cold and wind combine to impact the effects of cold upon the human body.

The combined effect of cold and wind is referred to as the Wind Chill Factor.Wind Chill Factor.


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


Wind Chill Factor

The USFA (United States Fire Administration) recommends initiating rehab operations whenever the wind chill factor drops to 10ºF (-12º C) or lower.


Other Situations Where Rehab May Be Necessary

• Crime scene/standoffs

• Search activities

• Public events

• Training events


Crime Scene / Standoffs

• Bomb squad members who have been operating for long periods of time in heavy protective clothing.

• Police tactical unit teams who have been operation in forward positions for a long period of time.


Search Activities

• Large area searches for person(s) who have wandered away from their home.

• Urban search and rescue (USAR) incidents following a natural or manmade disaster, such as a structural collapse.

• Searches for climbers, hikers, or others involved in sports or recreation activities.


Public Events

• Fairs, carnivals or other festivals

• Auto Races

• Parades

• Concerts

• Major sporting events

• Political rallies

• Large-scale religious ceremonies


Establishing and Managing A Rehab Area

The first five minutes of an The first five minutes of an incident can dictate the incident can dictate the

outcome of the next five hoursoutcome of the next five hours.


Establishing and Managing A Rehab Area

• Once the need for a rehab has been established the most important decision and one that must be made almost immediately is where to locate the rehab operations.

• Making a good initial choice for the location of rehab is vital. Trying to relocate rehab later in the incident can be very difficult to nearly impossible.


Locating the Rehab

• Close to Incident Command– More easily keep track of who is in rehab– Easier to anticipate when people will be ready– More efficient use of equipment

• Away from Incident Command– Easier for the personal to relax– Fewer distractions


Site Characteristics

• The site for the Rehab must be selected on several criteria:– The estimated number of people that will need

to be rehabbed– The weather at the time of the incident– The duration of the incident



• The site should be outside, uphill and upwind of the operational hazard area.

• The site should permit prompt reentry into emergency operations when personnel have completed rehab.

• The site should provide maximum protection from environmental extremes.



• The site should be large enough to accommodate all those that need rehab.

• The site should be free of vehicle exhaust.• The site should be as quite as possible.• Access to the site by the media should

restricted.• The site should provide SCBA

replenishment/refill.



• The site should have easy entrance and exit routes for ambulances.

• The site should have a supply of running and drinking water.

• It is helpful if restroom facilities are part of the rehab.



• If the incident involves the recovery of fatalities, the rehab site should be out of view of the work area.


Staffing of The Rehab Area

The most highly trained and qualified EMS personnel on the scene should provide medical evaluation and treatment in the Rehab area.


Roles of the Rehab Staff

• EMT’s must assure that the sector provides a safe area in which fire and rescue crews can rest and receive rehydration.

• EMT’s must identify fire and rescue personnel entering the rehab who are at risk for heat- and stress-related illness or injury.



• EMT’s should have an AED readily available in the unlikely, but statistically important, event that a fire or rescue personnel experiences cardiac arrest.

• EMT’s must assure accountability for fire and rescue personnel who enter and exit the rehab



• EMT’s must medically monitor crews to determine whether they:– Are fit to return to active fire/rescue duty.– Require additional hydration and rest.– Require transport to an ED for further.

evaluation and medical treatment.



• EMT’s must give regular reports/updates to the Safety Officer or the Incident Commander.


Rehab

• The amount of time that a responder will require in rehab will vary depending on a variety of conditions:– The responders level of physical conditioning.– The atmospheric conditions.– The nature of the activities the responder was

performing prior to entering rehab.– The time needed for adequate rehydration.


Rehab - Rest

It is recommended that departments establish a minimum amount of time that fire/rescue personal spend in rehab. This will vary with the atmospheric conditions and the number of personal available but a good rule of thumb is that each person spend at least 20 20 minutesminutes in rehab.


Rehab - Rehydration

• The hydration that occurs in the rehab is very important to a responders recovery.

• Personnel who perform heavy work under stressful conditions, while wearing heavy personal protective clothing are subject to excessive fluid loss.


Rehab - Rehydration

• While fluid loss is obvious in hot weather conditions, do not overlook the fact that dehydration also occurs in cold climates.

• Maintaining sufficient levels of water and electrolytes in the body can greatly aid in the prevention of heat- or stress-related illness or injury.


Osmolarity

• Osmolarity can be roughly defined as the “thickness” of a fluid as determined by the electrolyte and carbohydrate content of the beverage.

• The higher the osmolarity the longer the time it will take to absorb the fluid.

• In general it is recommended that rehydration solutions do not exceed an osmolarity of 350mOsm/liter.


Characteristics of Beverages Commonly Used for Rehydration

Beverage Sugar Concentration Sodium Potassium Osmolarity

Gatorade 6% 110mg 25mg 280-360Exceed 7.2% 50mg 45mg 250Body Fuel 4.2% 80mg 20mg 21010-K 6.3% 52mg 26mg 350Quickick 4.7% 116mg 13mg 305Coca-Cola 11% 9.2mg trace 600-715Sprite 10.2% 28mg trace 695Cranberry Juice 15% 10mg 61mg 890Orange Juice 11.8% 2.7mg 510mg 690Water ---- low low 10-20Serving Size 8 fluid ounces.


Rehab - Rehydration

• Assure that the rehydration solutions have an osmolarity of less than 350 mOsm/liter.

• Assure that rehydration solutions are administered in reasonable rather than excessive amounts.

• Assure that rehydration solutions are not carbonated.


Medical Evaluation

• On entry into the Rehab each fire/rescue personal should be triaged to determine if medical treatment or transport is necessary.


Medical Evaluation

• On entry any rescue fire personal with any of the following should be sent immediately to the treatment area of rehab– A heart rate of greater the 120 BPM– A systolic BP of greater then 200 mm/Hg– A systolic BP of less then 90 mm/Hg– A diastolic BP of greater then 110 mm/Hg– Any Traumatic injury


Medical Evaluation

• No fire/rescue personal should be returned to active duty if after 20 minutes of rest if he/she presents with:– A pulse of greater than 100 BPM– A systolic BP of greater than 160 mm/Hg– A systolic BP of less than 100 mm/Hg– A diastolic BP of greater than 90 mm/Hg


Medical Evaluation

• No fire/rescue personal should be returned to active duty if he/she presents with:– An injury that may be worsened by a return to

duty.– An injury that might in any way impair the

performance of his/her duty.


Medical Evaluation

• Any fire/rescue personal should be considered for transport to the hospital if he/she presents with:– Chest pain– Shortness of breath– Altered mental status– Skin that is hot and either moist or dry– Irregular pulse


Medical Evaluation

• Any fire/rescue personal should be considered for transport to the hospital if he/she presents with:– Oral temp of greater than 101ºF– Pulse of more than 150 BPM at any time– Pulse of more than 140 BPM after cool down


Medical Evaluation

• Any fire/rescue personal should be considered for transport to the hospital if he/she presents with:– Systolic BP of greater than 200 mm/Hg after

cool down– Diastolic BP of greater than 130mm/Hg at any

time


Medical Evaluation

• Any emergency worker should be considered for transport to the hospital if he/she is unable to orally rehydrate due to nausea and vomiting.


Application

• Define rehabilitation in context to emergency workers.

• Discuss the importance of rehabilitation to the fire and emergency services.

• Understand situations warranting, and criteria for initiating rehabilitation.


Application

• Discuss the impact of Heat Stress on emergency workers.

• Discuss the impact of Wind Chill on emergency workers.

• List criteria for the appropriate placement of a rehabilitation area.


Application

• List five (5) reasons to send emergency workers for medical evaluation.

• List four (4) criteria that should be meet before emergency workers are allowed to return to duty.


Application

• List two (2) reasons for not allowing an injured emergency workers to return to active duty.

• List ten (10) reasons to transport emergency workers to an appropriate hospital for further evaluation.


Application

• Discuss the physiological consequences of fluid loss.

• Define osmolarity and discuss the importance of osmolarity in the rehydration of fire / rescue personnel.


Summary

Deciding when and if to initiate rehab, and deciding where to set up rehab are decisions that must be made early on in an incident.

Rehydration and constant monitoring of fire /rescue personnel is of the utmost importance.


Summary

• Following accepted guidelines for returning emergency workers to duty, will aid in both returning fit workers to duty while at the same time keep stressed/injured workers from the risk of causing further harm to themselves.


Bibliography

The material presented in this course was compiled using Emergency Incident Rehabilitation, Edward T. Dickson, MD, NREMT-P, FACEP and Michael A Wieder, MS, CFPS, Brady publishing, International Fire Service Training Institute.

Photos by Julie Richardson, Kim Wheat, and Valarie Bell

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