Incident Rehabilitation for Incident Rehabilitation for Response Personnel Response Personnel

Capt. W Michael Collins, Capt. W Michael Collins, NREMT-PNREMT-P

Session ObjectivesSession Objectives

Identify the legal requirements for Identify the legal requirements for establishing the Rehab Group.establishing the Rehab Group.

Describe the “9 Elements of Rehab”.Describe the “9 Elements of Rehab”. Describe the fireground medical Describe the fireground medical

assessment.assessment. Describe how the Incident Describe how the Incident

Commander uses the Rehab Group in Commander uses the Rehab Group in the incident management process.the incident management process.

Legal RequirementsLegal Requirements

Occupational Safety and Health Occupational Safety and Health Administration (OSHA)Administration (OSHA)

National Institute for Occupational National Institute for Occupational Safety and Health (NIOSH)Safety and Health (NIOSH)

National Fire Protection Association National Fire Protection Association (NFPA)(NFPA)

Just what is “rehab”Just what is “rehab”

Defined as : Defined as : An An attempt to restore attempt to restore (a person) to (a person) to normal physical normal physical functioningfunctioning Sustain or restore Sustain or restore

work capacitywork capacity Improve performanceImprove performance Decrease injuriesDecrease injuries Prevent deathsPrevent deaths

Nine Key elements to RehabNine Key elements to Rehab

1.1. Relief from climatic conditionsRelief from climatic conditions

2.2. Rest and recoveryRest and recovery

3.3. Cooling or rewarmingCooling or rewarming

4.4. Re-hydrationRe-hydration

5.5. Calorie and electrolyte replacementCalorie and electrolyte replacement

6.6. Medical MonitoringMedical Monitoring

7.7. EMS tx according to local protocolsEMS tx according to local protocols

8.8. Member accountabilityMember accountability

9.9. ReleaseRelease

1. Relief from climatic 1. Relief from climatic conditionsconditions

Most common use is the Ride-On BusMost common use is the Ride-On Bus There are some positivesThere are some positives There are some negativesThere are some negatives

Consider some our resourcesConsider some our resources Decon unitsDecon units Other structures / facilitiesOther structures / facilities

Pegler’s Rehab AxiomPegler’s Rehab Axiom

CCommunications (ommunications (CChildren)hildren) HHydrationydration LLocationocation OOxygenationxygenation RRelaxationelaxation IInspirationnspiration NNutrationutration EEvaluationvaluation

2. Rest and Recovery2. Rest and Recovery

10 minutes of rest10 minutes of rest Removed form Removed form

stress and noisestress and noise Must have an area Must have an area

where FF can sit where FF can sit downdown

Out of Out of contaminated contaminated environmentsenvironments

3. Cooling and Rewarming3. Cooling and Rewarming

CoolingCooling

Heat StressHeat Stress InternalInternal

ExertionExertion ExternalExternal

Environmental conditions (Fire floor)Environmental conditions (Fire floor) Trapped heat (PPE)Trapped heat (PPE)

Heat StrainHeat Strain Body reacts to heat stressBody reacts to heat stress

CoolingCooling

PassivePassive Simple evaporationSimple evaporation Water changing Water changing

from liquid to vaporfrom liquid to vapor The higher the The higher the

humidity the more humidity the more difficult to change difficult to change

CoolingCooling

Active – ConvectionActive – Convection Movement of air Movement of air

reduces heatreduces heat NOTE:NOTE:

When to ambient air When to ambient air temperature is temperature is above 98above 98oo F this has F this has a warming effect.a warming effect.

CoolingCooling

Active- Radiation Active- Radiation Loosing heat to a Loosing heat to a

cooler environmentcooler environment Examples: Examples:

ShadeShade ShelterShelter A facility with acA facility with ac

Are the guys to the Are the guys to the right really cooling right really cooling off?off?

CoolingCooling

Active –ConductionActive –Conduction Skin contact with a Skin contact with a

cooler objectcooler object Cold waterCold water Cold groundCold ground Most of us hate it Most of us hate it

when all of our gear when all of our gear is soaking wet. Is it is soaking wet. Is it still operational?still operational?

Cooling MethodsCooling Methods

Cooling MethodsCooling Methods

Forearm immersionForearm immersion

Canadian study found Canadian study found

one of the fastest way one of the fastest way

to decrease body tempto decrease body temp

Requires a Requires a

commercially available commercially available

chair chair

Cooling MethodsCooling Methods 3 Bucket Cold Towel Technique3 Bucket Cold Towel Technique Bucket 1 (Sanitizing) Bucket 1 (Sanitizing)

¼ cup of bleach¼ cup of bleach Fill with waterFill with water

Bucket 2 (Rinse)Bucket 2 (Rinse) Removes bleachRemoves bleach Fill with clean waterFill with clean water

Bucket 3 (Rejuvenation)Bucket 3 (Rejuvenation) Fill bucket with ice and waterFill bucket with ice and water

3 buckets/20 towels = 60 3 buckets/20 towels = 60 members per hourmembers per hour

4. Re-hydration4. Re-hydration

During extreme During extreme exertion we may exertion we may lose as much as 1 lose as much as 1 qt of sweat per hourqt of sweat per hour

Will require 12 to Will require 12 to 32 oz to replace the 32 oz to replace the lost water.lost water.

Does not end in the Does not end in the Rehab AreaRehab Area

5. Calorie and Electrolyte 5. Calorie and Electrolyte ReplacementReplacement

Fruits, meal replacement bars, Fruits, meal replacement bars, carbohydrate drinks…carbohydrate drinks…

30-60 grams carbohydrate per hour30-60 grams carbohydrate per hour High fat foods inappropriateHigh fat foods inappropriate

6. Medical Monitoring 6. Medical Monitoring

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

6. Medical Monitoring in Rehab

Local (FD) medical monitoring protocols:Local (FD) medical monitoring protocols:

1.1. Immediate EMS treatment and Immediate EMS treatment and transporttransport

2.2. Close monitoring in rehab areaClose monitoring in rehab area

3.3. ReleaseRelease

6. Medical Monitoring in Rehab

Vital signs per FD protocolVital signs per FD protocol Options suggested:Options suggested:

TemperatureTemperature PulsePulse RespirationRespiration Blood pressureBlood pressure Pulse oximetryPulse oximetry CO assessment (pulse CO-CO assessment (pulse CO-

oximetry)oximetry)

Vital SignsVital Signs

Many departments do not measureMany departments do not measure No evidence or published studies:No evidence or published studies:

Determine when treatment necessaryDetermine when treatment necessary Predict type or duration of rehab neededPredict type or duration of rehab needed

Vitals may help set parameters for Vitals may help set parameters for monitoring, treatment, transport, monitoring, treatment, transport, releaserelease

Must be evaluated in Must be evaluated in contextcontext

TemperatureTemperature Core temp most accurateCore temp most accurate

NL = 98.6-100.6NL = 98.6-100.6°°F (37-38.1F (37-38.1°°C)C) Best measured rectally or temp transmitterBest measured rectally or temp transmitter

Oral or tympanic used in fieldOral or tympanic used in field Oral 1Oral 1°°F (0.55F (0.55°°C), tympanic 2C), tympanic 2°°F (1.1F (1.1°°C) lessC) less

Multiple user & environmental potentials Multiple user & environmental potentials for errorfor error

TemperatureTemperature

Elevated temps by measurement or Elevated temps by measurement or touch suggest possible heat related touch suggest possible heat related illnessillness

NOTE:NOTE: normal oral normal oralor tympanic tempsor tympanic tempsdo not exclude heatdo not exclude heatillness!illness!

PulsePulse

NL = 60-80, many influences.NL = 60-80, many influences. Very important to interpret in Very important to interpret in

context of individual.context of individual. Recovery rate may be more Recovery rate may be more

significant than actual heart rate.significant than actual heart rate. If > 100 after 20 min rest, further If > 100 after 20 min rest, further

eval needed before releaseeval needed before release Pulse ox offers accurate measurePulse ox offers accurate measure

Respiratory RateRespiratory Rate

NL = 12 – 20, NL = 12 – 20, should should with with fever and fever and exerciseexercise

Should return to Should return to normal with restnormal with rest

Blood PressureBlood Pressure

Most measuredMost measured Least understoodLeast understood Very contextualVery contextual Tremendous Tremendous

potential for errorpotential for error

Blood PressureBlood Pressure

Sources of errorSources of error::

1.1. Cuff sizeCuff size

2.2. Arm placementArm placement

3.3. NIBPNIBP

Potential for cross contaminationPotential for cross contamination::- Need to decon between each useNeed to decon between each use

Blood PressureBlood Pressure

NFPA suggests members with SBP > NFPA suggests members with SBP > 160 or DBP > 100 not be released 160 or DBP > 100 not be released from rehab.from rehab.

Oddly, Oddly, hypotensionhypotension (SBP < 80) is (SBP < 80) is probably of far greater concern than probably of far greater concern than high blood pressure…high blood pressure…

Pulse OximetryPulse Oximetry

Non-invasive measurementNon-invasive measurementof oxygen and blood flowof oxygen and blood flow

NL = 95-100%NL = 95-100% Most oximeters cannotMost oximeters cannot

differentiate oxyhemoglobindifferentiate oxyhemoglobinfrom carboxyhemoglobinfrom carboxyhemoglobin

Members with SpOMembers with SpO22 < 92% should not be < 92% should not be released from rehabreleased from rehab

CO AssessmentCO Assessment

Carbon monoxide is present at all Carbon monoxide is present at all fires and a leading cause of deathfires and a leading cause of death

NFPA suggests any member exposed NFPA suggests any member exposed to CO or with CO s/s be assessed for to CO or with CO s/s be assessed for CO poisoningCO poisoning

Exhaled CO meter or pulse CO-Exhaled CO meter or pulse CO-Oximeter are two detection devicesOximeter are two detection devices

CO Poisoning AssessmentCO Poisoning Assessment

CO Poisoning AssessmentCO Poisoning Assessment

CO levelsCO levels

Non-smokers = 0 – 5%Non-smokers = 0 – 5% Smokers 5 – 10%Smokers 5 – 10% If > 15%, treat with high flow OIf > 15%, treat with high flow O22

Between 10 – 15%, assess for s/s, Between 10 – 15%, assess for s/s, treat if necessarytreat if necessary

Release from rehab requires normal Release from rehab requires normal CO level per local protocolCO level per local protocol

CyanideCyanide Consider at all fire scenesConsider at all fire scenes All patients in cardiac arrestAll patients in cardiac arrest Any patient in shock, especially if low CO Any patient in shock, especially if low CO

levellevel Treat with cyanide antidote kitTreat with cyanide antidote kit

7. Transport per Protocol7. Transport per Protocol

Advise IC as soon as treatment Advise IC as soon as treatment beginsbegins

FF Name and Unit assignmentFF Name and Unit assignment Possible condition and treatment Possible condition and treatment

providedprovided Receiving hospital Receiving hospital

8. Accountability8. Accountability

Rehab is an assignment like fire attack or ventingRehab is an assignment like fire attack or venting Our Incident Commanders are taught to establish the Our Incident Commanders are taught to establish the

Rehab Group early onRehab Group early on It is the Rehab Group Supervisor responsibility to track It is the Rehab Group Supervisor responsibility to track

units/personnel in the Rehab Area and resources units/personnel in the Rehab Area and resources assigned to that area.assigned to that area.

The Rehab Group Supervisor must keep Command The Rehab Group Supervisor must keep Command advised of progress and what units are in the Rehab advised of progress and what units are in the Rehab AreaArea

REHAB SECTOR Rehab Control Officer’s Check Sheet

Section I Date: ______ Incident #: _________ Incident Commander: ___________

Location: _____________________________________________________

Rehab Officer: ____________________

Rehab Established @ _______________ Rehab Released @ __________

Primary EMS Unit in Rehab: ________

Additional EMS Units: __________________________________________

Section II

Unit #: _____ OIC: _______________ Time In: ____________

Ready for Assignment @: ______ Command Post Notified □ Time Out: ____________

Notes: _________________________________________________________________

Unit #: _____ OIC: _______________ Time In: ____________

Ready for Assignment @: ______ Command Post Notified □ Time Out: ____________

Notes: _________________________________________________________________

9. Release9. Release

Personnel are ready to return to workPersonnel are ready to return to work The Rehab Group Supervisor must inform The Rehab Group Supervisor must inform

Command when Units are readyCommand when Units are ready There will be times that Rehab may fell There will be times that Rehab may fell

like a staging area, and it might just be.like a staging area, and it might just be. Forward your Rehab Forms to the EMS Forward your Rehab Forms to the EMS

Office with any MAIS Forms.Office with any MAIS Forms.

MCFRS Policy

MCFRS Policy

MCFRS Policy

SummarySummary

1.1. Just do it!Just do it!̶U It’s Command’s job to establish the Rehab It’s Command’s job to establish the Rehab

GroupGroup

2.2. Define who will do whatDefine who will do what̶U Medical MonitoringMedical Monitoring̶U Emergency CareEmergency Care̶U Bring suppliesBring supplies̶U Record keepingRecord keeping̶U AccountabilityAccountability

Information for this session Information for this session came fromcame from

Emergency Incident Rehabilitation Emergency Incident Rehabilitation

FEMA FA-314 (July 2008)FEMA FA-314 (July 2008)

The Elephant on the Fire Ground: Secrets The Elephant on the Fire Ground: Secrets

of NFPA 1584 Compliant Rehabof NFPA 1584 Compliant Rehab

Mike McEvoy, PhD, REMT-P, RN, CCRNMike McEvoy, PhD, REMT-P, RN, CCRN

http://www.firerehab.com/http://www.firerehab.com/