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Amy Gutman MD EMS Medical Director Tobey Emergency Associates prehospitalmd@gmail.com

Emergency Incident Rehabilitation. Amy Gutman MD EMS Medical Director Tobey Emergency Associates prehospitalmd@gmail.com. Objectives. Define Emergency Incident R ehabilitation (EIR) Discuss importance of EIR Understand which situations warrant EIR Impact of weather conditions

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Amy Gutman MD EMS Medical Director Tobey Emergency Associates prehospitalmd@gmail.com

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  1. Emergency Incident Rehabilitation Amy Gutman MD EMS Medical Director Tobey Emergency Associates prehospitalmd@gmail.com

  2. 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

  3. Background • Job-related danger historically a “badge of courage” • Resting is sign of weakness • Firefighters often boast of element of danger • Firefighter deaths & injuries are not badges of courage but indicators of problems

  4. 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

  5. Process & Function of EIR • The process of providingrest, rehydration & nourishment • Medical evaluation & treatment • Initial evaluation • Continual monitoring of physical condition • Transportation for those requiring treatment at a hospital

  6. What Is Emergency Incident Rehabilitation (EIR)? • Rehab operations not limited to emergency scenes • Other activities potentially requiring EIR include: • Training exercises • Athletic events • Parade or event standbys

  7. 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

  8. Breakdown of Firefighter Deaths *2006 NFPA's Fire Incident Data Organization (FIDO) Cause of Injury Percent Exertion/Stress/Other 42.7% 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%

  9. The Functions Of A EIR Operation

  10. 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

  11. 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

  12. 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

  13. 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

  14. R4: Rx (Treatment) • Injuries • Obvious & “non-obvious” • Dehydration • Heat Exhaustion • Hypothermia • Seemingly minor complaints may lead to immediate or delayed cardiovascular abnormalities

  15. R5: Climate Relief • Personal climate • Environmental climate • Case climate A little something for the ladies

  16. 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)

  17. Physical Assessment • General Assessment • Vitals • Medical evaluation • Revitalization • Reassignment

  18. Revitalization • Rest • Adequate time for core temp & vitals to return to normal • Fluid replenishment • Provide appropriate fluids to replace losses • Nutrition • Nourishing & nutritionally sound food

  19. 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 priority • i.e. hypoglycemia or dehydration

  20. 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

  21. Establishing EIR

  22. 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

  23. 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

  24. Weather Conditions • Hot Weather • Ambient temperature • Relative Humidity • Direct Sunlight • Cold Weather • Ambient temperature • Wind chill factor

  25. 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)

  26. 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

  27. Injuries Associated with Heat Stress Index Conditions

  28. 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

  29. Cold Weather Rehab Challenges • Hypothermia • Insufficient clothing protection against the cold • Allows decrease in body temperature • Frostbite • Isolated body part freezing

  30. 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)

  31. Other Situations Where EIR Necessary • Crime scene/standoffs • Search activities • Public events • Training events

  32. Crime Scene / Standoffs • Bomb squad & tactical / SWAT team members • Operate for long periods of time in heavy protective clothing • Heat & Cold effects • High stress situations

  33. 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

  34. Public Events • Fairs, carnivals, festivals • Auto Races • Parades • Concerts • Sporting events • Political rallies • Large-scale religious ceremonies

  35. The first five minutes of an incident can dictate the outcome of the next five hours Establishing & Managing EIR

  36. 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

  37. Rehab Location • Close to Incident Command... • Easy tracking of personnel • Easy to track progress of those in rehab • Efficient use of equipment • But…Far enough away • Easier for the personnel to relax • Fewer distractions

  38. 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?

  39. 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

  40. Additional Resources • Metro Bus • Salvation Army &/ or Red Cross • BLS or ALS Engines • Additional Ambulance or Rescue Units • Medical Director (s)

  41. 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

  42. 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

  43. Roles of the EIR Staff • Rehab area should be equipped to handle a myriad of medical situations • Required Equipment: • Cardiac monitor/ defibrillator • Airway bag • Drug box & IV supplies • Suction • Trauma supplies • Rehab personnel must assure accountability for fire & rescue personnel who enter & exit rehab

  44. 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

  45. EIR Time Frame • The amount of time a responder requires in EIR varies depending on a variety of conditions: • Responders level of physical conditioning • Atmospheric conditions • Nature of the activities the responder was performing • The time needed for adequate rehydration • A good rule of thumb is 20 minutes per visit • Equates to change-out time for oxygen cylinders

  46. Medical Evaluation • Immediately on entry assess for injury • If no injury, then onto full assessment • Vitals • BP, RR, HR, SaO2, Temp – obtain and document • Personnel with abnormal VS should be sent for treatment • HR > 120 BPM • SBP > 160 mm/Hg or < 90 mm/Hg • DBP > 110 mm/Hg

  47. Medical Evaluation • No personal should return to active duty if after 20 minutes of rest if: • HR > 100 BPM • SBP > 160 mm/Hg or < 100 mm/Hg • DBP > 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

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