EMERGENCY INCIDENT REHABILITATION

1. Emergency Incident Rehabilitation 1 EMERGENCY INCIDENT REHABILITATION Alachua County Fire Rescue Reserves

2. Emergency Incident Rehabilitation 2 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.

3. Emergency Incident Rehabilitation 3 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.

4. Emergency Incident Rehabilitation 4 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.

5. Emergency Incident Rehabilitation 5 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.

6. Emergency Incident Rehabilitation 6 Objectives Discuss the physiological consequences of fluid loss. Define osmolarity and discuss the importance of osmolarity in the rehydration of fire / rescue personnel.

7. Emergency Incident Rehabilitation 7 What is Rehab and Why Do We Need It?

8. Emergency Incident Rehabilitation 8 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.

9. Emergency Incident Rehabilitation 9 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.

10. Emergency Incident Rehabilitation 10 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

11. Emergency Incident Rehabilitation 11 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.

12. Emergency Incident Rehabilitation 12 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

13. Emergency Incident Rehabilitation 13 Why Do We Need Rehab Over 50% of all firefighter deaths are to some extent, directly attributed to stress and overexertion.

14. Emergency Incident Rehabilitation 14 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

15. Emergency Incident Rehabilitation 15 The Functions Of A Rehab Operation Initial critical incident stress assessment and support. Reassignment

16. Emergency Incident Rehabilitation 16 The Functions Of A Rehab Operation

17. Emergency Incident Rehabilitation 17 Physical Assessment General physical assessment Basic vital signs Medical evaluation Revitalization Reassignment

18. Emergency Incident Rehabilitation 18 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

19. Emergency Incident Rehabilitation 19 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.

20. Emergency Incident Rehabilitation 20 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.

21. Emergency Incident Rehabilitation 21 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.

22. Emergency Incident Rehabilitation 22 Knowing When To Establish Rehab

23. Emergency Incident Rehabilitation 23 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.

24. Emergency Incident Rehabilitation 24 Knowing When To Establish Rehab Ideally, rehab operations should commence whenever emergency operations pose a risk of pushing personnel beyond a safe level of physical and mental endurance.

25. Emergency Incident Rehabilitation 25 Knowing When To Establish Rehab Extended fire incidents Hazardous Material Incidents Prolonged rescue/recoveries Adverse weather conditions Crime scene/standoff�s Search activities

26. Emergency Incident Rehabilitation 26 Extended Fire Incidents Structure Fires High-rise structural fires Wildland fires

27. Emergency Incident Rehabilitation 27 Weather Conditions Hot-Weather Ambient temperature Relative Humidity Direct Sunlight Cold-Weather Ambient temperature Wind chill factor

28. Emergency Incident Rehabilitation 28 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.

29. Emergency Incident Rehabilitation 29 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.

30. Emergency Incident Rehabilitation 30 Hot-Weather

31. Emergency Incident Rehabilitation 31 Hot-Weather Ambient air temperature and relative humidity can be factored together to create what is often referred to as a �Heat Index� Working in direct sunlight can add 10�F to the heat index. Working in full turn-out gear can add an additional 10�F to the heat index.

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33. Emergency Incident Rehabilitation 33 Injuries Associated with Heat Stress Index Conditions

34. Emergency Incident Rehabilitation 34 Heat Stress Index The USFA (United States Fire Administration) recommends that rehab operations be initiated whenever the heat stress index exceeds 90 �F (32 �C).

35. Emergency Incident Rehabilitation 35 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.

36. Emergency Incident Rehabilitation 36 Cold-Weather Conditions 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.

37. Emergency Incident Rehabilitation 37 Cold-Weather Conditions 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.

38. Emergency Incident Rehabilitation 38 Cold-Weather Conditions The most common cold-weather related injuries among emergency responders are localized cold injuries, commonly called frostnip or frostbite. These injuries occur when particular parts of the body are exposed to extreme cold for extended periods of time.

39. Emergency Incident Rehabilitation 39 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.

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41. Emergency Incident Rehabilitation 41 Wind Chill Factor The USFA (United States Fire Administration) recommends initiating rehab operations whenever the wind chill factor drops to 10�F (-12� C) or lower.

42. Emergency Incident Rehabilitation 42 Other Situations Where Rehab May Be Necessary Crime scene/standoffs Search activities Public events Training events

43. Emergency Incident Rehabilitation 43 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.

44. Emergency Incident Rehabilitation 44 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.

45. Emergency Incident Rehabilitation 45 Public Events Fairs, carnivals or other festivals Auto Races Parades Concerts Major sporting events Political rallies Large-scale religious ceremonies

46. Emergency Incident Rehabilitation 46 Establishing and Managing A Rehab Area The first five minutes of an incident can dictate the outcome of the next five hours.

47. Emergency Incident Rehabilitation 47 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.

48. Emergency Incident Rehabilitation 48 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

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50. Emergency Incident Rehabilitation 50 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

51. Emergency Incident Rehabilitation 51 Site Characteristics 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.

52. Emergency Incident Rehabilitation 52 Site Characteristics 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.

53. Emergency Incident Rehabilitation 53 Site Characteristics 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.

54. Emergency Incident Rehabilitation 54 Site Characteristics If the incident involves the recovery of fatalities, the rehab site should be out of view of the work area.

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56. Emergency Incident Rehabilitation 56 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.

57. Emergency Incident Rehabilitation 57 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.

58. Emergency Incident Rehabilitation 58 Roles of the Rehab Staff 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

59. Emergency Incident Rehabilitation 59 Roles of the Rehab Staff 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.

60. Emergency Incident Rehabilitation 60 Roles of the Rehab Staff EMT�s must give regular reports/updates to the Safety Officer or the Incident Commander.

61. Emergency Incident Rehabilitation 61 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.

62. Emergency Incident Rehabilitation 62 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 minutes in rehab.

63. Emergency Incident Rehabilitation 63 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.

64. Emergency Incident Rehabilitation 64 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.

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66. Emergency Incident Rehabilitation 66 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.

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68. Emergency Incident Rehabilitation 68 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.

69. Emergency Incident Rehabilitation 69 Medical Evaluation On entry into the Rehab each fire/rescue personal should be triaged to determine if medical treatment or transport is necessary.

70. Emergency Incident Rehabilitation 70 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

71. Emergency Incident Rehabilitation 71 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

72. Emergency Incident Rehabilitation 72 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.

73. Emergency Incident Rehabilitation 73 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

74. Emergency Incident Rehabilitation 74 Medical Evaluation Any fire/rescue personal should be considered for transport to the hospital if he/she presents with: Oral temp of greater than 101�F Pulse of more than 150 BPM at any time Pulse of more than 140 BPM after cool down

75. Emergency Incident Rehabilitation 75 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

76. Emergency Incident Rehabilitation 76 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.

77. Emergency Incident Rehabilitation 77 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.

78. Emergency Incident Rehabilitation 78 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.

79. Emergency Incident Rehabilitation 79 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.

80. Emergency Incident Rehabilitation 80 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.

81. Emergency Incident Rehabilitation 81 Application Discuss the physiological consequences of fluid loss. Define osmolarity and discuss the importance of osmolarity in the rehydration of fire / rescue personnel.

82. Emergency Incident Rehabilitation 82 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.

83. Emergency Incident Rehabilitation 83 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.

84. Emergency Incident Rehabilitation 84 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