What is Rehab

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What is Rehab?

• Restore condition of good health
• Mitigate effects of physical emotional stress
  of firefighting
• Sustain or restore work capacity
• Improve performance
• Decrease injuries
• Prevent deaths

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Firefighting

• Greatest short surge physiologic demands of any
  profession.
• 10 firefighter time spent on fireground
• 50 of deaths 66 of injuries occur on scene.

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Attempts to reduce FF deaths

• Medical condition
• NFPA 1582 set medical requirements for
  firefighting
• Fitness
• NFPA 1583 set fitness standards
• Rehab
• The next logical step
• For fit, medically qualified firefighters

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Objectives

• The main points of this class will be
• Determining when rehab should be established
• Roles and responsibilities of rehab personnel
• Vital sign parameters
• Recognizing signs and symptoms of heat and stress
  related emergencies

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NFPA 1584 Scope

• Covered
• Rescue
• Fire suppression
• EMS
• Haz Mat mitigation
• Special Ops
• Other emer svces incl. public, private, military
  industrial FDs

• NOT Covered
• Industrial fire brigades (emergency brigades)
• Fire teams
• Plant emerg organizations
• Mine emerg teams

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Implementation

• Incident Commander
• The IC will be responsible for implementing rehab
  procedures
• When should this be done?
• (2) 30 minute SCBA cylinders
• (1) 45-60 minute SCBA cylinder
• When chemical or protective clothing worn
• A supervisor shall be permitted to adjust the
  time frame depending on workload or environmental
  conditions.

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Incident Commander Roles

• Shall be responsible for the following
• Include rehab in incident event/size up
• Establish rehab unit/group
• Designate and assign a supervisor to rehab (Rehab
  Unit Leader)
• Ensure sufficient resources are assigned
• Ensure EMS personnel are available

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Rehabilitation Unit Leader

• Shall be responsible for the following
• Accountability-obtain a list of all companies on
  scene. Keep IC apprised.
• At a complex incident report to the Medical Unit
  Leader
• All companies shall be processed through Rehab
  before being released.

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Rehab Unit Leader responsibilities Will provide
or delegate

• Drinking water
• Sports drinks water for incidents gt1 hour
• Active cooling if indicated
• Medical monitoring
• Food when required (incidents gt3 hours) with a
  means to wash hands/face
• Blankets and warm clothing if needed
• Washroom facilities where required
• Document time entering and leaving

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Rehab Unit Leader Provide or Delegate

• Time personnel in rehab to ensure 10-20 minutes
  rest
• Ensure rehydration and active cooling measures if
  needed
• Maintain accountability at all times
• Request EMT-P level evaluation if v/s outside
  specified parameters. Transport if necessary.
• Will not release from rehab if v/s are outside
  North Zone established parameters.

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Rehab Leader Provide or Delegate

• Has obligation to follow through on all abnormal
  v/s until a qualified medical authority plan of
  action
• After an incident complete North Zone Rehab
  Record

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Elements of Compliance

• SOGs outline how rehab will be provided at
  incidents and training exercises (where FF
  expected to work 1 hour or more)
• Minimum BLS level transport capable EMS on scene
• Integrated into ICS

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But were adults

• Firefighters should know as much as professional
  athletes about rest, hydration, and endurance.

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Hydration and Prehydration

• Firefighters are often dehydrated
• Prehydrate for planned activities
• 500 ml fluid within 2 hours prior to event
• Hydrate during events
• Water appropriate most of the time
• Sports drinks after first hour of intense work or
  3 hours total incident duration
• Best to consume small amounts (60-120 ml) very
  frequently - Typical gastric emptying time limits
  fluid intake to no more than 1 liter per hour.

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NFPA 1584 - Overview

• Ongoing education on when how to rehab.
• Provide supplies, shelter, equipment, and medical
  expertise to firefighters where and when needed.
• Create a safety net for members unwilling or
  unable to recognize when fatigued.

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Company Officers

• Be responsible to assess crew every 45 minutes
• Know signs symptoms of heat and cold stress
• Monitor their company for these signs
• Notify the IC when stressed members require
  relief, rotation, or reassignment
• Report immediately to rehab when directed
• Provide crew access to rehab
• Ensure their company checks in with rehab manager
  and company remains intact

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Crew Members

• Be familiar with the signs symptoms of heat
  cold stress
• Monitor fellow company members for signs
  symptoms of heat and cold stress
• Inform the Company Officer when members require
  rehab and/or relief from assigned duties
• Refrain from consuming food or beverages prior to
  having rehab initial evaluation done
• Maintain Company unit integrity

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EMS Personnel

• Report to IC and obtain rehab requirements
• Coordinate with the Rehab Unit Leader
• Identify EMS personnel requirements
• Monitor v/s including carboxyhemoglobin if
  available, monitor for heat cold stress and
  signs of medical issues
• Document medical monitoring
• Provide or direct emergency care and transport if
  indicated
• Document emergency care provided

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EMS Personnel Should Pay Attention to

• Personnel with c/o chest pain, dizziness, SOB,
  weakness, nausea, headache
• Cramps, aches, pains
• Symptoms of heat or cold stress
• Changes in gait, speech, or behavior
• Alertness and level of orientation
• Vital signs considered to be abnormal by North
  Zone protocols.

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IC Rehab Decision Points
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IC Rehab Decision Points
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IC Rehab Decision Points
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What about informal rehab?

• Perfectly acceptable in NFPA 1584
• May be necessary for Wildfire Incidents
• Company or crew level rehab
• SCBA cylinder changes
• Work transitions (firefighting to overhaul)
• Small or routine incidents
• When IC fails to recognize need for rehab

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Wildland Fire Considerations

• A major challenge is personnel working extended
  periods distant from formal rehabilitation areas.
• Company Officers must practice self preservation
  techniques including
• Monitoring their own and their crew members
  conditions
• Taking short breaks
• Keeping hydrated

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Informal Rehab Considerations

• Fluids
• Shelter
• Place to remove PPE
• Seating for members

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2. Rest and Recovery

• Members afforded ability to rest for at least 10
  minutes or as long as needed to recover work
  capacity

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3. Cooling or Rewarming

• Members who feel hot should be able to remove
  their PPE, drink water, and be provided with a
  means to cool off.
• Members who feel cold should be able to add
  clothing, wrap in blankets, and be provided with
  a means to warm themselves.

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Heat Strain

• Heat strain the adjustments made in response to
  heat stress
• Biochemical
• Physiological sweating, tachypnea, vasodilation,
  tachycardia, etc.
• Psychological

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CASE STUDIES

• Lets review the case studies

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HEAT STRESS

• Body temp regulation is accomplished mainly by
  automatic responses controlled by the brain
• When the brain realises that the bodies temp has
  deviated from the norm it
• Dilates blood vessels in the skin and extremities
• Increases heart and respiratory rate
• Initiation of the sweating mechanism

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Increased risk factors

• Dehydration and salt depletion
• Lack of heat acclimatization
• Poor physical fitness? Excessive weight
• Skin problems
• Medications
• Chronic disease
• Recent alcohol use
• Prior heat injury
• Age
• Highly motivated people

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Heat Exhaustion

• Heat exhaustion occurs when excessive sweat loss
  and inadequate oral hydration cause depletion of
  the bodys fluid volume.
• Signs and Symptoms
• Fainting
• Profuse Sweating
• Headache
• Tingling sensation in the extremities
• Ashen color of the face
• Shortness of breath
• Nausea and vomiting

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Heat stroke

• Heat stroke is the most severe of the three types
  of heat related injured.
• Heat stroke victims have a high probability of
  permanent disability or death as a result of this
  injury
• Heat stroke results when the bodys temperature
  regulating and cooling mechanisms are no longer
  functional
• Sign and Symptoms
• Sudden delirium
• Loss of consciousness
• Convulsions
• Skins are hot, flushed and dry

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• As a patients condition worsens, symptoms of
  shock will develop
• Low BP
• Rapid pulse
• Cyanosis
• Incontinence
• Vomiting
• Kidney failure
• Pulmonary Edema
• Cardiac Arrest

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Cooling Methods

• Passive
• Active

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Active Cooling Cold Drinks

• Cold Drinks
• Serves dual purpose of hydration and cooling
• Ability to cool may be limited on scene
• Drinks usually stored warm - must be cooled or
  only benefit is hydration

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Active Cooling Cold Towels

• Cold towels employ conductive cooling
• Effective in all temp and humidity levels
• Ice water and cold towels are the most effective
  method of treating exert ional heat illness

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Cold Towels

• Temperature and moisture are controllable
• Damp towel holds 500g of water
• Surface area and location cooled are user
  controlled
• Strong psychologic appeal

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4. Re-hydration

• Potable fluids to satisfy thirst on scene
• Carbonated, caffeinated, high carbohydrate drinks
  are NOT appropriate

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4. Re-hydration

• Fluid losses of up to 2 liters per hour are not
  unusual
• No reliable method of assessing hydration status
  on scene
• Weights
• Urine specific gravity
• ? Saliva testing

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4. Re-hydration

• Encourage continued hydration post-incident

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Food

• Fruits, meal replacement bars, carbohydrate
  drinks
• 30-60 grams carbohydrate per hour
• High fat foods inappropriate

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6. Medical Monitoring in Rehab

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

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6. Medical Monitoring in Rehab

• Local (FD) medical monitoring protocols
• Immediate EMS treatment and transport
• Close monitoring in rehab area
• Release

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6. Medical Monitoring in Rehab

• Vital signs per FD protocol
• Options suggested
• Temperature
• Pulse
• Respiration
• Blood pressure
• Pulse oximetry
• CO assessment (pulse CO-oximetry)

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Pulse

• NL 60-80, many influences.
• Very important to interpret in context of
  individual.
• Recovery rate may be more significant than actual
  heart rate.
• If gt 120 after 20 min rest, further eval needed
  before release
• Pulse ox offers accurate measure

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Respiratory Rate

• NL 8 24, should ? with fever and exercise
• Should return to normal with rest

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Blood Pressure

• Systolic
• gt150 or lt90
• Diastolic
• gt100 or lt50

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Pulse Oximetry

• Non-invasive measurementof oxygen and blood flow
• NL 95-100
• Most oximeters cannotdifferentiate
  oxyhemoglobinfrom carboxyhemoglobin
• Members with SpO2 lt 92 should not be released
  from rehab

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CO Assessment

• Carbon monoxide is present at all fires and a
  leading cause of death
• NFPA suggests any member exposed to CO or with CO
  s/s be assessed for CO poisoning
• Exhaled CO meter or pulse CO-Oximeter are two
  detection devices

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Signs and Symptoms of elevated CO

• Mild (15 20)
• Headache
• Nausea
• Vomiting
• Dizziness
• Blurred Vision

• Moderate (21-40)
• Confusion
• Syncope
• Chest Pain
• Dyspnea
• Weakness
• Tachycardia
• Tachypnea
• Rhabdomyolysis

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• Severe (41-59)
• Palpitations
• Dysrhythmias
• Hypotension
• Myocardial Ischemia
• Cardiac Arrest
• Respiratory Arrest
• Pulmonary Arrest
• Seuzures
• Coma

• Fatal (gt60)
• Death

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CO levels

• Non-smokers 0 5
• Smokers 5 10
• If lt 10 Assess for headache/SOB
• If gt 10 High Flow O2
• If gt 20 High Flow O2 or CPAP and transport
  recommended

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7. EMS Tx according to local protocol

• Available on scene
• Monitoring documented in FD data collection
  system
• When tx or xpt, copy medical report to employee
  medical record

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9. Release

• Prior to leaving rehab, EMS must confirm that
  members are able to safely perform full duty.

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Thank You!