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

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 providing rest, 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/Other42.7% Struck by Object31.5% Entrapment22.5% Fall1.1% Electrocuted1.1% Extreme Weather1.1% Nature of Injury Percent Cardiac Arrest38.2% Trauma29.2% Asphyxiation10.1% Burns10.1% Crushing3.4% CVA3.4% Drowning2.2% Electrocution1.1% Arrythmia or Seizure1.1% Sepsis1.1%

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

28. Injuries Associated with Heat Stress Index Conditions

29. 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

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

31. 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)

33. Other Situations Where EIR Necessary  Crime scene/standoffs  Search activities  Public events  Training events

34. 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

35. 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

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

37. The first five minutes of an incident can dictate the outcome of the next five hours

38. 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

39. 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

41. 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?

42. 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

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

44. 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

45. 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

46. 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

47. 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

48. 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

49. 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

50. 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

51. Hospital Transport  Serious symptoms: Chest pain, SOB, AMS Heat exaustion  Irregular, persistent HR > 150 bpm  Oral temp > 105ºF  SBP > 200 mm/Hg post cool down  DBP > 130mm/Hg at any time

52. Summary  Deciding when & if to initiate EIR  Planning a EIR location  Understanding importance of early decision-making  Rehydration & constant monitoring is of the utmost importance  Following guidelines for returning emergency workers to duty aids in both returning fit workers to duty & preventing further harm to ill or injured personnel

53. Questions? prehospitalmd@gmail.com