The Care and Feeding of Firefighters

     You respond to a working fire. It's 0600 and near-freezing outside; the building is a three-story apartment with occupants trapped. Several residents have inhaled some smoke, but there are no burns or major inhalation illnesses. The fire extends from the first floor into an open attic area. Firefighters began their work early, and about an hour in, a firefighter went down.

     What are EMS' responsibilities at a scene like this? The answer changed with the January introduction of NFPA 1584: Standard on the Rehabilitation Process for Members During Emergency Operations and Training Exercises. This National Fire Protection Agency standard culminates an effort begun in 2005 to update the Emergency Incident Rehabilitation manual published by the U.S. Fire Administration in 1992.

     The standard recognizes the benefit of on-scene recovery of fire personnel. Just 32 pages long, it's comprehensive and readable, with appendices and diagrams to facilitate implementation of rehabilitation programs. EMS agencies that work with fire services will want to obtain copies so that, working with fire leaders, they can develop compliant programs.

SAFER OPERATIONS
     Firefighting has tremendous physiologic demands with high levels of short-term physical stress. The workload includes moving quickly, wearing heavy equipment, climbing, lifting and breathing from a tank. An incident may require the energy equivalent of running a marathon. Scenes are hazardous, and deaths are common.

     The most frequent cause of on-duty firefighter death is not burns or injuries, but heart disease. Forty-five percent of firefighters who die at work do so from cardiac events, compared to 22% of police officers, 11% of emergency medical providers and 15% of all workers. Firefighters are most likely to die during and immediately after heavy exertion.

     There are three contributors to firefighter injuries and deaths: underlying medical conditions, inadequate physical fitness and incident-related exertion. NFPA has addressed these risks sequentially. NFPA 1582 sets standards for an occupational medical program for firefighters. NFPA 1583 describes member fitness program requirements. NFPA 1584 has been created to reduce scene risks related to exhaustion, overheating and inhalation of combustion products. The association between fatigue and injuries is not proven to date, but studies of other professions suggest fatigue can lead to poor judgment, injuries and even death.

     The implementation of NFPA 1584 is a commitment to developing a safer incident environment. Fire agencies that don't provide EMS will need to develop operating relationships with their regional EMS organizations to provide rehabilitation service. This will benefit EMS in building the dual-response framework for all incidents, and the standardized principles of rehabilitation will help it develop safer work environments for its members.

IMPLEMENTING 1584
     The standard mandates that all departments, regardless of geography or incident type, prepare a rehabilitation program that maximizes safety practices. The fire service almost always has its greatest activity at the extremes of weather, particularly unusual weather, so essentially, all departments must develop a program that functions across time, temperature, moisture, humidity, wind direction and availability of natural shelter.

     For smaller EMS and fire agencies, the rehab program will need to be developed using mutual aid agreements with neighbors. Departments that don't have internal EMS resources must establish an interagency agreement with the local provider. In planning across the involved agencies, the process, protocol and paperwork should be standardized, and the necessary equipment purchased and placed for timely deployment. Grant sources may assist in funding.

     For independent agencies, there may need to be written agreements to provide rehabilitation services. These would specify the nature of the services to be provided, a system for notification and activation, and a delineation of cost reimbursement if needed. The paperwork to implement the program should be on file with each agency.

     However program resources are organized, the key to successful implementation is training. Training should include establishment of the rehab area, use of equipment, medical monitoring procedures, the release process, and documentation of the operation. The standard mandates training personnel in recognizing and managing hot and cold weather stresses.

WHEN TO REHAB
     Standard 1584 suggests rehab operations will occur "when emergency operations pose the risk of members exceeding a safe level of physical or mental endurance." The rehabilitation area is typically established at scenes where there is a significant amount of physical labor to be performed in stabilizing and controlling a hazard (and of course in training for such incidents). This includes structure fires, wildland fires, rescue situations, prolonged operations in inclement weather, and hazardous-materials operations. Fire and EMS leaders must also recognize the need for rehab during training exercises.

     The rehab area will be utilized by fire and EMS personnel, and possibly mutual aid providers, law enforcement and others. It is good practice to help other members of the emergency response community rehab themselves in this area, to prevent illness or injury among their members as well. Utility crews, relief workers and media personnel can benefit from rehab resources, and this builds good relationships for future operations.

SETTING UP THE REHAB AREA
     The rehab area should be in a safe location. In general, it will be upwind of any emergency site with potential for smoke or hazardous materials. It should be appropriately heated or cooled, and sheltered in rain and snow. At structure fires it should be near equipment resources and air bottle refill.

     Certain resources will assist in setup and management of the area. A planning process must outline resource needs. Many items can be placed on front-line fire apparatus. Many medical monitoring resources will be on front-line EMS vehicles. Equipment for large-scale incidents may need to be stored in vehicles and then transported to emergency sites as needed. Very long-term incidents (i.e., lasting days) need rehab areas equipped with generators, tents or shelter vehicles, portable toilets and potable water sources. Most departments will need instant purchase order capability or short-term rental arrangements for these assets when needed.

     Water is a key resource. Domestic water, obtained through a simple garden hose, is the best option, and at most incidents, local residents or businesses will allow rehab personnel to access it.

     EMS agencies planning for these incidents may consider other supplies to facilitate the work of providers. Think about simple things like sunblock. These are often dirty and wet scenes, so a durable work kit for medical supplies would be beneficial.

WHAT IS INVOLVED IN THE REHAB PROCESS?
     NFPA 1584 defines eight key objectives and parameters:

• Relief from climate conditions
• Rest and recovery
• Active and/or passive cooling or warming, as needed
• Rehydration
• Calorie and electrolyte replacement for longer incidents
• Medical monitoring
• Member accountability
• Release to return to duty.

     As EMS and fire departments develop rehab procedures, they must cover time, temperature and stuff coming out of the sky. Some incident sites will have special rehab needs. Operating guidelines must address specific hazards. The standard gives particular importance to relief from the effects of hot and cold environmental conditions.

     Warm conditions concerns include:

• Extra hydration
• Shelter from sun
• Prevention of burns on hot asphalt
• Cooling therapies.

     In hot conditions, firefighters can quickly overheat in turnout gear, and they may lose their appetites.

     Priority rehabilitation elements during cold weather include:

• Wind shelter
• Increased calorie consumption
• Thawing of gear
• Frostbite check.

     Locate rehab areas away from vehicles, because exhaust stays close to the ground in cold conditions. Supplies of dry socks and boots are very important. Access to salt or sand to treat walking surfaces is essential, as slips and falls are a high risk. And bathroom facilities are imperative as cold conditions create a physiologic response that causes humans to want to urinate.

WHO'S IN CHARGE?
     Command will delegate management of the rehab area to an appropriate member of the department or EMS agency. Who is in charge must be clear. That individual must have the authority to release firefighters from or retain them in the rehab area, or even transport them to a hospital for further evaluation. A plan that outlines decision elements for EMS personnel will be useful.

     The Rehab Officer will oversee operations and communications with Incident Command and the Safety Sector. He will oversee the rehabilitation and availability for work of all responders placed in this area.

     There is a very important interface with the Safety Sector at dangerous operations. The rehab process provides personnel management support to Safety by evaluating every working responder at the scene and ensuring their physical capability to perform usual duties. This allows the Safety Officer to focus on other hazards.

     There is often a protocol that specifies when personnel will report to rehab. It may specify that providers enter rehab as their first or second air bottle is changed (this often changes with weather and working conditions). Where breathing apparatus is not utilized, firefighters will begin reporting to the area after about 30 minutes of operations. Each needs to be checked according to a medical monitoring protocol. Each should be assessed, hydrated and released to return to work.

     As appropriate to the scene, the Rehab Officer will oversee equipment and processes to provide these elements:

• Shelter, including seating
• Fluid and calories
• Equipment rehabilitation
• Health evaluation and therapy
• Mental decompression.

     Priorities differ with weather conditions. In cold weather, shelter must be wind-shielded and may need warmers; in hot, it requires shade and possibly coolers. In the cold, beverages should be served lukewarm; fluids can be warmer once the workload decreases. Calories are beneficial, soups and stews are suggested. In the heat, extra fluid is encouraged, lukewarm or cool; food may not be a priority, but consider fruits and starches. Equipment rehab involves thawing, drying and warming when it's cold, and prevention of SCBA malfunction and icing. In the heat, it may become sweat-soaked and require drying to prevent molding. Health evaluation and therapy in cold weather includes observation for frostbite to the extremities. Encourage hoods, ear coverage, warm feet and dry gloves. There is a relatively higher risk of CO poisoning. At other extremes, observe for signs of heat stress, and cool personnel with water over the head, neck and wrists. In the cold, a warm environment will enhance revitalization; a cool, shaded area will do so in the heat.

MEDICAL MONITORING
     NFPA 1584 calls for a minimum of BLS care available on scene, and transport capability if it's likely to be needed. The medical monitoring process will be used to evaluate firefighters when they first enter the rehab process and prior to release.

     There is not a consensus on how to measure performance capability and fatigue. Department medical authorities will need to define what vital signs will be taken and what constitutes abnormal. The annex to NFPA 1584 lists the vital signs typically used in assessing firefighters; these are often the same ones used for EMS patients or athletes, including temperature, heart rate, respiratory rate, blood pressure, pulse oximetry and carbon monoxide level.

     The standard specifies that EMS personnel assess firefighters for:

• The presence of chest pain, dizziness, shortness of breath, weakness, nausea or headache;
• General complaints such as cramps or aches and pains;
• Symptoms of heat or cold-related stress;
• Changes in gait, speech or behavior;
• Alertness and orientation to person, place and time;
• Vital signs, particularly those considered abnormal in local protocol.

     EMS personnel should evaluate personnel as they appear. Each arriving worker must be questioned regarding any symptoms, asked about any injury, and have appropriate vital signs assessed. Any injury or symptoms should be addressed immediately by the most highly trained and qualified personnel available. Care should be provided, and an injury report completed.

     Appropriate vital signs should be assessed on each individual on each visit to the rehab area, and at a minimum will include pulse rate, pulse oximetry and a CO-oximetry reading in all operations that involve firefighting, enclosed-space rescue or hazardous-materials operations. Blood pressure should be assessed once during the operation, and can be repeated at the request of the individual or if the value is abnormal. Blood pressures higher or lower than the person's usual level are treated under standard protocols.

     Pulse rate values in the emergency responder will normally be below 100 a minute at rest, 120 at a working incident, and at no time safely exceed 180. Values above 140 on arrival should result in a minimum of 15 minutes in the rehab area, with appropriate hydration. At no time should a responder be allowed to return to duty until their pulse rate is below 120. Those with persistent rates of more than 120 should receive evaluation and treatment per standard protocols.

     Values for pulse oximetry must be above 92%, or the individual cannot be allowed to return to operations. Values below 90% should result in complete evaluation and treatment.

     Values for CO-oximeter readings will normally be below 5% in nonsmokers and 8% in smokers. Note any symptoms as you obtain and record a reading. A detector reading more than 12% indicates moderate carbon monoxide inhalation, and a reading of more than 25% indicates severe inhalation.

     In summary, a simple medical release protocol to guide rehab personnel should be approved by medical direction and department leaders. It may set simple guidelines like "Firefighters and emergency responders cannot return to emergency operations until they have a pulse less than 120 beats a minute, pulse oximetry level above 92%, and CO level below 5%. A responder with medical complaints, injuries or abnormal vital signs should receive evaluation and treatment per standard medical protocols."

RELEASE FROM REHAB
     Personnel working in the rehab area will need to utilize an accountability system for tracking members entering and leaving the area. NFPA 1584 dictates time-in/time-out documentation for crews or members, and offers a template.

     If members become ill or are injured, the department's standard medical protocols will be followed. While BLS care is a minimum, for high-risk operations (e.g., hazmat operations), it will be appropriate to have ALS resources available.

PRIORITIZING WORK
     When EMS responds to a fire incident, with or without civilian casualties, there will be numerous fire units, and there must be an appropriate number of EMS providers to manage personnel. Initial EMS crews may have multiple duties, including triage of civilian casualties, transport of injured or ill civilians and assisting in establishing the rehab area.

     Managing these multiple functions will involve delegation of roles and prioritizing work. Using pre-incident planning, agencies must understand the role of each provider group in the operation. The first priority is casualties from the incident; then there's a need to reassess the workload. It is likely that EMS will assist in firefighter medical monitoring within the rehab area. Personnel must balance the needs of civilian patients and firefighters needing support. At any moment, they must be prepared to provide primary treatment to anyone at the scene.

     It is appropriate to give ill and injured children and members of the fire team priority status for removal from a scene. Children who are acutely ill or injured have smaller reserves than adults, are more likely to be negatively affected by environmental conditions (particularly cold), and have a higher likelihood of complications from prolonged immobilization. Injured children and firefighters are much more likely to produce a stressful work environment for the remaining rescuers, and the distraction can detract from effective management of the emergency.

COMPLETING THE OPERATION
     Concluding the rehab operation will involve completing documents that verify the medical monitoring process, a report on supplies used, filing the necessary paperwork with Incident Command and restocking for the next incident. All firefighters or rescuers who receive medical care will need reports completed for their employee health records.

Management of CO Inhalation
     Management of carbon monoxide poisoning includes breathing air free of the toxin and, if a victim is symptomatic or has high enough levels, breathing higher concentrations of oxygen. Local medical direction should have a protocol for management of CO inhalation in firefighters and civilians that relates to symptoms and CO levels. An example protocol is:

     "Emergency workers with CO levels between 8%–15% must be allowed to breathe ambient air for five minutes. If their level is still above 8%, they should be given oxygen via a mask until it drops below 5%. Those with levels of more than 15% need to be given oxygen via mask until it drops below 5%. Any victim with value of more than 25% must be completely evaluated and removed to a hospital, preferably one with a hyperbaric oxygen chamber. No emergency responder can leave the rehab area until their CO level is below 5%. This is intended to improve scene safety and reduce injuries by ensuring that personnel are not impaired by CO toxicity."

Vital ACHES
     EMS personnel may find the mnemonic Vital ACHES useful to recall the necessary elements of medical monitoring:

• Vital signs
• Altered mental status
• Carbon monoxide
• Heat/cold stress
• Exhaustion
• Stroke-like symptoms (changes in gait, speech or behavior)

Oximetry as a Monitoring Tool
     Many departments have begun proactively screening members for CO during rehab. Tools such as oximeters and exhaled-breath carbon monoxide meters have been available for years. In 2006, a CO-oximeter was approved for the market (the Rad-57, Masimo Corp.) that can provide a pulse rate, oxygen saturation and carboxyhemoglobin level with one noninvasive finger reading.

What Do You Think?
     Is your department prepared to meet the NFPA 1584 Standard? Write to us at nancy.perry@cygnusb2b.com and tell us what your agency is doing to provide adequate firefighter rehab operations. 

CONCLUSION
     When a firefighter goes down, EMS providers have a primary role to play. Other firefighters may remove the victim from the "hot" zone, but thereafter, EMS personnel will perform a complete examination, necessary treatment and removal to a hospital as needed. Fire and EMS have new opportunities to work collaboratively with the implementation of NFPA 1584. This standard is intended to minimize firefighter exhaustion and related injuries and illnesses at working incidents, and to prevent injury or illness at the next incident. EMS services should familiarize themselves with it accordingly.

Bibliography
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Augustine JA. Triage at a major incident: Tough decisions in triage. Emerg Med Serv 34(6):46–49, 2005.
Becker D. Rehabilitation operations. J Emerg Med Serv 25(11):37–47, Nov 2000.
Dickinson ET, Wieder MA. Emergency Incident Rehabilitation, 2nd ed. Upper Saddle River, NJ: Pearson Education, 2004.
Espinoza N, Contreras M. Safety and Performance Implications of Hydration, Core Body Temperature, and Post-Incident Rehabilitation. Orange County (CA) Fire Authority, 2007.
Heightman AJ, O'Keefe M. 20 tools to customize your rehab toolbox. J Emerg Med Serv 25(11):49–58, Nov 2000.
Kales S, et al. Emergency duties and deaths from heart disease among firefighters in the US. NEJM 356(12), Mar 2007.
NFPA 1584, Standard on the Rehabilitation Process for Members During Emergency Operations and Training Exercises, 2008 edition.
Rosenstock L, Olsen, J. Firefighting and death from cardiovascular disease. NEJM 356:1,261–63, 2007.
U.S. Fire Administration. FA-114, Emergency Incident Rehabilitation. Emmitsburg, MD: USFA, July 1992.
Walton SM, et al. Cause, type and worker's compensation costs of injury to firefighters. Am J Industrial Med 43(4):454–58, Apr 2003.

James J. Augustine, MD, FACEP, is an emergency physician from Atlanta. He serves as medical director for many fire services in the Atlanta area, including Atlanta Fire Rescue, He served as first chair of the Ohio EMS Board, and has participated in field care for 27 years as a firefighter and EMT-A. Contact him at jaugustine@emp.com. Disclaimer: Dr. Augustine serves as a consultant to Masimo Corp., and on the company's EMS Clinical Advisory Board.

EMS EXPO
Jim Augustine is a featured speaker at EMS EXPO, October 15–17, in Las Vegas, NV. For more information, visit www.emsexpo2008.com.