IMPLEMENTING EFFECTIVE ON-SCENE REHABILITATION

By Denise L. Smith, Ph.D., and Craig Haigh, CFO, NREMT-P

Fire departments must constantly struggle to find a balance between the desire to implement new programs, including on-scene rehabilitation, and the reality of finding the resources to do so. National standards, such as those of the National Fire Protection Association (NFPA), can help by providing a national perspective as to what programs or policies are essential. But they may also complicate the equation by seeming to suggest that programs must be implemented without providing a convincing rationale for the benefits or explaining how they should be funded.1


An exhausted firefighter is rehabbed. Notice the removal of protective equipment, the wet cooling towel around the neck, and the simultaneous monitoring of blood pressure. (Photos by Kenneth Zaccard.)

On-scene rehabilitation can be defined as an intervention to mitigate against the physical, physiological, and emotional stress of firefighting to improve performance and decrease the likelihood of on-scene injury or death. This definition immediately leads us to ask, what are the most serious threats to life on the fireground and how are they related to the stresses of firefighting?

Line-of-Duty Deaths

The leading cause of line-of-duty deaths in the fire service is heart attacks, with approximately 45 percent of deaths from this cause in any given year.2,3 While it is clear that such incidents are related to long-term disease progression, it is likely that the stress of firefighting serves as a “trigger” for many of these cardiac events. To achieve the goal articulated by the United States Fire Administration and the National Fallen Firefighters Foundation of significantly decreasing line-of-duty deaths, it is essential that the fire service decrease the number of deaths and disabilities resulting from cardiac events. To achieve the goal of decreasing cardiovascular deaths in the fire service, a multipronged approach is necessary, including medical and fitness standards for hiring personnel, periodic medical evaluations for current personnel, health and safety programs, fitness programs, and on-scene rehabilitation.

Physical and Physiological Stress of Firefighting

The physical and physiological strain that results from firefighting is from a combination of several factors, including performing heavy muscular work, performing strenuous work while wearing heavy protective gear (including SCBA), working in hot and hostile environments, and working under conditions of emotional stress. Figure 1 briefly outlines several of the factors that affect the magnitude of the response to firefighting. Notice that those factors listed at the top of the figure refer to factors that are external to the firefighter (namely, the work that is performed), the clothing that is worn (usually personal protective clothing, or PPE, mandated by the department), and the thermal environment. Structural firefighting activity encompasses a wide range of muscular activity, including climbing stairs (or ladders) with heavy loads, interior attack and suppression activities, ventilation operations, and so on. The PPE worn is typically mandated by the department; but, during many firefighting activities-and certainly during structural firefighting activity-it includes heavy, fully encapsulating gear. The thermal environment varies greatly with different incidents and different jobs on the scene. During structural firefighting activity, firefighters may be subjected to environments that are heated in excess of 800°F.


The factors identified at the lower portion of Figure 1 relate to the individual firefighter-that is to say, the physical and physiological responses to any given firefighting activity will depend on the medical, hydration, and fitness status of the firefighter. Effective on-scene rehabilitation programs address factors in the environment and those related to the individual.

Dehydration

Firefighters sweat profusely as a result of performing strenuous work in heavy protective gear, and the sweating response may be exaggerated during structural firefighting with high ambient temperatures. Figure 2 provides a schematic of human sweat rates as a function of increasing intensity of work4 As noted in Figure 2, the sweat rate increases with increasing levels of activity, and for any given level of activity the sweat rate is higher when work is performed in a humid environment. Since firefighting gear has a vapor barrier that effectively prevents the evaporation of sweat, there is a microclimate created next to the firefighter’s skin that reaches a humidity of nearly 100 percent. Based on the information in Figure 2, we can estimate that firefighters regularly lose two or more liters of sweat during strenuous firefighting activities. When considering the amount of sweat lost during firefighting activity, it is important to note that under most conditions firefighters will begin sweating as soon as they don protective gear and will continue to sweat even after the fire has been extinguished, particularly during the overhaul and cleanup activities but extending even into the recovery period. Thus, even a relatively quick knockdown can result in substantial fluid loss; and, of course, fluid loss can become extreme during prolonged operations.


The loss of sweat, or dehydration, has multiple effects on the body: It decreases plasma volume, increases thermal strain (leading to a decreased stroke volume and an increased heart rate), leads to earlier onset of fatigue, and can decrease muscular strength. Research studies conducted at the University of Illinois Fire Service Institute (UI FSI) have documented substantial loss of body weight (up to 1.0 kg) and plasma volume (15 percent) with short-term (~18 – 20 min.) bouts of simulated firefighting activity.5,6 Replacing fluid loss is obviously an important goal of on-scene rehabilitation.

Cardiovascular Strain

The cardiovascular system responds to exercise or strenuous physical activity by increasing the amount of blood pumped by the heart with each beat (called stroke volume), increasing heart rate, and increasing the amount of blood pumped each minute (cardiac output; calculated as SV × HR). Cardiac output increases five- to sevenfold during strenuous activity to provide increased blood flow and, hence, oxygen to the working muscles, the skin, the heart, and other vital organs.

It is well known that firefighting activity leads to increased heart rate. In fact, research at UI FSI has documented that firefighters reach maximal heart rate levels during relatively brief bouts of strenuous firefighting activity. Perhaps more importantly, research has shown that during these strenuous bouts of firefighting activity stroke volume does not continue to increase. Figures 3a and 3b show heart rate and stroke volume response to three brief (~7 min.) bouts of firefighting activity. Between the second and third bout, the firefighters changed their SCBA bottles and ingested cold fluids. Notice that following the first seven minutes of firefighting, heart rate had increased to approximately 92 percent of maximum and stroke volume had increased as expected. By the third bout of firefighting activity, heart rate had reached maximal levels (~190 bpm) and stroke volume had actually decreased.7 The significance of these findings is that at the very time the body needs the greatest amount of blood to be pumped by the heart to supply blood to active muscles, the skin, the heart, the brain, and other tissues, the ability of the heart to pump that blood is diminished because of a decreased stroke volume because of loss of plasma volume (as a result of sweating) and a vasodilatation of veins from heat. Thus, effective on-scene rehabilitation must address rehydration and cooling and monitor heart rate and other signs of cardiovascular stress.


Another cardiovascular factor that appears to be affected by strenuous firefighting activity is blood-clotting potential. Pilot studies at the UI FSI have indicated that <20 minutes of firefighting leads to an increased platelet number, increased platelet activity, and changes in several coagulatory factors.8 These early results reinforce the need for additional research into the physiological (particularly the cardiovascular) effects of firefighting.

Thermal Strain

Although it should be obvious that firefighting activity leads to an increase in core body temperature, it has been difficult to describe the magnitude of this increase in body temperature because of the difficulties in obtaining accurate measures of body temperature. Figure 4 shows rectal temperatures of firefighters following three bouts of simulated firefighting activity. (7) Although rectal temperatures never reached extremely high values, such as those seen with fever or prolonged exercise, it is important to note that the body temperatures increased rapidly (in terms of how quickly body temperature can change given its thermal properties), which could have serious implications for prolonged firefighting activity. Furthermore, temperature continued to rise after firefighting activity, reaching its highest level after 10 minutes of recovery. An effective on-scene rehabilitation program must require firefighters to remove their personal protective gear and aggressively cool the body.


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Goals and Purpose of On-Scene Rehabilitation

NFPA 1584, Recommended Practice on the Rehabilitation of Members Operating at Incident Scene Operations and Training Exercises, was established by the Technical Committee on Fire Service Occupational Medical and Health and was approved as an American National Standard in January 2003. The standard provides a recommended practice at a minimum level for the development and implementation of an effective on-scene rehabilitation program.


Partnerships are an essential component in the provision of rehab. Here, the Salvation Army canteen is used to provide on-scene rehabilitation.

The general goal of the standard is to ensure that the physical and mental condition of firefighters operating at the scene of an emergency/training exercise does not deteriorate to a point that affects firefighter safety or the integrity of the operation.

The primary purposes of NFPA 1584 are the following:
• Provide medical monitoring and treatment.
• Establish standards for food and fluid replacement.
• Provide relief from climatic conditions.
• Provide for rest and recovery.
• Provide for member accountability.

There is both anecdotal and scientific evidence to suggest that these goals are appropriate to address to the physical and physiological responses to firefighting and that achieving these goals may play an important role in improving firefighter performance and decreasing injuries and deaths on the fireground.


The rehab sector encompasses rehydration, rest and recovery, medical monitoring, and accountability.

On-scene rehabilitation programs combat the stresses that endanger the lives of firefighters, including dehydration, cardiovascular strain, and heat stress. Although firefighter health is a compelling reason to institute such a program, many departments are challenged to find feasible ways to implement a program given the limited resources of time, money, and personnel.

In the era of “do more with less,” departments are asked to provide traditional fire services plus accept a multitude of ever-increasing responsibilities, including haz mat, technical rescue, all-hazards preparedness, and more. Few departments are increasing personnel, and most are faced with dramatic increases in required responsibilities. Company staffing in general is decreasing. However, we are operating at fires that are burning hotter and faster, within structures not designed to take the associated fire load. These trends necessitate the effective rehabilitation of personnel after periods of peak workload to minimize the detrimental physical and physiological effects of fire suppression activities.

IMPLEMENTING REHAB

A variety of objectives need to be accomplished to effectively provide sound and appropriate rehab services.
• Command and control and accountability.
• Provision of fluids.
• Medical monitoring (EMS).
• Climatic relief/rest and recovery.
• Calorie replacement.

Rehab must begin prior to an incident, as should policies and procedures, methods for obtaining rehab supplies and equipment, and building relationships with rehab providers. Likewise, the rehab sector must be included in the postincident analysis/critique to develop and improve techniques for management of this particular sector.

Command and Control and Accountability

Successful rehab is all about attitude. Policies and procedures that are not embraced by the members will rapidly fail in the heated battle of emergency incident management. Personnel who embrace rehab as an integral part of their overall health and safety will tend to follow the protocols as a matter of routine compared with those who see it as a mandate that hinders fireground operations and brings into question their “toughness” to do the job.

Recently while leading a live-fire evolution at a state fire college, I saw a sticker affixed to a helmet that read “Rehab Is for Sissies.” In my estimation, this firefighter and the message he is conveying to his fellow firefighters is the same as one who says we don’t need to wear our protective equipment into a fire, or that it is okay not to wear your seat belt while riding in a 40,000-pound fire engine hurtling down the road at 50 mph. By allowing these types of editorial comments to be made within our organizations, we are endorsing a dangerous position and the deadly consequences it promotes. If rehab can diminish the line-of-duty deaths that occur each year, we have the responsibility to embrace the concept wholeheartedly.


Additionally, policies need to be established for the tracking and long-term documentation of on-scene rehab. The Hanover Park (IL) Fire Department uses forms that document company-level accountability as well as individual information for medical tracking. Form A documents the department name, the apparatus number, crew size, time of arrival at rehab, and time of release from rehab. Form B documents the individual firefighter’s name, the time of evaluation, the number of SCBA cylinders used, vital signs, and any complaints or noted medical conditions. Space is provided for three evaluations prior to being released from rehab. This documentation is then attached to the finalized fire incident report for long-term tracking. Firefighters who are transported or have significant medical complaints and require medical monitoring/treatment beyond what is commonly provided in the rehab sector have full EMS incident reports completed as well as refusals/releases should they choose not to be transported.


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Provision of Fluids

Fluid replacement is the single most important component of an effective rehabilitation program. Water is vital to every body system and comprises 60 percent of our total body mass. Water is the fluid of choice. Recommended fluid intake is as follows:

• 1 bottle (12 to 16 ounces) of water consumed during an air bottle change.
• 2 bottles (12 to 16 ounces) during rehab.
• Another 1 to 2 bottles post incident.
• A 50/50 mix of water and sports drink is desirable one hour into the incident (in prolonged incidents, a sports drink should be consumed after every 2 to 3 bottles of water).

Medical Monitoring

A key component of an effective rehab system is medical monitoring. First and foremost, we need to have firefighters whose health and fitness level are appropriate for the task of firefighting. Medical monitoring for on-scene rehab involves the evaluation of the following: rating of perceived exertion (Figure 5), heart rate, blood pressure, and temperature.


Medical monitoring needs to be conducted by personnel trained to evaluate vital signs and must provide assessments of the firefighters’ level of physical distress from hyper- or hypothermia and respiratory/cardiovascular compromise. EMS personnel are a natural fit for this function on the fireground. Departments need to establish protocols for the immediate dispatch of EMS units to any emergency incident where firefighters will be operating in protective equipment for an extended period of time. Departments that themselves are the EMS provider and use cross-trained personnel need to provide for additional EMS units other than those being used for fire suppression activities.

Departments need to work with their fire department physician as well as their respective EMS systems to develop medical protocols for acceptable physical parameters for firefighters completing rehab. In many cases, it is appropriate for these guidelines to focus on decreases in vital signs following entry to rehab rather than on absolute values.

Despite the importance of body temperature in assessing thermal and cardiovascular strain, the truth is that body temperature is a very difficult variable to measure accurately on the fire scene. Oral temperatures will be artificially low following heavy breathing, use of SCBA, and particularly fluid ingestion. Tympanic thermometers are very convenient, but measures are affected by tester differences, physical activity, and environmental conditions. Under resting conditions, tympanic temperatures tend to underestimate core body temperatures; following exercise or in a cool environment, this underestimation is greater.

Thus, if tympanic temperature is measured, rehab personnel must consider it just one piece of information in an overall clinical picture. A firefighter with an elevated heart rate, high blood pressure, profuse sweating, nausea, headache, and a tympanic temperature of 98.8°F could indeed be suffering from heat stress.

Climatic Relief/Rest and Recovery

Along with the urgent need to rehydrate personnel, it is also necessary to rapidly cool core body temperatures. The rehab sector needs to be established in a shaded area where the firefighters are far enough away from the incident to reduce stimuli and be free of the products of combustion. It is essential for firefighters to remove their protective equipment, including their bunker pants, in warm weather. The use of wet towels around the neck and head, fans, water misting fans, and hand and arm submersion chairs are all helpful in the aggressive cooling process. Many departments have found air-conditioned city buses helpful during periods of severe heat conditions. These same buses work well for warming sites during cold weather months. Obviously, securing these assets preincident is critical and should be incorporated into policies and procedures.

Cold emergencies provide a special challenge in that firefighters need to stay warm or be warmed and provided with dry socks, gloves, and sweatshirts to minimize the risks of hypothermia following the hyperthermic experience of fire attack. It is important to remember that these firefighters have suffered from dehydration during the interior fire operations and need to be rehydrated using the same standards outlined above.

During periods of rest and recovery, firefighters need to be encouraged to sit down and allow their bodies to recover. A suggested work/rest ratio is 10 minutes of “self-rehabilitation” break after 30 minutes of SCBA use or 20 minutes of intense work. A 20-minute rehabilitation period should be completed after two 30-minute SCBA cylinders, one 45-minute or 60-minute SCBA cylinder, 40 minutes of intense work, and operating within encapsulating chemical protective clothing.

Calorie Replacement

Food is used to fuel our bodies and is critical for continued physical exertion over extended periods of time. For years, well-meaning groups have assisted the fire service with food on the scene of emergency incidents but have focused little on the benefits or detriment of certain nutritional products. Firefighters have frequently been given donuts, cake, sausage biscuits, pizza, fried chicken, hamburgers, and French fries and have then been expected to don protective gear and return to maximum exertion on the fireground. These well-meaning groups focused attention on feeding large numbers of people with safe and convenient food rather than focusing their attention on providing food that optimized performance or sped recovery. Calorie replacement should come from foods high in carbohydrates and protein and low in fats. Foods should also be well-liked and easy on the digestive system. Examples are sandwiches of sliced turkey/chicken/peanut butter and jelly; soups (split pea, bean-based, chicken noodle); apples, bananas, and pears; yogurt; trail mix; and high-protein energy bars. Training and relationship building are key. In many cases, groups that routinely feed emergency responders simply need to be informed about appropriate types of nourishment.

Delegation of Rehab Responsibilities

Most fire departments are stretched to the absolute maximum with regard to personnel. All hands are required for incident management, leaving a shortage of personnel to provide necessary rehab services. The question then becomes how to effectively care for fire personnel without jeopardizing the overall operation. The answer is to look outside your own department for partnerships with groups that are available and interested in providing rehab services. Fire department auxiliaries, service organizations, and religious groups are all possibilities. The Salvation Army has provided rehab for many departments, as have other groups. Many organizations exist, and have all played a valuable role in reducing the detrimental effects of heat stress and fatigue in the fire service. Departments willing to work with community organizations or forge relationships with other possible providers will greatly minimize the risk to their personnel.

Training is the key to making partnerships with outside agencies successful. Recently, the University of Illinois Fire Service Institute partnered with the Salvation Army to develop a rehabilitation training program for Salvation Army emergency workers. This program includes modules on the following:

• The Need for Rehab-The Physiological and Psychological Stress of Firefighting
• Understanding the Fire Service
  -Incident Command
  -Fireground Operations
  -Firefighter Safety/Protective Equipment
• Understanding Firefighters
• Implementing an Effective Rehab Program
• Psychological/Emotional/Spiritual Stress of Firefighting

The highlight of the training is a variety of live-fire evolutions in the university’s burn facility where the participants, under close supervision, are allowed to experience the work of a firefighter as well as the associated heat stress. Participants leave the two-day program with a clear understanding of the importance of rehab.

Training programs do not need to be as formal or as complex as the one developed for the Salvation Army, but providers do need to understand the importance of rehab, the techniques of cooling, and the appropriate choices for fluids and foods.

Finally, even highly motivated and well-trained groups cannot provide rehab services if they are not called. Departments are encouraged to add rehab services to their response cards early in the incident as well as EMS providers to assess the physical condition of firefighters. For many departments, this may mean mutual aid or an increase in the number of companies assigned to a response, but the benefit will far outweigh the cost.

Endnotes

1. NFPA 1584. Recommended Practice on the Rehabilitation of Members Operating at the Incident Scene Operations and Training Exercises. 2003 Edition.

2. Fahy, R. “Sudden Cardiac Death,” National Fire Protection Association Journal, July/August, 2004, 44-47.

3. United States Fire Administration. (2002). Firefighter Fatality Retrospective Study. FA220. Federal Emergency Management Agency. National Fire Data Center.

4. Sawka, M. N. and K.B. Pandolf. “Effects of body water loss on physiological function and exercise performance.” In C.V. Gisolfi & D.R. Lamb (eds), Perspectives in Exercise Science and Sports Medicine. Vol. 3: Fluid Homeostasis During Exercise. Carmel, IN: Cooper Publishing Group, 1990.

5. Smith, D.L., and S.J. Petruzzello. “Selected Physiological and Psychological Responses to Live-Fire Drills in Different Configurations of FireFighting Gear.” Ergonomics, 1998, 41(8), 1141-1154.

6. Smith, D.L., M.A. Petruzzello, J.J. Chludzinski, J.A. Reed, Woods. “Effects of strenuous live-fire firefighting drills on hematological, blood chemistry, and psychological measures.” Journal of Thermal Biology; 2001, 26(4-5), 375-380.

7. Smith, D.L., S.J. Petruzzello, T.S. Manning. “The effect of strenuous live-fire drills on cardiovascular and psychological responses of recruit firefighters.” Ergonomics; 2001, 44(3), 244-254.

8. Smith, D.L. “Acute Effects of Fire Fighting Activity on Coagulation.” Medicine and Science in Sports and Exercise; 2002, 34(5), S194.

Denise L. Smith, Ph.D., is professor and chair of exercise science at Skidmore College in Saratoga Springs, New York, and a research scientist at the University of Illinois Fire Service Institute. She is the author of the textbook Exercise Physiology: For Health Fitness and Performance. She earned her Ph.D. in kinesiology with a specialization in exercise physiology from the University of Illinois at Urbana-Champaign. Her research is focused on the physiological effects of firefighting, particularly the cardiovascular strain associated with the combination of heavy physical work, heat stress, and the psychological stress that firefighters routinely encounter. She has published her findings in peer-reviewed scientific journals such as Ergonomics, Journal of Applied Physiology, Journal of Thermal Physiology, European Journal of Applied Physiology, and Aviation, Space and Environmental Medicine.

Craig A. Haigh, CFO, NREMT-P, a 22-year veteran of the fire service, is chief of the Hanover Park (IL) Fire Department and a field staff instructor with the University of Illinois Fire Service Institute. Haigh began his career as a volunteer in Hampton, Illinois, being promoted through the ranks to the position of chief. He also worked as a career firefighter with the Rock Island (IL) Fire Department. He served both agencies until becoming chief of the King (NC) Fire Department. Haigh is a nationally registered paramedic, has a B.S. degree in fire and safety engineering technology, and is an accredited chief fire officer.

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