REHAB FOR LIFE

REHAB FOR LIFE

BY WILLIAM F. SULLIVAN

Much has been written about the need to rehabilitate fire crews, particularly in recent years as more fire departments–including many of the nation`s largest–make the transition from traditional turnout gear to bunker gear.

The U.S. Fire Administration issued a definitive publication on the topic (see side- bar “For Additional Information…” on page 55), describing in detail what should be done and why. Many fire departments have incorporated that advice into standard operating procedures (SOPs).

Enforcing these SOPs, however, has proven problematic. Most firefighters don`t like to be placed on the sidelines, regardless of the reason. And many chiefs are reluctant to order crews to rehab for the following reasons:

They didn`t plan for sufficient relief crews in a timely manner.

They are argued out of it by company officers who don`t think they need rehab.

They believe that crews should be able to “take it” until they make the red stuff go away.

What follows is a fictional account of an event that could happen any day, any time, in all too many fire departments. As you read it, keep in mind the question, “Would they have died at your fire?”

As the crew of Ladder 1 emerged from the building, air supplies and bodies near exhaustion, the chief approached the officer: “I really need a hole in the roof, Lou. If you guys want to take a break, I can get another company to do it.”

The lieutenant removed his face piece and sucked his first breath of fresh air. For a long moment, he pondered the request, but he knew his answer was never in doubt. “No, Chief, we`ll take care of it.”

Satisfied, the chief turned his attention back to the 212-story dwelling. An aggressive search got everybody out, but the fire was stubbornly working its way from the first-floor kitchen to the attic.

Twenty minutes later, at 3:45 p.m., the three firefighters found themselves on the building`s pitched roof, punching through the ceiling of the finished attic apartment.

All three were physically spent. “That`s good enough. Let`s get down,” the officer announced. But when he turned toward the crew`s senior member, he found the 53-year-old veteran clinging to the ridge pole, gasping for air.

“Give me a minute, Jack. I`ve gotta catch my breath.” The officer understood because his body, too, was beginning to revolt. He glanced at the third member of the crew, a 24-year-old with less than a year on the job. The rookie had an eager expression, but his face was flushed.

Just as the man resting at the peak began to vomit violently, the draft created by the roof opening started to do its work. Smoke that had initially risen slowly now was billowing across the roof, obscuring all but the man`s legs.

“MAYDAY, MAYDAY!”

The officer fumbled for his microphone button. “Mayday! Mayday! This is Ladder 1. I`ve got a man in bad shape down on the roof.”

The officer was straddling the ridge 10 feet from the stricken firefighter. The rookie was a few feet below the veteran on the roof ladder. A moment before, the older man had gone into cardiac arrest. His right leg had kicked the saw, sending it tumbling toward the rookie, who rolled to his left to get out of its path. Finding himself off the ladder and sliding toward the edge, the young man clawed at passing shingles and managed to halt his descent.

He looked to his right and spotted the tip of the aerial three feet below. It appeared to be an easy reach. He planned to get into a crouched position and move to it, but as he did so, his muscles refused to do what his mind commanded.

Less than 30 seconds later, a police officer was running toward the fire chief in front of the building.

“Chief, one of your men just fell off the roof.”

The Board of Inquiry that was convened four weeks later heard testimony from everyone from the dispatcher, who received the report of the fire, to the police officer, who witnessed the rookie plunge to his death. Firefighters working elsewhere in the building and the medical examiner who had performed the autopsy on the fatally stricken veteran–all were questioned.

One board member was a well-known safety consultant whose appointment was jointly agreed on by the city manager and the firefighters` union. After asking the chief about fire conditions and strategic decisions, the consultant asked if the department had a policy that governs on-scene firefighter rehabilitation.

“Oh, yes, we have an SOP on the subject,” the chief replied. “We`ve been telling them how important it is to stay hydrated, especially with the heat that builds up in the new turnout gear we`re wearing.”

“Chief,” the consultant continued, “I`ve reviewed your SOP. It says here that members should be sent to rehab after 30 minutes of exertion or after 15 minutes if weather conditions warrant. Could you tell the board if you implemented that SOP at this fire?”

“Well, I struck a third alarm as soon as I learned what had happened on the roof,” was the chief`s reply.

“But, at what point did you order relief crews to replace the firefighters who had responded on the first alarm?”

The chief was silent for a few moments. “I had asked a lot of the officers if they wanted a break. I even asked Ladder 1`s officer, but he said his crew was all set.”

HEART FAILURE

A physician from a local teaching hospital told the board that heat exhaustion can progress to heat stroke, a potential outcome of which can be heart failure. He also testified that severe dehydration can cause permanent kidney damage. “Individuals can be expected to become lethargic, and their judgment will be impaired,” the doctor said. “Firefighters in such circumstances will probably not realize how bad their condition really is.”

Later, a meteorologist from the U.S. Weather Service at a nearby airport testified that the temperature at the time of the incident was recorded at 797F and the relative humidity was 70 percent.

Ten weeks later, the Board of Inquiry issued its report. It concluded that the department`s failure to follow its own rehabilitation policy and to relieve the crew of Ladder 1 after it had completed its search and rescue mission directly contributed to the death of the two members:

“There is ample evidence that the department was knowledgeable of the dangers posed to firefighters who are required to perform extended periods of physical activity in environmental conditions that are likely to result in impaired judgment and diminished physical function.

“At a time when all occupants were accounted for, the department`s management failed to require fire crews to undergo rehabilitation consistent with the applicable SOP in force at the time.”

Devastated by the fallout from the report, the chief filed his retirement papers. The families of the two firefighters filed suits again the city and the chief.

The truck officer never returned to duty. Under care for severe depression, he is seeking a disability pension based on stress.

Even before the report was issued, the city manager–acting on the advice of the city`s legal counsel–ordered the fire chief to assign an officer to monitor firefighter accountability and rehabilitation at every working fire.

Many chief officers (as the one depicted in the story) trick themselves into believing that they`ve satisfactorily considered the need for rehab by asking company officers if they need a break. Company officers, however, usually respond in the same way as a hockey player would if the coach were to ask him if he wanted to come off the ice for a break: “No way, coach!” That, of course, is the reason hockey coaches don`t ask. They simply change lines periodically to avoid the embarrassment of having players fall down on the ice in exhaustion or making stupid mistakes. Hockey players understand this and don`t argue. They know that they`ll be in better shape to rejoin the game after a short rest. Similarly, ordering firefighters to rehab must be a command decision not subject for debate.

COMMAND DECISION

Is it ever advisable to delay rehab? Sure, if you need to sustain an active search and rescue operation for occupants or members. The possibility of saving human life tilts the risk-reward equation. Outside of that scenario, rehab should proceed on schedule. In collapse situations, where rescue operations will be conducted over an extended period, rehab becomes crucial.

The reason we get away with ignoring rehab is easy to figure. Many firefighters have been killed by heart attacks and many have fallen from roofs, but the cause rarely is linked to failure to take rehab. We know from experience, however, that overexertion is intrinsically associated with cardiac arrest. And we know, too, that we make more mistakes when we`re exhausted.

Likewise, very little thought is given to the costs of failure to carry through on rehab. Aside from the human costs (death and injury), consider the monetary costs: medical expenses, personnel expenses for covering shift absences, and pension costs for permanently disabled members. One firefighter, disabled even for a few weeks, could cost a municipality thousands of dollars. The cost of a permanent disability could easily be measured in the hundreds of thousands.

These costs are hidden under various budget categories. Taken as a whole, however, they represent one of the largest–and most preventable–drains on municipal public safety budgets. These same funds could be better spent maintaining adequate staffing levels.

TAKING RESPONSIBILITY

If the answer to this dilemma is better fireground management of the rehab function, someone has to have the responsibility of making it work. Expecting the incident commander to do it without assistance is unreasonable, given the competing demands for his attention. A rehab sector officer, working in conjunction with the emergency medical service, should be given specific authority to coordinate fireground rehabilitation.

Maintaining a rehab schedule is critical. The rehab officer needs to record the time of each alarm to determine when replacements must be summoned, what time crews should go to rehab, and when those crews are likely to be ready for reassignment (see sidebar “Rehab Schedule” on page 55).

It is paramount that the rehab officer advise the incident commander of personnel needs that would require the transmission of additional alarms. Sufficient time must be allowed for response and deployment. Waiting until the last minute to summon relief crews is a sure way to throw the rehab program into chaos.

Chiefs who fear that wholesale relief will place an unnecessary burden on their mutual-aid network should be comforted by the fact that a well-managed rehab program will provide fresh crews for reassignment on a rotating basis. A nonexistent or ill-managed system, however, is likely to result in crews` being exhausted to the point that they are not fit for reassignment.

Crews being released from rehab can be used for two purposes:

To relieve crews scheduled to enter rehab and

to fulfill needs for additional personnel.

It is difficult to overemphasize the importance of closely managing the rehab process. Without coordination and direction, rehab will not get done; this will result in too many or too few firefighters` being called to the scene.

Although bunker gear affords superior thermal protection, bunker pants preclude ventilation, and firefighters heat up much more rapidly than when they wore hip boots.

Determining how long members can perform before requiring relief depends on exertion levels and climatic conditions. The USFA publication explains how you go about it. When conducting interior structural firefighting, it may be necessary to relieve crews after as little as 15 minutes or after one air bottle has been used up.

Firefighter accountability, another often overlooked fireground function, could well be handled by the rehab officer. These positions complement and overlap each other.

The task of monitoring crews for symptoms of heat stress must be shared by the incident safety officer, the rehab sector officer, and individual company officers. A lieutenant who knows that his crew needs an unscheduled break has to have the confidence and courage to say so. That action may save a life because failure to take the time out for rehab can lead to the firefighters` experiencing heart failure or a stroke. Strong leadership is essential to success. The chief has to make it clear that subordinates are expected to enforce rehab guidelines. The chief bears the ultimate responsibility for establishing rehab as an integral part of overall fireground discipline.

LESSONS LEARNED

We always look for lessons learned from experience. If we apply that principle to the

fictional account above and our own experience, the results will tell us the following:

Asking firefighters if they need a break is sure to result in a negative response.

Failure to plan for replacement crews will result in delayed rehabilitation or no rehabilitation.

The costs of not rehabilitating crews will have a significant negative effect on personnel and medical budgets.

Someone needs to assist the incident commander in managing rehab efforts.

Without strong leadership, effective rehab will not be accomplished.

Tragic events do–at least for a while–affect how we do our job. Loss of life causes us to pause and think critically about what we do and how we do it. But we don`t have to wait until our comrades die before we do it right. A commitment now to a safer fireground can make all the difference. n


WHY REHAB?

Rehabilitation can help prevent the following:

Heat injuries

Heart failure

Stroke

Kidney damage

Impaired judgment

Diminished physical function

FOR ADDITIONAL INFORMATION. . .

Detailed recommendations, including a sample SOP, are available in Emergency Incident Rehabilitation, which is available without cost from USFA Publications, P.O. Box 70274, Washington, DC 20024.

WILLIAM F. SULLIVAN is an 18-year veteran of and a captain in the Chelsea (MA) Fire Department, where he serves as hazardous materials officer. He has a bachelor`s degree in fire department administration from the University of Massachusetts and a master`s degree in education from Harvard University.

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