Photo by Darin Overstreet / www.defenseimagery.mil
By P.J. Norwood
According to some in the fire service, the most dreaded spot on the fireground is in rehabilitation (rehab). What many fire and emergency medical services (EMS) professionals fail to realize is the importance of this position and division in the overall incident.
For many years, the fire service defined rehab as the place to obtain a new full self-contained breathing apparatus (SCBA) bottle, a cup of coffee, and a donut. However, rehab should be very different; it is a critical part of incident management crucial to providing a standard each and every time.
Firefighter rehabilitation should be governed by a set of standard operating guidelines (SOGs). The SOGs should be consistent with the National Fire Protection Association (NFPA) 1583, Standard on Health-Related Fitness Programs for Fire Department Members. Although NFPA 1583 is a consensus standard, it is not law; it is the standard of care and best practices that all departments should follow whenever possible. Firefighter rehab is not only for the fireground; consider rehabilitation and perform training evolutions as well.
The fireground is an extremely dynamic environment that exposes firefighters to extreme conditions. Extreme conditions exist on every fireground and at time during extreme weather conditions. Rehab is an intervention designed to mitigate against the physical, psychological, and emotional stress of firefighting to sustain a member’s energy, improve performance, and decrease the likelihood of on-scene injury or death.
Firefighter rehabilitation consists of the following five elements:
- Initiation of the rehab sector.
- Define the responsibilities.
- Maintain accountability.
- Ensure safety.
- Release personnel from rehab only when it is safe to do so.
Initiate rehab at the request of the incident commander (IC) through previously established SOGs, which should have been clearly communicated to all personnel. Define clearly the responsibility of the rehab sector, especially when EMS personnel are staffing the rehab sector. The initiation and responsibilities, when defined ahead of time, will provide the necessary groundwork that sets up the team for success.
On the fireground, accountability is of utmost importance. Within the rehab sector, accountability must include accounting for who is in rehab, who has been in rehab, and when and where they were released. The system will also ensure that personnel do not leave without approval.
The rehab sector must be safe for those working within and entering it, spending time in, and eventually being released from. Some of the safety items also include keeping those assigned to rehab safe from the incident, the environment, the media, societal threats, and “prying eyes.”
The last piece is release from rehab. Release from rehab may mean the firefighter is capable to return to active firefighting or possibly less demanding tasks or to EMS for further evaluation and possible transport. Release from rehab is the most difficult piece of the process to manage. It is critical that release parameters are clearly defined and understood by those staffing the rehab sector and the firefighters entering ahead of time. Following are the standard set of questions that you should ask that will help guide release:
- Is the firefighter adequately rested?
- Is the firefighter adequately hydrated?
- Has the firefighter received proper nutrition?
- Has the firefighter responded appropriately to care measures?
The ultimate decision to allow or disallow a member to return to work is vested in the rehab sector officer through authority delegated by the IC. This does not mean it will be clear cut or easy to make the right decision each and every time. Most firefighters clearly know and understand the process and may be inclined to twist the facts so they can be released to go back to work rather than be released from the scene.
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One of the most important pieces of firefighter rehab comes in the preparedness and the development of SOGs. The SOGs developed should include and address the following:
- Relief from climactic conditions.
- Rest and recovery.
- Active and/or passive cooling or warming as needed based on the event and climate.
- Calorie and electrolyte replacement.
- Medical monitoring.
- EMS treatment.
Although the incident will always be very dynamic, an impromptu setup may have already occurred. Assess the location to ensure adequate safety, and move it if necessary. Some of the items and scene aspects that you must consider when establishing the rehab location include the following:
- Protecting the firefighters:
a. From the media.
b. From prying eyes.
c. From the incident.
d. From the elements (i.e., smoke from the fire, carbon monoxide from vehicles).
- It must be large enough to accommodate the needs of the incident and have it be easily expanded if the incident expands.
- It must located with EMS so that it can facilitate quick transfer to transport vehicle, if necessary.
- It must be close to the incident and easily identified by personnel.
- The setup and operation must be in accordance with preestablished guidelines and SOGs.
NFPA 1584, Standard on the Rehabilitation Process for Members During Emergency Operations and Training Exercises, calls for a minimum of basic life support care available at incident scenes and the resources for transport, if needed. Personnel performing the medical monitoring should evaluate all working members for symptoms suggestive of a health or safety concern when they enter the rehab process and prior to being released. This will help ensure there are no obvious indications that they aren’t capable of performing their job requirements.
The standard also specifies that EMS personnel performing medical monitoring should assess for the following:
- Chest pain.
- Shortness of breath.
Additionally, you should assess each firefighter for the following symptoms:
- 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.
- Abnormal vital signs (the specific vital signs and what defines abnormal is to be defined by the department medical authorities).
Firefighter rehab starts well before the incident. Educate firefighters and give them the time to focus on their health and fitness levels. Firefighters who maintain a high level of fitness will recover quicker and exhibit fewer negative effects from the incident. Additional education to the rehab SOGs is crucial for the rehab sector’s success.
The firefighter rehabilitation sector is a crucial piece to every incident and training ground that should be governed by established SOGs consistent with NFPA 1584. Communicate the SOGs to all personnel, and then have them train on them.
Although the fireground can still include coffee and donuts, they should be carefully monitored and ingested appropriately.
P.J. NORWOOD is a deputy chief training officer for the East Haven (CT) Fire Department and has served five years with the Connecticut Army National Guard. He has authored Dispatch, Handling the Mayday (Fire Engineering, 2012); coauthored Tactical Perspectives of Ventilation and Mayday DVDs (2011, 2012); and was a key contributor to the Tactical Perspectives DVD series. He is a Fire Engineering University faculty member, co-creator of Fire Engineering‘s weekly video blog “The Job,” and host of a Fire Engineering Blog Talk Radio show. He is certified to the instructor II, officer III, and paramedic levels.