When Do You Send Crew Members to the Rehab Area?
Standard Operating Procedures (SOP) should be established and in place prior to any incident. Unfortunately, there aren’t many guidelines for when to rehab. NFPA 1584 provides the following two guidelines for company or crew rehabilitation in terms of work-to-rest ratio and/or self-contained breathing apparatus (SCBA) usage:
The company or crew must self-rehab — rest with hydration — for at least 10 minutes following the depletion of one 30 minute SCBA cylinder or after 20 minutes of intense work without wearing an SCBA. The Company Officer (CO) or crew leader must ensure that all assigned members are fit to return to duty before resuming operations.
Company or crew must enter a formal rehab area, drink appropriate fluids, be medically evaluated, and rest for a minimum of 20 minutes after any of the following:
- Depletion of two 30 minute SCBA cylinders
- Depletion of one 45 or 60 minute cylinder;
- Whenever encapsulating chemical protective clothing is worn
- Following 40 minutes of intense work without an SCBA.”
Establishing a Rehab Area
Choosing a rehabilitation area varies due to environmental concerns, man made structures, distance to the site of operations, severity of weather, and the duration of the event. This all assumes that there aren’t any Standard Operating Procedures in place for when, where and what conditions require a rehab area be established if at all. “The closest to any requirement in the code world can be found in National Fire Protection Association (NFPA) 1584, “Recommended Practice on the Rehabilitation of Members Operating at Incident Scene Operations and Training Exercises” (2003 ed.). Objective 4.2.4 of that document states, “procedures should be in place to ensure that rehab operations commence whenever emergency operations pose the risk of pushing personnel beyond a safe level of physical or mental endurance.” Little concrete direction can be derived from that statement and much is left to the judgment of incident command personnel.”
“The “big three” considerations that will need to be taken into account are:
1. The estimated number of responders who will need to be rehabbed.
At small incidents with a limited number of firefighters on the scene, typically less than five or six personnel will be in rehab at any given time. This will not require a substantial amount of space or equipment to accomplish. As the size of the incident and the number of firefighters grow, so will the need for space in the rehab area.
2. The climatic conditions at the time of the incident.
If the weather is mild and dry, it may not be necessary to select a location that shelters the responders, other than to get them out of direct sunlight. Excessively hot, cold, or wet weather will require a site that shelters the firefighters from the elements.
3. The duration of the incident.
Rehab at short duration incidents — less than six to eight hours — may be handled adequately using apparatus and portable equipment. If the incident is going to last for the better part of a day or longer, it may be better to locate rehab in an available building. If a building is chosen, make sure it is suitable for proper rehab operations and that displacing occupants of the building for a period of time will not affect them adversely in the name of firefighter safety.
NFPA 1584 does provide some recommendation on desirable site characteristics for rehab operations. The following is a summary of characteristics and considerations that must be evaluated in addition to the “big three” described above:
- Locate the rehab area in the incident’s “cold zone” so that personnel in the area can remove protective equipment and truly relax and recharge. In general, the rehab area should be outside, uphill, and upwind of the hazard area.
- Be reasonable in the distance from the work area to the rehab area. You don’t want to be so close that the rehab area is in the way of incident operations. On the other hand, it should not be so remote that firefighters are tired by the time they get back to the work area.
- Choose a site that protects responders appropriately from the weather conditions. Look for a shaded, cool area in hot weather and a warm, dry, wind-protected area during cold-weather operations. Always try to stay out of precipitation.
According to NFPA 1584, rehab operations should, at a minimum, have the ability to meet the following five emergency incident rehabilitation needs:
- Medical evaluation and treatment.
- Food and fluid replenishment.
- Relief from climatic conditions.
- Rest and recovery.
- Member accountability.”
“In reality, regardless of departmental SOPs, the IC must consider a variety of factors when determining the need to establish rehab operations. These factors, when considered as a whole, will make the need for rehab operation apparent. One fact is clear: ICs should not play “catch-up” when deciding the need for a rehab area. That is, do not wait for people to starting dropping over from exhaustion before putting rehab operations in motion. At this point you are acting too late. Rather, the establishment of rehab should be a routine, proactive measure to prevent personnel from getting to the point of injury or illness at an incident.”
Equipment Needed for Rehab Areas
The most common response for all fire departments is structure fires. This is also the most common area which has the most need for a rehab area to be established, especially in extreme conditions of heat or cold and longer deployment times. Some basic things needed for a rehab area are:
- Portable shelter from the sun — should also have an option of being enclosed for cooling or heating systems to be attached. This could be a tent, inflatable structure, camper or utility trailer with an AC/Heater.
- Fluids — cool but not ice cold in hotter times, warm but not piping hot, in cold times. Water and sports drinks are best. DO NOT USE caffeinated energy drinks, soda, coffee, tea, fruit juice, fruit drink, milk or iced tea as these all counteract the absorption of water into the body.
- Food — be sure to provide hand-wipes or hand sanitizer — dependent upon limitations of the provider, duration of the incident, and personal preference. Every effort should be made to ensure the foods meet or exceed nutritional standards. “...food containing large quantities of carbohydrates should be served to firefighters at medium and long-duration incidents. This includes breads, potatoes, pasta, rice, and other high starch food. Short- and medium-term incidents use simple foods that do not require preparation. These include things such as fruits, doughnuts, candy bars and energy bars. Some of these items, such as the candy and energy bars, have long storage lives and may be carried on the apparatus or stored at the fire station until needed. Other types of food may need to be acquired from a local grocery store or restaurant.”
- Blankets and towels which can be made wet for cooling or kept dry for warming.
- Medically trained attendees — EMTs or medical staff for the department.
More advanced items needed for rehab include:
- Misting fan or regular fan for evaporative cooling. — a generator may be required
- Cooling device for conductive cooling
- IV Fluid warmer and cooler for more severe forms of heat and cold stress — administered by medical professional
- Thermometers — special hypothermic thermometers are needed for measuring hypothermic conditions
“The fire department’s responsibility for safeguarding the well-being of their members does not end when the last firefighter leaves the rehab area at an incident. Policies and procedures must be in place to ensure that firefighters continue to receive restorative care after the incident. The fire department also must ensure that the resources used to provide rehab services are replenished and ready for the next incident where they may be needed.”
As stated before in the 2011 report physiological recovery from fire fighting activities in rehabilitation and beyond by The University of Illinois the conclusion was, “The time line for recovery from fire fighting activities is significantly longer than the typical 10 to 20 minute rehabilitation period that often is provided on the fire ground.”
Termination of Incident Rehab
“Before getting too deep into any discussion on the scaling back and terminating of rehab services at an incident, it is important to recognize that we are talking about scaling back the number of resources assigned to the rehab operation; not the services that the rehab operation is capable of providing. All of the basic functions of the rehab operation that were discussed previously ... must be provided to the end of the incident. They may not require as many people to perform each one of them as the number of personnel working at the incident scene decreases.
“Many rehab concerns actually increase for those personnel remaining on the scene until the conclusion of an incident. Experienced fire service leaders recognize that some of the hardest work of the incident occurs after the fire is out or after a rescue has been completed. Salvage and overhaul operations, as well as retrieval of equipment are grueling tasks for personnel who may be very worn and tired already from the demands of the operational period of the incident. All rehab services must be available to these personnel to ensure their well-being.”
With the bulk of this article pertaining to physical health and well-being “...it must be recognized that the duties and activities that firefighters routinely perform also come with a heavy burden on the psychological well-being of these individuals. Fire and rescue operations can be extremely emotional events involving serious injury and death to civilians and firefighters alike. Regular exposure to dangerous situations and potential for harm also takes a toll on individuals and the combination of these factors can increase stress in daily family life. Fire departments and labor organizations must ensure that programs are in place to address and mitigate the psychological hazards of the job.”
Stress can be attributed to a variety of physical and mental symptoms which, if not treated, can have serious and fatal consequences. The way of operating in the past was ineffective. This social stigma consequently affected the way firefighters dealt with the emotional toll of their career. In addition, some tried to wipe away these thoughts with drugs, alcohol or other self-destructive behavior. This is why it is so important to establish a comprehensive behavioral health program.
Behavioral health has progressed from informal discussions of individual events to our current understanding of the need for comprehensive programs of prevention, effective intervention, and follow-up care to prevent long-term effects.
The goals of a comprehensive critical incident stress management (CISM) program are to:
- Minimize the emotional impact of critical incidents on emergency responders
- Increase firefighters’ resistance and resilience to this type of stress
- Prevent harmful effects following critical incidents by working with response personnel at or near the time of such incidents
- Prevent any chronic effects, such as posttraumatic stress disorder, through the use of follow-up care and employee assistance programs
Post-Incident Hydration and Well-Being
The main thing to remember is that complete rehabilitation may take a lot longer than the 20 minutes given at the incident. The only way for personnel to be sure they have done enough is to “self-monitor” after the event —sometimes, if rehab has not been made available, during the event. One simple tool for doing this in the station house is to post a urine color chart. This is a fast way of making sure ones fluid levels are good and healthy. It is also important to be aware of the food and beverages one consumes prior to the call and after the incident. It may take up to 24 hours after the event for serious complications to manifest themselves.
Once the rehab operation has been terminated and all the resources returned to service, the job of those who were assigned to provide rehab services is complete. However, the firefighters and other first responders who received the services of the rehab operation must continue to monitor their own well-being. Make sure they complete the necessary rehydration, rest and nourishment required to bring them back to a total state of well-being.
A properly run and used rehab area at the incident will go a long way towards making sure that personnel are medically evaluated, treated, rehydrated, and that they receive food when necessary. However, the job cannot be totally completed in a rehab setting. Additional rest, fluid intake, and in some cases, food intake will be needed after the incident to ensure that proper metabolic levels are restored.
In particular, in almost all cases require additional fluid intake after the incident. It is generally recommended that firefighters drink an additional 12 to 32 ounces of electrolyte- and carbohydrate-containing fluids within the two hours following the operation. One simple way to monitor if proper hydration has been restored is to self-monitor one’s urine output. A properly hydrated person should have a reasonable volume of urine output and that urine should be relatively clear and odor-free. Following an incident or strenuous training exercise, if the firefighter notices that his or her urine continues to be dark in color or strong in odor, then additional rehydration will be necessary to restore a proper water balance. Continue drinking fluids until the urine output appears to be normal.
Firefighters also should monitor themselves and their fellow firefighters for signs of delayed medical problems following an incident or training exercise. Serious medical conditions, such as heart attacks, strokes, and other potentially fatal conditions can occur up to 24 hours following the activity. That is why most firefighter insurance and line-of-duty death programs recognize these injuries and deaths as line-of-duty related when they occur within 24 hours of the performed duty. Any members showing signs of an illness or injury should receive immediate medical attention following department SOPs and local EMS protocols.”
This article should give a good overview of some of the considerations for rehabilitation for firefighters. However, some of the issues and sections require much more detail than can be provided here. Please download the report from the U.S. Fire Administration Emergency Incident Rehabilitation, February 2008. Many parts of this article are taken directly from this report. In addition, training programs should incorporate information for the individual to monitor their own performance and health as well as their team members. A program of overall health should be instituted for the department. This will improve the outcomes of all rehabilitation efforts, reduce sick days and lead to stronger and more resilient team members.
Kevin P. Ensor is Marketing Director for EMS Innovations and is responsible for aiding in new product development and systems management. In addition, he is part of the EMS Innovations Response Team who trains hospital staff and responders in the proper use of EMS Innovations inflatable shelters and other products. He is a member of the Anne Arundel County Local Emergency Response Team (AALERT) in Maryland and has received training in search and rescue, minor fire suppression, CPR/AED use and overall preparedness.Dr. Joseph G. Ferko III, DO, M.S. is the owner and president of EMS Innovations. Dr. Ferko has vast experience in disaster medicine and response of over 29 years. He has participated heavily in the response efforts of numerous natural disasters and man-made events for more than a two decades.References:Emergency Incident Rehabilitation, by the US Fire Administration, February 2008