Rehab and medical monitoring...


Are we doing it right?

CarolinaFireJournal - By Franklin H. Russell and Keith Armfield
By Franklin H. Russell and Keith Armfield
10/05/2012 -

How many times over the past few years have you heard the term rehab or medical monitoring? These terms are some of the latest buzzwords in the emergency services realm. With that being said, how many people truly understand what it means to establish and maintain a rehab sector? In many situations people think of rehab as a bottle of water and medical monitoring as a blood pressure check. The process is much more involved and technical than that. Some situations only require company level rehab such as a single family dwelling fire or a motor vehicle crash with a pin in. Other situations require a formal technical rehab sector being established.

Rehab has been around for years in one form or another but never standardized. In recent years people have been taking a different approach to rehab and putting more validity behind the process. NFPA 1584 states that rehab is now a standard rather than suggestion. Rehab and medical monitoring should be put in place anytime that an operation is expected to stress responders and subject them to mental and physical strain.

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Your rehab sector should allow responders to take their mind off of the scene for a few minutes, lower their anxiety level which will lower heart rates and blood pressures and allow them to rehydrate so they are ready to get back to work upon being released from rehab.

Structure fires are the most common place to find rehab operations, however, there are plenty of other scenarios that warrant rehab and medical monitoring, such as extended or complex rescue operations, wild land firefighting, land-based search and rescue, extended law enforcement operations and so on.

The ability to practice proper rehab has been plagued by several different factors. The first is reluctance of the responders to actually report for rehab. Some first responders are still in the mindset that “nothing bad can happen to me” or “I’m too tough to need this.” Everyone needs to realize that bad things do happen and they can happen to anyone at any time. Let’s take a second to highlight some of the “bad things” that we encounter on a daily basis running calls. We have environmental conditions to deal with, strenuous work in bulky PPE, physical and mental demands, toxic gases such as carbon monoxide and hydrogen cyanide, dehydration, heat exhaustion, heat stroke and traumatic injuries just to name a few. The second obstacle facing us is manpower at the scene. If we are dealing with a rural district that has a minimal amount of firefighters on scene and a working structure fire in front of them, how many firefighters can that Incident Commander (IC) commit to rehab at one time and still accomplish the task at hand? If there are firefighters that come through rehab and are sidelined due to various reasons what has that done for manpower numbers? The third obstacle is having well-trained personnel assigned to rehab that truly understand what the position involves.

There are several issues to address when the decision is made to set up a formal rehab. Your rehab sector should allow for:

  • Mental rest and recovery for your responders
  • A place for them to shed their PPE
  • Enough room for the anticipated number of personnel
  • Fluid replacement
  • Shelter from the elements
  • Shelter from the prying eyes of the public and media
  • Accountability
  • Cooling or warming depending on weather
  • Room for medical monitoring

Selecting a Rehab Site

It is important to select a site that is appropriate and safe. Many times rehab is established about 150 feet from the front of the structure under a tree or on the bumper of an engine. Having rehab set up too close to the active incident does not allow for mental rest and recovery. If your responders are sitting in rehab looking at their co-workers advancing lines or ventilating a roof, their mind is going to be on getting back to the fight. Your rehab sector should allow responders to take their mind off of the scene for a few minutes, lower their anxiety level which will lower heart rates and blood pressures and allow them to rehydrate so they are ready to get back to work upon being released from rehab. Another issue with establishing rehab too close to the active scene is smoke and toxic fumes. You could very well have a rehab sector with elevated levels of CO due to the fire or engine exhaust from your apparatus. A good practice is to have some form of air monitoring capability in your rehab sector to insure a safe environment.

It is important to clearly define an area inside of rehab where responders can shed their PPE. Most firefighters gladly take their pack and coat off upon reporting to rehab but are sometimes hesitant to come out of their bunker pants. You should insure that all responders in rehab come out of their bunker gear. If you only take half of it off you’re not allowing for adequate cooling of core body temperatures. We will discuss body core temperatures in depth later in this article. You should also have enough room to comfortably handle the maximum anticipated number of responders at any given time. If you have established rehab in the back of an ambulance, which can handle one company, and then all of the sudden have three companies report to rehab at the same time, there is an issue. You should establish an area that could accommodate half of the personnel on scene at one time.

Rehab should offer shelter from the elements. During extreme cold weather an enclosed area that could be heated would be ideal, however, that is not always an option. If you do not have access to an enclosed area you should at least shield responders form the wind. Keep in mind that your bunker gear is going to get wet and so are the clothes that you have underneath. Wet clothing and cold wind will greatly increase heat loss and can result in hypothermia. During extreme heat we need to offer shade and attempt to cool the area to the best of our ability. Great tools for hot weather operations are cool mist fans. Mist fans used in conjunction with shade can lower the ambient temperature by up to 15 degrees. If misting fans are not available an electric smoke ejector works well.

A rehab sector should be clearly defined and have controlled entry and exit points. Not only should we keep responders out of sight of the event while they are in rehab, but we need to insure that the responders are kept out of sight of the general public and the media. People wandering around your rehab sector or cameras and reporters coming in and out filming are going to increase stress and anxiety levels.

Use a Tracking System

Accountability is another important facet to rehab. You should have a tracking system in place. The best thing to use is a simple paper form. You should be able to document name, unit assignment, time-in, initial and repeat vital signs, time out and if the responder was sent to treatment or transported to the hospital. The forms need to be kept simple to eliminate a backlog in flow. Establishing controlled entry and exit points allows rehab personnel to maintain accountability and safety for all responders in the sector. It is vital that you do not have personnel wandering in and out of rehab without proper documentation and check in.

Rehydration

In order to provide much needed rehydration in rehab, fluids must be readily available. The kind of fluid has been up for debate for some time. Even though most people enjoy the taste of a cold soft drink when they are hot and sweaty you should steer clear of this option. Soft drinks can act as diuretics and actually cause your kidneys to remove more fluid from your body so water is a good choice if activity has lasted less than an hour. If your activity has lasted for more than an hour you should be looking at offering a sports drink. After an hour of activity we need to offer something that has sodium and carbohydrates. Although water alone will satisfy your body’s thirst mechanism you could walk away dehydrated and depleted of electrolytes. There have also been numerous discussions on diluting sports drinks for rehab. Sports drinks are formulated for maximum absorption and taste. If you change the concentration you will actually alter the effectiveness of the drink itself. A good sports drink contains four to eight percent carbohydrates and 0.5-0.7g of sodium per liter. Your personnel should have an intake of two to four ounces per 20 minutes of work. Once assigned to rehab, fluid intake should be 12 to 32 ounces during a 20-minute rest period. Fluid intake should be increased during temperature extremes. Too much fluid taken too quickly can cause abdominal discomfort and lead to nausea and vomiting. You should also encourage your crews to consume 12 to 32 ounces of fluid during the first two hours post incident.

Cooling/Heating Methods

On large-scale incidents, medical personnel might elect to go ahead and establish a treatment area. This area should be an extension of medical monitoring but should be isolated from the rest of rehab.

When operating in high temperature extremes we need to be offering a method of cooling for our responders. There are several different variations of cooling at our disposal. Some options are cool towels to place around the neck, forearm immersion cooling chairs and cool vests. Wet towels placed around the neck cool at a similar rate when compared to forearm immersion chairs. Feedback from responders indicated that there is an additional psychological benefit of the cool towels. This is from a sense of immediate relief from the towel being placed on their skin. Forearm immersion chairs are nice, however, they take up much more room on an apparatus compared to a cooler and a stack of towels. Most vehicles have enough room to add a cooler and towels so you don’t have to wait for a specialized rehab vehicle to arrive to begin cooling measures. It is as simple as placing an additional cooler on your unit, filling it a quarter of the way with ice, another quarter with water and then having a stack of towels that you place in the cooler if the need arises. During extreme cold weather you need to ensure some way of warming and maintaining core temperatures. You bunker gear and clothes are going to be wet due to sweat and water flow. Hypothermia is a real concern in these situations. In these cases we need to attempt to secure an enclosed area that can be heated for rehab. Also, as we discussed earlier shielding rehab from the wind will help prevent heat loss. During cold weather it is a good idea to keep a change or clothing with you in case you need it.

Medical Monitoring

Medical monitoring and rehab go hand in hand, however, they are not the same thing. Medical monitoring is not the same as medical treatment. Medical monitoring is a short assessment to evaluate a responder’s well being and determine if they need further evaluation, treatment or are fit to return to duty. As I mentioned earlier, most people think of medical monitoring as a simple blood pressure check. Let’s break down the process and discuss it further.

Trained medical personnel, of course, should perform medical monitoring, but that does not mean wait for an ALS unit to arrive before you initiate it. A well-trained EMT-B is just as capable of managing a medical monitoring operation as a paramedic. The first thing that you should be evaluating is the responder’s level of consciousness and mentation. Simply looking at them can do this. Are they making eye contact with you when you speak to them? Are they having difficulty ambulating? Do they look confused? If they appear to have a change in LOC this makes them a priority for further evaluation.

When your crews begin arriving in rehab resist the urge to immediately attack them with a blood pressure cuff. Blood pressure readings are important but this is not the most important thing at this moment. In addition to that, most medical monitoring places emphasis on the blood pressure, however, that is the least understood reading that we could obtain. Let’s think about the cardiovascular system for a second to explain this. If you just spent 20 minutes dressed in full PPE inside of a burning structure engaged in strenuous activity how would your cardiovascular system respond? Your heart rate should be greatly elevated due to the anxiety and physical stress of the event and a decrease in the amount of circulating fluid secondary to dehydration. Your heart rate is a component of your blood pressure so we should see an increase in blood pressure readings. If we take a blood pressure and pulse rate as soon as you shed your PPE are we getting a true representation of your status? You should wait at least 10 minutes before taking your first vital sign measurement. Secondly, what does a blood pressure reading do for us in this situation?

If we use a blood pressure reading alone to evaluate the need for further evaluation or treatment we are going to miss things. If you had the time to take pre-entry vital signs you now have something to compare to. If a responder comes through rehab with a blood pressure of 118/74 we might say that is a good blood pressure and everything is well. What if that same person had a baseline blood pressure of 168/94 prior to going into that fire? He is now hypotensive and could be exhibiting signs of the same. We still have criteria to say that a systolic B/P >200 or diastolic B/P of >110 after 10 minutes of rest needs further evaluation. Pre-entry vitals are a good practice, however, how often do we have time to take blood pressures on our crew prior to advancing that hand line through the front door? One way that we could work to remedy this would be taking 15 minutes at the beginning of your shift to take and record blood pressures on each other.

Pulse rates are quick to obtain and give us good information. We should be assessing pulse rates using the NFPA 85 percent of maximum predicted heart rate model. If you have someone that has a heart rate above 85 percent of their predicted maximum heart rate after 10 minutes of rest they need further evaluation.

Temperature measurement is another vital sign that we could look at. The one issue with taking temperatures would be the limitations of the equipment we are using. Oral thermometers are one option, however, oral temperature readings are altered when you drink fluids. Everyone in rehab should be drinking fluid so that option is out. The next option would be tempanic thermometers. Tempanic thermometers are easy to use and quick to obtain. The problem with this is tempanic thermometers can be 2.5 degrees lower than actual body core temperature. After you come out of your gear in rehab your body core temperature continues to rise for approximately five minutes. During those first five minutes when your core temperature is continuing to rise, tempanic readings are beginning to fall. You might have a tempanic temp of 99.5 degrees, which sounds good but the actual core temp could be 102 degrees. The only way to easily obtain a true core temperature is to measure it rectally. I am fairly confident that no one wants to get that up close and personal on a fire scene.

The best thing to access during those first 10 minutes or so in rehab is the person’s overall level of consciousness and addressing any physical complaints that they have. You should always be vigilante and looking for warning signs of heat stress, heat exhaustion, heat stroke, dehydration and toxic inhalation injury.

Medical Treatment

You must also take into account the possible need for medical treatment and transport of injured or symptomatic responders. On large-scale incidents, medical personnel might elect to go ahead and establish a treatment area. This area should be an extension of medical monitoring but should be isolated from the rest of rehab. In the event of an injury or illness you do not want treatment taking place in plain view of the rest of the responders. If you have to perform medical treatment on a firefighter you do not want his co-workers sitting in rehab watching. The individual in need of treatment is one of their own and if they are seeing oxygen flowing and IVs being started, their mind is going to be on their buddy not their own well being. You should also be concerned for the privacy of the injured person.

In conclusion, rehab and medical monitoring are an important part of emergency operations. If you have an effective rehab and medical monitoring program in place and execute it we can help to ensure everyone goes home at the end of the shift. We can’t help others if we become patients ourselves.

Franklin Russell is currently a Critical Care Paramedic with WakeMed Mobile Critical Care Services and an EMS instructor with Guilford Technical Community College. He previously spent 13 years as a paramedic with Guilford County EMS. Russell served as the team leader of the Medical Assistance Strike Team and State Medical Assistance Team for Guilford County as well as Hazmat Technician with the Guilford County Hazmat Team. He was also a firefighter with the Horneytown Fire Department in Forsyth County.Keith Armfield began his career in emergency services in 1982 as a volunteer firefighter with the Pinecroft Sedgefield Fire Department in Greensboro. He most recently served with the Stokesdale Fire Department in Guilford County as well as an EMT instructor with Guilford Technical Community College. He is currently employed with Guilford County emergency services as a senior paramedic, also serving on the state medical assistance team as well as being trained as an advanced hazmat life-support paramedic.
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