By David Jaslow
Throughout this series, we have isolated and compartmentalized an approach to the fireground medical screening exam. We have developed goals and objectives followed by strategy and tactics to efficiently and effectively evaluate firefighters and other emergency responders who present to the rehab sector or who seek out EMS providers when the possibility of an ill or injured firefighter exists. As we all know, fireground emergencies are usually chaotic events that are characterized by communications failures and lack of information flow concerning incident details. Thus, it behooves EMS providers and EMS managers at these incidents to plan an algorithmic approach to screening firefighters in order to standardize and prioritize the medical evaluation so that there is some degree of confidence that this evaluation is being done correctly.
For this final part of the Fireground Medical Screening Exam series, we shall use an example case to demonstrate not only the approach to a firefighter who may be acutely ill but also several potential outcomes of the evaluation process.
Case: A 24 year-old morbidly obese (300 pounds) male volunteer firefighter is brought to the rehab sector after spending 30 minutes participating in the evacuation of a high rise building that contains mostly elderly and handicapped persons. He is wearing a full structural firefighting ensemble. He is tachypneic and diaphoretic. He does not have any known past medical history. The other members of his engine company are concerned that he could no longer climb stairs. He offers no medical complaints but appears to be exhausted.
Questions: What initial assessment must be done to determine whether or not a medical emergency exists that would mandate transport to an emergency department? How quickly can this be accomplished? What tools are required to perform this assessment?
This firefighter must be evaluated quickly but there is no need to immediately rush him to an ambulance for transport to an emergency department. This may sound surprising to many readers since rapid transport is the norm at US firefighting incidents for persons who fit this clinical picture. Let’s digress for a moment to explain this decision. The point here is that it is the norm not because it is necessary but because most EMS providers are not trained to evaluate and/or differentiate physical exhaustion from acute illness (which they should be since it is extremely rare that a firefighter in his early 20s develops a serious medical emergency on the fireground). While it is certainly appropriate and the standard of care to transport acutely ill or injured firefighters to an emergency department for treatment, we have not yet defined this hypothetical case as a patient. Indeed, this entire series on the fireground medical screening exam has been designed so that the readership may more easily understand the difference between a firefighter who has experienced the predictable stresses of heavy physical exertion and one who meets the definition of a patient. Clearly, the majority of athletes from high school to professional sports are not transported to the hospital because they are panting on the bench after playing. Despite the fact that our case example features an individual who is deconditioned and overweight (i.e. the opposite of a healthy athlete), the majority of firefighters do not require transport for what is essentially the same physiologic state (exhaustion) as the athlete’s.
The firefighter should be brought to an area that is designated for firefighter rehabilitation, if one is available and established. If this is difficult or impossible, attempt to place him in an environmentally controlled area away from incident operations where there may be some privacy to partially undress him and perform a medical evaluation. The other benefit to removing personnel who require medical evaluation from the area of operations is that it reduces the stress level for both EMS personnel and the firefighter. Both need to concentrate on the task at hand instead of the noise and commotion around them. It is much easier to remove someone emotionally from the incident if he/she is also physically removed from it.
Bunker gear should be shed, if possible. At a minimum, remove the coat and have the firefighter lower the pants to at least the knees to allow the release of heat. In a cold weather scenario, it is still important to release excess heat that has been produced during strenuous physical activity. In these cases, doffing bunker gear may have to be modified to only opening the coat, depending on exactly how low the ambient temperature drops.
Perform a focused history of present illness within the first minute. What activities was the firefighter performing and for how long? Did he have any symptoms of illness other than feeling exhausted (chest pain, dyspnea, etc.)? Was there any potential hazmat exposure including the possibility of smoke inhalation, even if he was wearing SCBA (poor mask fit)? What is his medical history, medication list and does he have any allergies to medications? Did he feel ill prior to responding to the incident? Obtain a radial pulse (estimate the rate if very fast) while taking the history.
The primary survey is now complete since airway, breathing and circulation are intact. Next, perform a focused physical exam while an assistant (or you if there is no assistant) begins to attach medical devices to the patient to obtain ancillary information. The physical exam is very brief because the few common fireground medical emergencies that could occur in the absence of defined symptoms or complaints (cardiac ischemia, hypertensive crisis, mild-to-moderate CO poisoning, heat exhaustion) tend not to produce gross abnormalities in the physical exam. Look at the skin for evidence of rash and sweating. Listen to lung sounds. The patient’s neurologic exam has probably already been accomplished via talking to the patient, observing them walk into rehab and/or move all extremities and follow commands.
Apply the RAD-57 and it will provide a pulse rate, pulse oximetry value and carbon monoxide value all from one finger probe. If there is any possibility of cardiac ischemia, obtain a 12-lead ECG. How will you know which firefighters require this test? The best practice is to obtain a 12-lead on every male 35 years of age or older, every female 45 years of age or older and any person who complaints of chest pain, shortness of breath, epigastric pain, back pain, nausea or exhaustion to the point that they have difficulty standing or walking (i.e. potential symptoms of cardiac ischemia). Note that there is almost no utility of a Lead II ECG by itself in someone who has a regular tachycardia less than 140 and no history of atrial tachydysrhythmia —they will be in sinus tachycardia. Therefore, do not fall into the trap that a Lead II rhythm strip will somehow demonstrate that an acute emergency exists and a normal Lead II rhythm strip is sufficient! Think, “12-lead or nothing,” (i.e. not necessary). Attach the automated blood pressure cuff from your cardiac monitor and make sure to use the obese BP cuff (for this particular patient).
Recalling the previous nine columns in this series, the purpose of the fireground medical screening exam that is conducted in the rehab sector is to determine whether or not a fireground medical emergency exists. If such an emergency does not exist, the firefighter may be rehabilitated (by whatever means is necessary) in the rehab sector rather than being transferred to the treatment sector (akin to transport to the emergency department in most settings). In this case example, it is the responsibility of the EMS provider evaluating the firefighter (or the rehab sector officer) to rapidly create a mental list of what possible fireground medical emergency conditions could be responsible for the clinical presentation described above and then sequentially eliminate them based upon results of the history and physical, ancillary testing, observation and response to any therapy instituted.
Process of elimination
Our list of medical emergencies to rule out (i.e. the differential diagnosis) for this case example should include smoke inhalation (CO poisoning), pre-existing infectious illness, which has lead to dehydration, deconditioning and cardiac ischemia despite his young age. The latter condition should always be in the differential since failure to identify it could be catastrophic for the firefighter; it has been known to occur in younger individuals under extreme physical duress and because it has been recognized as the most dangerous commonly occurring medical emergency on the fireground. The presence or absence of these conditions should be fairly easy to ascertain based upon history, physical and the technology listed above. If emergencies have all been ruled out and he improves with rest and other rehab measures, the most likely explanation for his clinical presentation is deconditioning/physical exhaustion. In this scenario, transport to an emergency department is not necessary.
Should we consider entities such as pulmonary embolism to explain the case example? Clearly, PEs can occur spontaneously in persons without classic risk factors or warning symptoms, but this is extremely rare on the fireground. Furthermore, abnormal vital signs, shortness of breath and tachycardia would not be expected to resolve with rest as it would if that clinical presentation were due simply to exhaustion. The bottom line in medical evaluation of the firefighter is that healthy individuals who are physically spent or just deconditioned and overworked will improve relatively rapidly with rest, oral hydration and release of heat stress. Failure to see an improvement in overall clinical condition or failure to meet established benchmarks for wellness should tell the EMS clinician that a true medical emergency may exist (even if the exact nature of that emergency is unclear) and that transport to an ED may be necessary.
The entire evaluation of this firefighter should be able to be accomplished in five minutes or less. Once technological measures such as pulse ox, SpCO reading, 12-lead ECG and BP all fall within limits that do not indicate an emergency condition, the firefighter can be placed into observation with instructions to other rehab sector personnel and to the individual that the firefighter will be reevaluated every 15 minutes or so until he has met wellness benchmarks for vital signs and lack of physical complaints according to rehab SOPs. During this period, he should be drinking water and relieving heat stress as appropriate in the environmental conditions. Let’s assume that the initial vital signs in this individual are a pulse of 140 and a BP of 140/100. Recall that the exact respiratory rate is irrelevant when the firefighter is neither hypoxic nor symptomatically short of breath. Tachypnea in this scenario simply represents recovery from a state of exhaustion.
On a final note, how efficiently the rehab sector operates and how effective it is in adhering to its own SOPs depends largely on proper ratio of personnel to workload. Do not underestimate the importance of trained personnel to staff rehab who can function semi-autonomously. Lastly, rehab personnel should always think and act conservatively. While many firefighters will not be suffering from a fireground medical emergency, there is no margin for error when it comes to identification of the few that exist.