By Dr. Ken Lavelle
This column's title isn't meant to be such an inflammatory start! But I recently responded to a structure fire in the local of the EMS agency for which I serve as medical director. On arrival we had an injured civilian and several firefighters received minor injures early in the incident. These patients were treated and transported, and the local department was making good progress on this well-involved single family dwelling.
As in most suburban communities, this department had other local departments respond on the alarm. Let's call the department in whose local the fire happened 'Mayberry,' and the neighboring town, 'Anytown.' The Mayberry safety officer was doing a good job, identifying firefighters that needed rehab early on and bringing them to our rehab sector.
He brought a young firefighter from Anytown who appeared to be in mild distress. His assessment revealed no life threatening conditions, but his heart rate was over 140. Not surprising in light of an aggressive fire attack, but still too high to head right back into battle. He immediately asked if he was done and could go. I advised him, "No, sit and relax and we'll recheck the vitals in about 10 minutes." He was disgruntled and I said something to the effect of, "Hey, that's what your Chief wants," and pointed to the safety officer. (In reality it's not just what the Chief wants, its also good medical practice and a standard rehab procedure, but I knew better then to try to explain all this to him at the time.) His response? You got it: "He ain't my chief."
Assessing the problem
Sigh. Well, there are obvious issues with this comment and the mentality of this firefighter who feels he does not serve the incident commander (Mayberry) but his own chief (Anytown), who was not in a command role at this incident. But as an EMS physician, I'm not going to change that — it's an issue for those departments to hash out around a conference table, not a command board. However, it becomes an issue for the EMS providers performing rehab at an incident, and that's what I do want to discuss — how do you handle this situation?
Let's face it — in a small volunteer fire department that doesn't see that much fire, telling a firefighter that he can't go back to one of the largest fires of the year isn't easy. But it really isn't our call. Even as a doc, I am not in charge of the firefighters — the chief is. The determination of who needs to undergo rehab, how long they have to stay and whether they can return to duty is the chief's decision. He or she does this, however, with the guidance of laws and standards such as those from the NFPA, and with advice from the emergency medical community. That's my job as a medical director — to provide advice and input to the chief so they can make an informed decision. This needs to be done ahead of time, before the big one.
Making a plan
Vital signs are often used to determine who can return to firefighting activities and who cannot; and as mentioned in prior columns, the heart rate is a fairly good indicator, especially after 10 minutes of rest time. A good, healthy heart should return to baseline fairly quickly. If it does not, the firefighter needs to remain in rehab a bit longer, and he or she may need more of an evaluation to ensure nothing else is going on. To accomplish this we need a clear, established policy, including how low the heart rate needs to be to be released from rehab. If every firefighter knows this and all other release criteria going in, it should be better accepted and we in EMS don't look like the bad guys. Mutual aid companies should abide by the same rules, and this should be confirmed ahead of time.
So, we have an established policy and the firefighter does not fall into the accepted range for return to duty. But he or she insists on leaving. What should the EMS staff do? Well, obviously don't engage in a confrontation. Document that the firefighter left without being officially released on your rehab paperwork. (If he suffers a myocardial infarction or cardiac arrest a few hours later, this will be looked into — C.Y.A.) Then notify your rehab officer or EMS officer — follow the chain of command up and over. Keep doing your job and move on to the next firefighter to be evaluated. Remain professional at all times. Medical command staff should notify the department safety officer who should handle the situation with the Incident Commander according to department policy. Try to the safety officer in a face to face meeting — putting this out over the radio is generally unnecessary and may only enflame the situation. The bottom line is this firefighter, who has abnormal vital signs and has not been officially released from the rehab sector, needs to refrain from firefighting activities. The last sentence is my opinion as a medical director, but it is up to the incident commander to act on this opinion.
Fire and EMS departments are microcosms of society. There are enough politics, egos, opinions and attitudes to fill a small stadium. Most of us are type A personalities and at times can come into conflict with one another. By establishing protocols ahead of time, providing some pre-event education, utilizing the chain of command and by remaining professional, we on the medical side can understand each other and keep our brothers and sisters on the fire suppression side safe to fight the next battle.