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The Rehab Zone
by Ken Lavelle

3 key factors in tactical rehab

When the scene is vastly different from a typical fire, the rehab and EMS response must match that need

By Kenneth G. Lavelle, MD, FACEP, FF/NREMT-P

When we talk about rehab, we normally think of rehab at fire scenes. The vast majority of working fires have a short period of intense activity early on, with initial search and rescue and fire suppression.

Much of this activity goes on before rehab is established and may occur before EMS even arrives. The mission is fairly clear, and the risks involved are measured. In general, there is a fairly predictable course of a structure fire and the establishment of rehab.

When a firefighter comes into the rehab sector with a fairly minor injury or illness, we generally don't allow that person to return to duty. Most of the time there is another firefighter who can fill the role. Rarely is a single firefighter, or even a chief (gasp!), indispensable.

We can treat the firefighter's condition and he either goes to the hospital, or more often, is released but not cleared to return to firefighting at this particular fire.

But does this translate to other events where a rehab sector is established?

Other incidents
While fire rehab is what most of us are most familiar with, there are other events where rehab is indicated. Often, rehab at other events is a bit different than at fires. Let's take rehab at a tactical or law enforcement scene for example.

When one hears the term tactical EMS, the vision of paramedics in black uniforms and helmets may come to mind. But the reality is that medical care at a law enforcement standby or tactical event is part sports medicine, part occupational medicine, part primary care and a very small part EMS.

There are three primary characteristics of a tactical event that EMS providers should be familiar with when setting up medical care: activity, length and mission.

The activity
At fires much of the most intense activity is done in the first few minutes of the call. At a tactical event, it is often in reverse. There may be some initial action, but we then settle into a wait-them-out approach.

This can be good and bad. The good is that EMS can plan and set up for the various activities that may be needed — tactical care, rehab, nutrition, restroom facilities, etc. The bad is that having to wait generates a whole different set of injuries and illnesses that we may not be familiar with.

If previously trained in tactical care, then a certain number of EMTs or medics may be deployed with the team to some point. If not, then any patients will most likely be brought out to waiting crews — so set up an area with the equipment that is most likely to be needed. Nutrition and restroom needs can be determined and established. 

A small rehab area can be established. Even if there is not much going on, tactical team members are still posted and staged, and as with fires, extremes of temperatures and environmental exposures play a significant role in the illness and injuries seen.

Instead of being primarily concerned with abnormal vitals after intense firefighting activity, the individuals coming through the rehab area are more likely to have conditions such as sunburn, insect bites, allergies, blisters and dehydration — tactical operators don't want to or cannot leave to urinate, so often will forgo drinking.

Many of these injuries are not the usual forte of the street EMS provider, so do not hesitate to use staff that have had additional training such as nurses, athletic trainers or your response-capable medical director, if he or she is available. Also, contact base command for advice if that option is available.

If this is an activity that you will be involved in regularly, then it is time to do some reading and get familiar with these conditions.

Injury prevention is a primary focus of EMS. If the medics are assigned to a specific team then they will get to know the officers and vice versa. This makes it easier to tell command that it is time to rotate out or otherwise do something to prevent injuries. EMS providers not as familiar to the tactical team will have a harder time getting this accomplished, but it is still important to try.

The length
The length of these events is also frequently different from the average fire. Even a large working fire is usually under control in a few hours. However, one standoff in Maryland lasted 10 days over several different locations.

When events go from hours to days, the focus of medical care and rehab changes. We still need to be prepared for the acute conditions, but fatigue and exhaustion come into play.

We may be the only one to advocate for the officer, not only for their safety, but for the safety of others around him or her. Rarely will snipers tell their superiors that they are tired and need a break. But we may observe behavior, speech or other signs that indicate that this is the case, and we can advocate for the individual we are concerned about.

The length of the event also forces us to be more concerned about logistics and staffing. Where will our relief come from and who is covering our normal response area? What will the weather conditions be like tonight or tomorrow? 

Often this planning will fall on the tactical EMS provider as we have the time to be concerned and to address it. The tactical team itself has a specific mission, and if we can handle the other issues it can allow them to focus more clearly.

The mission
The mission itself plays are huge role in the medical care of both the tactical team and the public at a tactical event. There are times when the tactical mission will supersede the medical care to an individual, even an officer.

This is somewhat foreign to many EMS providers. While we do sometimes have to wait for a scene to be secured before entry, this wait is usually brief.

In a tactical situation, a suspect or an officer may be injured, but medical care may need to be delayed until it is safe to provide care or until another specific goal is met. For example, if there is a hostage situation in a daycare, the tactical commander may choose to push forward with an offensive action even if an officer goes down. 

In a structure fire, if a firefighter is injured, the primary mission will likely change with a goal of saving that firefighter. At a hostage situation, the mission may not change when an officer is injured. EMS needs to wait and follow the commander's direction.

In fact, we can often assist by providing a medical evaluation from a distance and advise the commander of the seriousness of the situation — either the apparent minor nature of an injury or the likelihood of a fatal injury, both of which would permit delayed care.

This also is involved in the decision making when treating injuries in the rehab sector. If we have a firefighter with an injury, it is unlikely that the fire chief will push for her immediate return. But what if the person we are treating is one of two snipers available for the foreseeable future? If the condition is mild and the officer could return to effective duty, the command may put that person back in service.

Many of the concepts of fire rehab can be used in other areas such as at tactical events, however it is important to understand that there may be differences in terms of planning and priorities. If this is an area that your department will be involved in, it is a good idea to discuss and plan for this type of rehab in advance.
 

About the author

The Rehab Zone. Kenneth G. Lavelle, MD, FACEP, FF/NREMT-P, is Clinical Instructor of Emergency Medicine at Jefferson Medical College, Philadelphia, and Attending Physician at CapitalHealth, Trenton, N.J. He was previously an attending physician at Albert Einstein Medical Center, and previously spent 14 years working as a firefighter and EMS provider.

Ken can be contacted via e-mail at Ken.Lavelle@firerescue1.com.


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