Quick company-level rehab keeps responders ready for action

PHOTO JEFFREY MAYES

The goal of emergency incident rehabilitation (rehab) operations is to provide rest, rehydration and medical monitoring for fire-rescue personnel engaged in strenuous activities. In many departments, rehab operations occur only within a formal rehab area established on the incident scene. Although this practice remains the backbone of rehab operations, it generally occurs relatively late into an operation, perhaps after two 30-minute SCBA cylinders have been used.

There has been increasing focus on the need for fire-rescue personnel to receive some degree of rehab earlier in an incident, before a formal rehab sector is established. This concept of “informal rehab” or “company/crew level rehab” (as coined by the NFPA) has clearly emerged as an essential enhancement of emergency incident rehabilitation operations.

The fundamental goals of company/crew level rehab are the same as formal rehab sector operations. However, the means by which we address them differ due to the relatively austere environment that exists on fire-rescue scenes.

REST — KEEP IT SIMPLE
Obtaining rest at the company or crew level can prove elusive. In many ways, rest is a relative term here, i.e., kneeling on the ground or sitting on the tailboard while an SCBA cylinder gets changed certainly seems like “rest” as compared to advancing a 13⁄4" hoseline down a flame-filled hallway. Twenty years ago, as a probationary firefighter, I was greatly influenced by a seasoned engine company lieutenant who would tell us to “take a knee and take a blow” whenever we were between fireground assignments. Although not a lot of rest, assuming a kneeling or sitting position does provide some reduction in cardiovascular stress as opposed to constantly standing, especially when wearing full turnout gear and SCBA. Note: Unlike rest that occurs in a formal rehab sector, it’s sometimes unsafe and impractical to remove protective gear while resting at the company level. If possible and safe, responders should remove their helmets and turnout coats for more efficient cooling.

REHYDRATION — AVOID TOO MUCH
Rehydration at the company/crew level requires the availability of appropriate rehydration solutions in close proximity to personnel. In structural firefighting, the ideal location for rehydration solutions is on the crews’ apparatus. Placing rehydration solutions in predetermined locations, such as with spare SCBA cylinders, is an excellent strategy that encourages firefighters to replenish fluids during the initial air cylinder change or whenever they are near their apparatus as they move about the emergency scene.

PHOTOS ED DICKINSON Figure 1 Placing 12-ounce sports-drink bottles near SCBA canisters ensures timely and appropriate hydration

Figure 2 If your company uses large beverage dispensers, limit responders to “two trips to the spout” during company level rehab.

One concern about rehydration at the company/crew level is consuming too much fluid, too rapidly and then immediately returning to strenuous activity. Ingesting too much fluid in this setting could result in gastrointestinal discomfort, such a bloating or even nausea and vomiting. For this reason, it’s important to restrict the volume of fluid intake at the company/crew level, especially if the crew will be immediately returning to strenuous activity on the emergency scene. NFPA 1584 takes such restrictions to an extreme, recommending only 2 to 4 ounces of rehydration solution at the company/crew level. In practical terms, it’s almost impossible to restrict personnel to such a small volume of fluid after 15 or 20 minutes of very strenuous activity. A more reasonable volume may be 6 to 8 ounces. Physiologically, the adult body can handle this volume. However, it may be prudent to limit the size of the sport-drink containers placed near the SCBA cylinders to those with a 12-ounce capacity. This practice effectively limits the risk of excessive fluid intake (See Figure 1).

Some departments favor the use of larger common fluid dispensers on their apparatus for company/crew level rehabilitation. (See Figure 2.) These large containers are usually filled with water at the start of the tour each day, and powdered sportdrink concentrate is added when the crew needs rehydration. When using these large dispensers, officers should monitor the crew’s intake. Follow a “two trips to the spout” rule, and use 6-ounce cups with these large volume dispensers to moderate fluid ingestion.

MEDICAL MONITORING — THE LOOK TEST
Medical monitoring in a formal rehab area is largely based on objective findings, such as pulse rate, blood pressure and temperature, but medical monitoring at the company is a far more subjective process based on the company officer’s general observations. The simplest way to assess a responder’s physical well being is the so-called look test. Simply put, it allows the company officer to rapidly assess a firefighter’s overall appearance. Although the look test only offers a general overview, it comprises many specific observations, such as poor skin color (flushed, pale or sallow in appearance), altered mental status, loss of strength and/or coordination, poor posture, and labored breathing. Any of these abnormalities may indicate simple exhaustion or may be signs of potentially life threatening stress or heat related illnesses.

Like the coach on the sidelines of a soccer match who watches his players for signs of fatigue, all company officers and members should observe fellow crew members with the specific goal of identifying those who fail the look test. When such a member is identified, depending on their condition, the crew should either initiate rest and rehydration at the company/ crew level, move as a crew to the rehab area or deliver the affected firefighter to medical personnel.

ILLUSTRATION ED DICKINSON/JASON PELC

PUTTING IT ALL TOGETHER
Determining when to implement crew-level rehab will vary depending on the type of operation. Figure 3 illustrates NFPA 1584, which recommends rest and rehydration at the company/crew level for at least 10 minutes.

In establishing departmental policies, key components of company/crew level rehab operations include:

• Formal incorporation of company/crew level rehab into departmental SOPs and policies;
• Proper orientation of all officers and members to the logistics and dynamics of company/crew level rehab;
• Training of all members in the recognition of heat and stress-related illness and exhaustion among fellow company/ crew members; and
• Ready availability of appropriate rehydration solutions to crews on their apparatus.

Because company/crew level rehab maintains a strong sense of company autonomy, it is in some ways easier than other aspects of rehab (such as rotations through a formal rehab area) to incorporate into a department’s policies and gain acceptance among members.

One of the additional benefits of establishing and implementing a policy of company/ crew level rehab in addition to more formal rehab area operations, is that it not only further ingrains the importance of rehab, but adds to a pervasive culture of assuring the well-being of firefighters and rescue personnel.

Ed Dickinson, MD, NREMT-P, FACEP is the co-author of Emergency Incident Rehabilitation, published by Brady-IFSTA. He is the Medical Director of the Malvern and the Berwyn Fire Companies in Pennsylvania and the Director of EMS Field Operations for the Department of Emergency Medicine of the University of Pennsylvania. He has also been involved with the fire service for more than 20 years, having served as a company officer, training officer and assistant chief.

REFERENCES
Emergency Incident Rehabilitation, 2nd Edition. Dickinson ET, Weider MA. Brady. Prentice Hall Health, Upper Saddle River, 2004.

NFPA 1584 Recommended Practice on Rehabilitation of Members Operating at Incident Scene Operations and Training Exercises. 2003 Edition, NFPA, Quincy MA, 2003.