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Sponsored by:
Masimo
Rehab and Revitalize
by James Augustine
Sponsored by Masimo

Pulse CO-oximeter Utilization in the Emergency Scene Rehab Area

Emergency scene operations are dangerous for rescue personnel, and every opportunity to improve the safety of the working emergency provider should be utilized. A new tool has been developed that will significantly improve the ability to assess the wellbeing of emergency workers, by instantly detecting elevated levels of carbon monoxide.

The Pulse CO-oximeter is intended to improve scene safety and reduce injuries to rescue personnel, by ensuring they are not impaired by carbon monoxide toxicity. Application of this new tool will be maximized if a protocol is utilized to drive rehabilitation area operations, and functional worksheets can be used to guide the evaluation of each rescue worker.

Best practices when using the Pulse CO-oximeter
Emergency operations require significant physical activity, but no rescuer will be required to perform emergency operations beyond safe levels of physical or mental endurance. An emergency scene emergency ground rehabilitation area should be utilized at all working incidents to provide a staging area for on-scene personnel, as well as an immediate source of personnel for rescue or aid, and an area for recovery and rehabilitation for emergency workers. Personnel rehabilitation using appropriate protocols in this area will decrease injury risk and enhance recovery for later emergency operations.

The emergency ground rehabilitation area is typically established by incident command at emergency scenes where there is a significant amount of physical labor to be performed in stabilizing and controlling a hazard or emergency. This includes working structure fires, wildland fires, rescue situations, prolonged operations in inclement weather, and hazardous materials operations where proximity suits are utilized.

The emergency ground rehabilitation area should be established in a safe location. In general, it will be upwind from any emergency site with potential of smoke or hazardous materials. It should be appropriately heated or cooled, and sheltered if raining or snowing. At working structure fire incidents it should be near the air bottle refill area and the equipment resource area.
 
The emergency ground rehabilitation area is utilized by fire and EMS personnel. It could also be used by law enforcement, other response personnel, and mutual aid providers. It is typically staffed by the EMS crew assigned to the incident, who will perform health assessments and medical care, including appropriate screening for hazardous exposures.

An appointed rehab area command will oversee rehabilitation operations. Their responsibility is to oversee provision of food, fluids, equipment, oxygen, and rehabilitation operations in the area. They will oversee the rehabilitation and availability for work of all emergency responders placed in this area.

The protocol for individual emergency personnel reporting into the emergency ground rehabilitation area is as follows: At the scene of a working incident, this area will be utilized by each responder as their first air bottle needs to be changed. At incidents where breathing apparatus is not utilized, the responders will begin reporting to the area after about 30 minutes of operations. The emergency worker needs to be checked at that time by rehab area personnel according to the enclosed health assessment protocol. The individual should be assessed, hydrated, and reassessed before returning to further emergency work.

Medical evaluation in the rehab area
EMS personnel should evaluate persons arriving to the rehab area as they appear. Each arriving emergency worker must be questioned regarding any medical symptoms, be asked about any injury resulting from incident work, and have assessment of appropriate vital signs. These items will all be documented. Any injury or medical symptoms should be addressed immediately by the most highly trained and qualified EMS person available. Injury care needs to be provided, and an appropriate injury report completed. 

Appropriate vital signs should be assessed on each individual on each visit to the rehab area, and will include pulse rate, pulse oximetry reading, and a carbon monoxide oximetry reading in all operations that involve firefighting, enclosed space rescue, or hazardous materials operations. Blood pressure needs to be assessed once during the operation, and can be repeated at the request of the individual, or if the value is found to be abnormal. Blood pressure values that are higher or lower then the personís usual level will be treated under standard medical protocols.

Values for pulse oximetry must be above 92%, or personnel can not be allowed to return to operations. Values below 90% should result in complete evaluation, and treatment per standard medical protocols.

Values for pulse rate in the emergency responder will normally be below 100 beats per minute at rest, below 120 at a working incident, and at no time safely exceed 180. Values above 140 on arrival at the rehab area must mandate a minimum of 15 minutes in the area, with appropriate hydration. At no time will an emergency responder be allowed to return to duty until the pulse rate is below 120 beats per minute. Persons with a persistent heart rate of more than 120 should receive evaluation and treatment per standard medical protocols.

Values for carbon monoxide oximeter readings will normally be below 5% in non-smokers, and below 8% in smokers. On arrival in the rehab area, a reading should be obtained and recorded.  Any symptoms should be recorded. A detector reading more than 12% indicates moderate carbon monoxide inhalation, and a reading of more than  25% indicates severe inhalation of carbon monoxide.  Emergency workers with a CO level of more than 8% but below 15% must be given the opportunity to breathe ambient air for five minutes, and the result repeated. If still above 8%, they should be given oxygen via a mask until the value drops below 5%.  Workers showing any value of more than 15% need to be given oxygen via a mask until the value drops below 5%. Any value of more than 25% must be completely evaluated and removed to a hospital, preferentially one which has a hyperbaric oxygen chamber. No emergency responder can leave the rehab area until the CO level on the monitor is below 5%. This is intended to improve scene safety and reduce injuries to rescue personnel, by ensuring that working personnel are not impaired by carbon monoxide toxicity. 

With each subsequent air bottle change, or period of physical activity appropriate to the incident and the environment, the same assessment protocol must be followed. At each assessment, the emergency worker should drink 8-16 ounces of fluid. During extremely hot or humid weather conditions, heat stress can be minimized by a washdown with cool water to the waist. 

At prolonged medical incidents, the emergency ground rehabilitation area should be used for emergency personnel assessment, critical incidents stress debriefing, and rehydration. 

In summary regarding emergency worker vital sign and release back to work duty, responders can not return to emergency operations out of the rehab area until they have a pulse less then 120 beats per minute, pulse oximetry level above 92%, and CO level below 5%. A responder with medical complaints, injuries, or abnormal vital signs should receive evaluation and treatment per standard medical protocols.

Click here to view a sample worksheet for Rehab operations

About the author


James J Augustine, M.D., is medical advisor for Washington Township Fire Department in the Dayton, Ohio, area. He is director of clinical operations at EMP Management in Canton and a clinical associate professor in the Department of Emergency Medicine at Wright State University. He formely served as Deputy Chief-Acting Medical Director for Washington, DC Fire EMS. He has served 27 years as a firefighter, and was the first Chair of the Ohio EMS Board. Contact him via email at James.Augustine@FireRescue1.com.



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