Introduction to the ED Medical Screening Exam
By David Jaslow
|Editor's note: Check out part 1 of the Albert Einstein Medical Center's guide to the 'FireGround Medical Screening Exam.' |
AP Photo/Shiho Fukada
FDNY firefighters rehydrate during an incident in August 2006.
The medical evaluation of firefighters in the rehabilitation sector at a fireground or any long duration incident can be seen as similar to the emergency department medical screening exam performed in hospitals.
Several questions must be answered before we can begin to construct a properly designed fireground medical screening exam:
1. Who performs such an exam?
2. What is the purpose of such an exam?
3. Why is such an exam conducted?
4. What is the outcome of such an exam process?
The standard of care in the emergency department setting is that the medical screening exam is performed by the emergency medicine physician, who represents the highest level of medical training and qualifications among the emergency department staff. From both a medicolegal and a practical standpoint, the performance of a brief screening exam designed to detect acute and potentially medically dangerous conditions should be done by the individual most familiar with those conditions and their varied presentations. Anyone other than the physician who performs the MSE will be held to the same standard as the physician in court if a negative outcome occurs.
It is the opinion of the Center for Special Operations Training that the historical lack of demand for paramedic oversight and direct supervision of the rehab and medical monitoring sector represents a continued disservice to emergency responders nationwide. The EMT-Basic curriculum is inadequate and the scope of practice is insufficient for basic level emergency responders to medically evaluate, detect and definitively treat the majority of conditions which are relevant to this discussion (and which will be discussed at length in future columns).
This is precisely why it is a paramedic who is recommended to staff the treatment officer position in a mass casualty incident. Frequently, initial triage decisions are incorrect and secondary triage occurs at a funnel point as patients arrive at the treatment area. The degree of education and capability to direct appropriate triage and treatment is best suited to the ALS level of training.
The purpose of the fireground medical screening exam is two-fold. First, EMS personnel must isolate and identify acute illness and injury upon presentation to the rehab sector. It is unlikely that a firefighter will fail to self-identify and report a significant injury to EMS personnel or to their direct supervisor at an emergency scene. Likewise, there is almost no mechanism to identify minor injuries such as muscle strain or joint sprain unless the firefighter verbalizes these complaints or an abnormal gait or other body mechanics are noted as he/she makes their way into the rehab sector. Thus, most of the fireground medical screening exam is devoted to the detection of acute illnesses.
Second, EMS personnel must determine if and when the firefighter is fit to return to duty. Akin to the typical requirement of a firefighter who is injured and must report to the department occupational medicine physician or their personal physician prior to being allowed back to active duty, the firefighter who enters the rehab sector must meet certain "discharge" criteria. Such criteria should be established by the EMS medical director and/or fire department physician offline and incorporated within the rehab sector standard operating procedure. Generally speaking, discharge criteria include vital signs and physical exam, which demonstrate that physical exhaustion and heat stress or any other environmental factors have been addressed satisfactorily. Discharge criteria may also be met when it becomes obvious that the firefighter has become a patient and is transferred to the treatment sector.
A fireground medical screening exam is conducted for two reasons. First, firefighters may not recognize that they are exhibiting an acute medical condition. Second, they may be "requesting transfer" to another location (back to the manpower pool) which requires medical clearance that they are stable to do so. As NFPA 1584 becomes a standard to which every fire chief will be held accountable, EMS personnel and fire officials must understand that the individual who authorizes a medical evaluation of firefighters who enter rehab is the incident commander.
Regardless of whether the firefighter believes that he/she may be ill or exhausted, a systems approach to rehab requires that every firefighter is medically evaluated using a uniform approach to reduce the chances of death or significant morbidity from a critical fireground medical condition. Furthermore, aggressive rehab sector management should limit the time that the firefighter needs to spend in rehab and optimize the recycling to the manpower pool or to a condition in which the firefighter is ready to respond to the next emergency.
The outcome of the fireground medical screening exam is a determination that either the firefighter is ready to return to active duty or not. Those personnel who have not performed significant exertion and whose baseline health status is good should be immediately cleared for return to active duty. If not immediately ready to return to duty, there are several options. Most commonly, the firefighter who is healthy at baseline requires about 15-30 minutes of rest and adequate rehydration. Those who have significant abnormalities in vital signs may require either more rest and hydration or they may need to be limited to light duty at the scene.
Firefighters whose vital signs do not improve, those who deteriorate and those who are readily identified as having a fireground medical emergency or other acute medical condition should be removed from active duty and/or sent to the emergency department for further treatment. Specific benchmarks and an algorithm for decision-making concerning return to active duty will be presented later in this series.
David Jaslow, MD, MPH, FAAEM is a board certified emergency physician who is fellowship trained in EMS and disaster medicine. He is the director of the Division of EMS and Disaster Medicine within the Department of Emergency Medicine at Albert Einstein Medical Center in Philadelphia. Dr. Jaslow is a state-certified Firefighter I and he is credentialed by the Pennsylvania Department of Health as a pre-hospital physician. He functions as a chief officer in several suburban Philadelphia fire and EMS agencies and provides medical oversight as the lead physician for the Bucks County Technical Rescue Task Force as well as Pa. Task Force-1 Urban Search and Rescue.