Developing a strategy to meet goals and objectives
By David Jaslow
In part one and two of this series, we discussed the parallel to an emergency department medical screening exam and the reasons why such an exam should be conducted within the rehabilitation sector at a fireground or any long duration emergency incident. For the remainder of this series, we will concentrate on eliciting the goals, objectives, strategy and tactics of the fireground medical screening exam, providing some epidemiological information and definitions to support how we have arrived at certain decision points.
We identified two goals of the fireground medical screening exam last month:
1. Isolate and identify acute illness and/or injury upon presentation to the rehab sector.
2. Determine if and when the firefighter is fit to return to duty.
Decisions about what to do with someone who is not fit to return to active duty fall outside the scope of the discussion about the fireground medical screening exam. However, the choices are basically a) return to limited or light duty, b) off duty and no return to work until cleared by either an occupational health or fire department physician, or c) transport directly to an emergency department for acute care and treatment.
First, let me explain the basic definitions of goals and objectives. A goal is the end to which effort is directed. Once goals have been defined, we can build objectives to meet these goals. Objectives are specific and measurable components or building blocks through which one can meet goals.
The primary objective to meet Goal #1 is the deployment of the fireground medical screening exam process itself, namely to screen every incoming firefighter or other public safety provider as they arrive in the rehab sector.
The endpoint of screening is either to elicit a critical fireground medical emergency or other less serious condition or injury, or to declare the firefighter to have passed the screening process successfully. In order to meet Goal #2, the objectives are similar.
We can create a list of exclusionary vital signs, physical findings and chief complaints that should be absent if that individual is ready to resume active duty. A fireground medical screening exam which fails to identify these situations translates to the equivalent of a passing grade — the firefighter is fit for continuance of duty!
Now that we have established objectives, the next step is to define a strategy to meet these objectives. Strategy is the approach which one will use to meet certain objectives. In other words, it is our overall game plan. If the objective is "there," strategy is how we get there. The strategy we will follow is one that will allow us to most easily perform the fireground medical screening exam. This will be done within the rehabilitation and medical monitoring sector that must be created in some fashion at every event in which it is recognized as necessary and ordered by the incident commander or his designee (safety officer, etc.).
Most emergency services personnel are familiar with Internet photos of what appears to be a rehab sector. They typically show firefighters sitting in chairs or on the ground in some defined geographic area that is proximate to EMS personnel who are charged with the medical evaluation process.
Why do we need a defined sector? First, the fire service follows a paramilitary structure based upon interaction in groups:
- ICS is based upon organizing personnel into functional groups
- Triage in a mass casualty incident is based upon categorization of patients into groups of like stability and then sending them to a treatment area where they remain together
- Span of control, unity of command and all of the other NIMS principles are contingent upon organization and discipline, which typically do not exist when there is lack of adherence to group behavior.
Thus, everyone who participates in the rehab process must collocate in the same place. Second, there are usually not enough EMS personnel and equipment available at these incidents to deploy multiple rehab and/or treatment sectors. It is much more efficient to bring everyone to a single location. Third, one of the concepts of rehab and medical monitoring is that EMS personnel can keep an eye on firefighters so that any changes in their condition are immediately noticed and acted upon. Fourth, accountability is maintained when company officers bring their entire squad to rehab and stay with them throughout the process.
The individual who ultimately takes charge of this sector and operates it according to established SOPs is the rehab officer. Position descriptions for such a functional position abound on the Internet and are beyond the scope of this article. However, the strategic plan deployed by the rehab officer in support of the goals and objectives we have defined must include following medically approved protocols for the evaluation and classification of firefighters and other public safety providers as part of the fireground medical screening process. Protocols should include definitions of what vital signs outliers trigger mandatory compliance with rest periods, hydration quantities, more in-depth medical evaluations and transport to an emergency department.
Finally, tactics can be designed which will allow us to most efficiently and effectively operationalize this strategy. Tactics are the actionable instructions which are employed congruent with a particular strategy that is being followed. In part IV of this series, we will begin to create a roadmap with step-by-step instructions for performance of the fireground medical screening exam.
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.