Developing a Strategy
By David Jaslow
There are four overall strategies for delivery of a fireground medical screening exam:
1. Appoint a rehab officer and initiate the rehab sector SOP/SOG
2. Deploy a medical monitoring capability within the rehab sector
3. Follow medically approved guidelines for firefighter disposition
4. Recognize that the medical screening exam is also a measure of fitness for duty
Just as the emergency department must be lead by an emergency physician at all times, the rehab sector must be developed, organized, supervised and promoted by a dedicated individual whose sole responsibility is that sector. The rehab sector officer must operationalize the rehab SOP and make it a living document. He must approve all policies within the sector, supervise decision-making by clinical staff and act as a liaison with the EMS treatment officer and the incident command post.
The rehab sector officer is designated by the incident commander, although this individual may self designate once the order or request to prepare for or begin rehab operations is issued. Self-designation typically occurs at local level incidents. Individuals who are trained and qualified to function as the rehab sector officer can take the initiative to fill this ICS position once they receive word from the IC or recognize that criteria exist which mandate the need for rehab.
The concept of medical monitoring is one of the least well understood parts of the rehab process and, in our opinion, has not been well explained by NFPA 1584
. The concept of medical monitoring is that fire and EMS personnel should be specifically trained to:
- Observe and recognize signs and symptoms of fireground medical emergencies and common conditions that develop after extreme physical exertion
- Predict and attempt to prevent some of these conditions by adherence to the rehab SOP itself.
Simply stated, prevention of or early intervention for heat-related illness and early recognition of ischemic heart disease symptoms are the focal point of the rehab sector. Whereas most firefighters and fire officers see rehab as something which is initiated only after firefighters become exhausted or appear ill, the actual goal is to get the sector up and running well before that happens.
The term "monitoring" also implies that the rehab sector is not akin to the waiting room where triage personnel take a brief look at you and then there is no medical care until your number is called. Monitoring is an active process, although it does not mean that it's hands-on directly with every firefighter for the entire duration of their stay in the sector. What is necessary is that the rehab sector officer instruct his personnel how to observe when firefighters appear to be ill or do not appear to be recuperating in the expected fashion. Exhausted personnel will not be able to stand up to obtain water refills and they may appear too weak to engage in conversation. Other signs of illness may include pale color, changes in behavior, inability to laugh and sitting apart from others. Of course, the better medical personnel know their firefighting brethren, the easier it is to detect some of these subtle findings.
Vital signs are a hotly debated topic in rehab operations and few SOPs or national standards define not only what but when is abnormal. Perhaps the biggest mistake concerning vital signs in the rehab sector is when they are taken. Vitals should not be taken immediately upon the firefighter’s presentation to the sector unless it is apparent that the individual has transitioned from rehab to treatment, i.e. he is now a patient. This should be obvious based upon complaint or the appearance of an ill or injured state.
Instead, vitals should be obtained once the firefighter has spent his requisite 15-20 minutes in rehab and the first opportunity for "discharge" is apparent. If the vitals at this point do not fall within parameters for discharge as defined and approved by the medical director, the firefighter will have to spend additional time in the sector and drink additional fluids. It is also at this point that a more thorough history and physical be performed to determine the underlying cause for failure of the vitals to normalize. More explanation can be found in future columns as we explore specific tactics.
While delay in acquisition of vital signs seems counterintuitive, there is a simple explanation why this is the proper decision. Every firefighter who enters rehab directly from an operational assignment will have vital signs which demonstrate the corresponding degree of physical exertion, i.e. they will all be tachycardic and tacypneic and many will be hypertensive as well. This is not abnormal. In fact, it's the opposite as this is the response of our bodies to the need for increased energy. What is abnormal is if these vital signs do not return to what we consider normal after a period of rest, hydration and release of heat stress, which is usually accomplished by shedding PPE once it is safe to do so. After a reasonable period of time in rehab — and provided they do not smoke or engage in other behavior which might alter what we are trying to accomplish in Rehab — healthy firefighters should have vitals that approximate "normal." This time period is typically cited as at least 15-20 minutes. A detailed explanation about what vital signs are important and how to interpret them will appear in later parts of this series.
Deployment of a medical monitoring capability within the rehab sector can occur once sufficient personnel and medical equipment are present to perform the necessary duties, i.e. the medical screening exam. This point may seem self-explanatory, but many rehab sectors have failed to perform their responsibilities properly or thoroughly because medical personnel have underestimated the degree of work involved in evaluating and tracking firefighter health.
The evaluation process is akin to the phases of search at a fire or rescue incident. Someone must be observing all arriving personnel for a quick look (hasty search) as they enter the rehab sector. This once over is necessary to pick out those who appear obviously ill but will not complain or ask for help. A primary survey is similar to a primary search. Once firefighters are seated and/or are beginning to shed their PPE and obtain hydration, anyone who appears unable to complete these actions in a reasonable time period or without assistance should be singled out for early medical evaluation. Finally, when vital signs are taken, the brief medical screening exam is performed (secondary search).
Logistics supports incident operations and rehab is a logistics function. If it does not work like a well oiled machine, its efficiency will suffer, firefighters will slip through the cracks and we will have let down the IC. Medical information must be documented in an organized fashion. Supplies must be managed as must the flow of personnel into and out of the sector. This is clearly not a one-person operation.
Strategy #3 outlined at the start of the article instructs us to follow medically approved guidelines for the rehab sector. As a point of fact, this is referenced in NFPA standards for Rehab and for Occupational Health and Safety. Medical evaluation must be standardized and must follow both accepted concepts of emergency and occupational medicine as well as current scientific literature. EMS personnel or firefighters with medical training who are tasked to assist in the rehab sector can not freelance or make up their own guidelines for what constitutes a firefighter healthy enough to return to duty. There should be no subjective evaluation here.
Firefighters are undergoing a medical screening exam to determine if and to what degree they manifest signs and symptoms of a variety of conditions, some of which can become life threatening. There is a science and a process to guide this examination. Unfortunately, many personnel who staff rehab sectors and many incident commanders responsible for ensuring that this process is performed properly are not familiar with these concepts or the literature support behind it.
Lastly, our strategy for returning healthy firefighters back to duty is the recall that the fireground medical screening exam itself is really one and the same as a fitness for duty exam. Discharge from the rehab sector to the manpower pool or the operations sector is akin to successful completion of the rehab process. Discharge to light duty, off duty, the treatment sector or to the emergency department are other outcomes that may be necessary based upon failure to meet the medically defined criteria for discharge to active duty. Such criteria will be described in detail in the tactics pieces in the coming months.
Fireground Medical Screening Exam – Part 1
Fireground Medical Screening Exam – Part 2
Fireground Medical Screening Exam – Part 3
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.