By David Jaslow
Last month we discussed our overall game plan or strategy which would allow us to meet the goals and objectives necessary to deploy a fireground medical screening exam. The development of such a strategy mandates knowledge of the characteristics of a successful exam, equipment necessary to perform it and personnel who will actually do the work for it. Now we will launch into a discussion of the actual implementation or tactics.
How can we guarantee that the process of subjecting firefighters to a medical screening exam which is sensitive enough to detect abnormalities will actually work? The overall success of the operation can be defined in these terms: Rapid, Painless, Efficient, Consistent and Timely.
Rapid: The fireground medical screening exam must be rapidly performed. It should not take longer than:
- Thirty seconds to detect possible life threatening situations during the "hasty evaluation," as outlined in our previous column, where a firefighter collapses in or on the way to rehab.
- Two minutes to detect seriously acutely ill individuals during a primary survey when the firefighter appears unwell while sitting down.
- Five minutes to detect evidence of a fireground medical emergency condition during a secondary survey which is performed in a calm manner after some time in the rehab sector. Any longer than this and the rehab sector will fall behind and firefighters will be missed in the screening process.
Ideally, the evaluation of a firefighter without any complaints who has rested for 15-20 minutes and consumed one bottle of water will take about two minutes, exclusive of logging clinical information into a spreadsheet or log of some sort. Incidentally, it is helpful to have a scribe who can perform these non-clinical functions.
Painless: The fireground medical screening process does not employ any invasive medical testing so there is no need for needles or other sharp devices. All of the diagnostic medical testing which must be done to evaluate for the presence of a fireground medical emergency condition is non-invasive. The exact tools and tests will be described in a future column. Note that point-of-care glucose testing is not necessary in this situation. While there are case reports of hypoglycemia occurring in diabetic firefighters, insulin requiring diabetes is an exclusionary condition according to NFPA 1582 so there should be fewer and fewer of these persons engaging in emergency operations. Furthermore, the more likely clinical scenario is for someone to be hyperglycemic due to poorly regulated blood sugar or the surge in blood sugar due to release of stress hormones in response to heavy physical labor. Unless a firefighter misses a meal to respond to an emergency or unintentionally injects too much insulin, acute hypoglycemia should not occur on a fireground. If a sudden change in mental status occurs in a diabetic firefighter and there is no other explanation, a blood glucose check should be performed. Of course, this individual should be in the treatment sector and not the rehab sector, and the point of how to minimalize diagnostic testing when it is known that few diseases occur in healthy persons who exert themselves becomes a moot argument.
Efficient: If rehab sector personnel know exactly what to do and how to do it, there should be relatively few instances in which they must stop activity because they are not aware of their roles or responsibilities. The rehab sector should be an efficient machine which takes inputs (firefighters exiting the operations sector) and puts them through a process (rehab). It then produces outputs (healthy rehabbed firefighters) who are ready to go back to work. Of course, this requires education, practice, adherence to ICS principles and sufficient personnel to accomplish the workload.
Consistent: One of the elements most lacking in rehab sectors established at incidents across the country is consistency. There is little continuity in what medical screening is performed on the fireground, when it is performed, how it is performed, by who it is performed and under what circumstances it is performed. If we truly want to standardize the medical evaluation of firefighters, we must demonstrate that we have reliable outcomes and reproducible outcomes. In summary, firefighters should be evaluated similarly and using the same SOP no matter which EMS provider is performing the screening within a particular jurisdiction. The results of such screening should not be person dependent. It means firefighters sent back to duty should meet discharge criteria regardless of whether examined by an EMT-B or an EMT-P. Exact definitions of these epidemiological terms will be presented in future articles.
Timely: A fireground medical screening exam should be performed in a timely fashion. There must be sufficient personnel so that those firefighters who need immediate attention are seen while not compromising the function of the rehab sector. Firefighters will eventually wander out of the sector if they perceive that its function has broken down. This defeats the purpose of rehab. Ensure that staffing minimums are met and that senior EMS personnel who may be in a position to become the rehab sector officer are aware of "the earlier, the better" paradigm for initiating the rehab process. It's important to remember that it takes time to assemble personnel and equipment in addition to actually building or designing an area to serve as the rehab sector.
Previous articles in this series:
Fireground Medical Screening Exam – Part 1
Fireground Medical Screening Exam – Part 2
Fireground Medical Screening Exam – Part 3
Fireground Medical Screening Exam – Part 4
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.