Factoring in Environmental Conditions for Rehab

Example Fire Incident: Working residential structure fire in a large two-story residence, approximately 40x60, with a basement at 2200 hours. Fire begins in the basement and extends to the second floor inside the walls. It eventually extends to an open attic area. Rehab sector initiated within 20 minutes, and the cool damp night will not require any severe weather rehabilitation operation. There will be extensive overhaul operations. The original crews set up the rehab area across the street from the fire building, near the engines providing fire support. Utility trucks have also arrived in the area, to disconnect power and gas into the residence.

This will be a difficult and time-consuming operation, chasing down fire from the basement to the attic, and overhaul at those multiple levels. The climate conditions are not unusually stressful, but the time of day is challenging. 

Appropriate to the scene, the rehab sector must include these elements:
• Shelter to include seating
• Fluid and calories
• Equipment rehabilitation
• Health evaluation and therapy
• Mental decompression

A late evening fire operation needs to focus on safety, at a time when scene lighting, natural end-of-the-day fatigue, and the stress of incidents earlier in the day make safety planning a priority for the rehab leaders. At this incident site, crews entering the rehab area are screened for pulse rate, oxygen saturation, carbon monoxide oximetry, and any symptoms. Most crews have been drained as they enter rehab, and most firefighters have pulse rates in the range of 130 to 150 beats per minute as they arrive. They offload their breathing apparatus for refill, and are given fluids and a place to sit down to rest. 

Many have insulation material covering their uniforms, so a "domestic" hose has been set up to wash that material off before they take off their jackets. 

After a 10-15 minute break, the crews are checked to return to duty. But a trend is noted. As their key vital signs are rechecked, the carbon monoxide saturation of many of the firefighters has risen during the course of rehabilitation. All the personnel arrived with CO saturation of 1 to 4 percent. But as these same individuals are screened to return to duty, their CO saturation has risen to the 5 to 9 percent range. Pulse rates for each has decreased to a range of 80 to 100 beats, and oxygen saturation remains in the range of 96 to 98 percent. None of the firefighters describe any symptoms.

What is at work at this incident?  Exhaust from the nearby vehicles, on a damp night with calm air. To check their hypothesis, the crew that was checking the ambient air carbon monoxide levels inside the burned house brought the meter out to the rehab area. The carbon monoxide level was in the range of 150 to 400 parts per million, with the higher range near the idling utility trucks. The personnel assigned to perform rehab sector operations check their own CO saturation, and they have levels in the 8 to 12 percent range.

Corrective action
Time to move the rehab operation to another site. The utility trucks and fire apparatus cannot be moved, so command is informed that rehab must move to a "fresh air" site. That site will need to be a little further from the scene, and not as conveniently located adjacent to the air unit, but it is far from the vehicle exhaust. This is a common scene challenge, when a "tight" operating scene and geography that results in still air conditions leaves personnel in areas where they can’t breathe well.

At this incident, rehab was moved to a site away from operating vehicles and smoke from the fire. Within minutes, and without the need for oxygen, all personnel have levels that fall back to the 1 to 3 percent range. Rehabbed firefighters are returned to duty. Neither the involved firefighters nor the rehab personnel develop any symptoms. Carbon monoxide levels change fairly rapidly, as measured by the co-oximeter, and many individuals will clear carbon monoxide rapidly from their lungs and blood when removed out of the toxic environment. Oxygen therapy improves the clearing time for individuals poisoned by carbon monoxide, and remains the treatment of choice for civilians and rescue personnel that are symptomatic and demonstrating high levels.

Bottom line
The rehabilitation program must address the safety of firefighters across all environmental conditions. Each incident produces a unique set of challenges, and rehab leaders must set the priorities for each of the elements. Reducing risk by providing clean air is critical. Most departments have now forbidden personnel and civilians from smoking cigarettes in the area of rehab sector for that reason.

What other groups of individuals may be at risk for carbon monoxide intoxication at working incidents? Fire apparatus operators and command officers. Each of these may be restricted in their ability to move away from their operating vehicles. Many get "tethered" to the vehicle with radio wires. They may be breathing vehicle exhaust for hours in the operation from a working engine or a chief's buggy. It is good practice to check the carbon monoxide saturation on those individuals to insure the safety of those personnel.  Change their work site if ambient air levels of carbon monoxide are too high.

And don't forget about the vital utility workers assisting at the scene, and law enforcement, and even the media personnel assigned for hours to an incident. Building relationships with all these groups by offering them some fluids, sheltering them from a harsh environment, and checking their vital signs will benefit the department in the long run. 

Incident rehab requires leaders to address ongoing challenges to maintain a safe work environment. This works to produce the long-term goal:  Be a healthy retiree.

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