Firefighter Rehabilitation: More Harm than Good?

By David Jaslow

Photo AP/Kevork Djansezian
Firefighters rest after tackling a huge fire in L.A.'s Griffith Park in early May.

At first glance, the title of this column seems to indicate that I am intentionally launching friendly fire into the allies' camp. I urge you to keep in mind the classic line, "Don't judge a book by its cover," and continue reading.

There is no doubt that the concept of medical monitoring, rest, rehydration and screening for physical and mental health issues which may indicate the early onset of illness is not only appropriate, but essential.

It works to reduce firefighter and other emergency responder morbidity and mortality when operating at emergency incidents and training exercises. But it is not the process with which I have an issue, it is the terminology. To understand the origin of this argument, we need to dissect both the process of medical monitoring and the term rehabilitation.

Fighting a fire or performing heavy physical labor at an emergency incident scene is akin to running a marathon. No matter what degree of physical conditioning you possess prior to beginning the race, you will exhaust your energy stores at some — that point is a lot sooner for many firefighters than it is for amateur or professional runners, by the way.

The older and/or more deconditioned you are prior to the event, the less reserve you will have before exhaustion sets in. Furthermore, the older you are or the more pre-existing major medical conditions you have, whether or not these have been formally diagnosed, the more rapidly you will become fatigued.

Lastly, the longer the incident duration, the more likely it becomes that mental exhaustion develops, which can contribute to anxiety, agitation, poor decision-making and increased stress (beyond what lead to mental fatigue in the first place).

Two distinct disciplines
Medical support provided to emergency responders at an incident scene or training evolution is a form of public health practice. Public health traditionally has been described in terms of two distinct disciplines — health promotion and disease prevention.

Health promotion includes education and wellness activities. Disease prevention includes education and early screening to avoid development of disease as well as early treatment of disease that does exist to prevent further morbidity or mortality.

Firefighter rehabilitation is designed to efficiently and effectively deploy limited diagnostic and therapeutic interventions to achieve three objectives in support of health promotion and disease prevention:

1) Identify which firefighters are physically and mentally fit to safely return to duty because they are healthy and lack disease.
2) Identify which firefighters are unfit to safely return to duty because they exhibit signs and/or symptoms of physical and/or mental fatigue not associated with acute illness or injury.
3) Identify which firefighters are unfit to return to safely return to duty because they exhibit. signs/symptoms/complaints of a perceived or actual illness or injury which requires evaluation and/or treatment in the treatment sector.

Clearly, those in group one can be sent to the staging/manpower pool or released from the incident after successful completion of the rehab process. However, that is defined by the incident commander, safety officer and/or rehab officer.

Those in group two who are healthy but exhausted follow a defined algorithm or pathway of diagnostics and therapeutics. They should be able to return to duty within 30-60 minutes. Those who have persistent tachycardia or hypertension would transition into the treatment sector (group three).

However, there is a subset of these personnel who may be able to return to some degree of duty at the incident scene after successful treatment has been administered, such as local wound care. More serious medical conditions may require invasive procedures, medications, oxygen and/or transport to an emergency department.

Support function
What has come to be coined as the rehab sector is clearly a medical logistics or support function. Lack of this medical logistics function is frequently recognized as a contributory factor in NIOSH LODD reports. There is an NFPA standard — 1584 — that addresses this function, numerous professional firefighting and medical organizations that stress its importance and a multitude of fire and EMS departments that think it is an important enough topic to post their protocols for its implementation and function on the Internet and in other public forums for the good of society.

At this juncture, the following question begs to be asked: Why, if firefighter rehabilitation is celebrated as one of the great demonstrations of a successful merger between the worlds of firefighting and medicine, is it so difficult to get firefighters and fire officers to truly follow the virtues extolled in NFPA 1584?

Specifically, this would include acknowledgment of the need for existence of a rehab sector, subsequent presentation of firefighters to such an area instead of bypass and rerouting towards the canteen vehicle or "smoking area," acquiescence to a focused and brief medical evaluation and actual rest and revitalization.

The answers to this question are numerous, involve discussions on a number of different fronts and can be politically charged. Suffice to say that, from my perspective, at least one of these reasons lies in the terminology we use to describe the process of rest and revitalization, which, much to my dismay, is termed rehabilitation.

From a strictly semantics standpoint, rehabilitation seems to be an appropriate choice to describe the functionality of the rehab sector. There are many definitions of the term which can be found on the Internet, but this is one of the most basic: restoration of, or improvement in, an employee's health and ability to perform the functions of his or her job. Other definitions include:

1) To restore to good health or useful life, as through therapy or education.
2) To restore to good condition, operations or capacity.

However, more commonly, a definition of the term includes reference to a pre-existing condition: The process of restoration of skills by a person who has had an illness or injury so as to regain maximum self-sufficiency and function in a normal or as near normal manner as possible.

In my opinion, the term rehabilitation has quite a negative connotation in the United States. It is associated with persons who have either a substance abuse background that requires them to attend inpatient or outpatient treatment programs or those who are attending some form of physical or behavioral therapy for serious physical or mental illness.

Sadly, these groups are shunned and frequently discriminated against because they are different.

Type A personalities
Firefighters are generally a group of Type A personalities, who like to think of themselves as a uniform, cohesive and invincible force. They describe their extended family as a brotherhood. Invincibility all too often is translated into one or more of the following themes: I can't be sick, the injury is minor, I don't need rest, the incident will not be mitigated without me, etc.

Brotherhood denotes the firefighting family that we all know and love, but too often this family atmosphere condones the group mentality that health promotion is for sissies and encourages unnecessary risk and a "living on the edge" philosophy. All of us are guilty of falling into this description at some point or another.

Only recently has it been postulated that perhaps these attitudes and behaviors may contribute to an unhealthy lifestyle and the development of disease. To this end, there is a move afoot in several professional fire organizations, including the IAFF, to change this image and promote healthy behaviors, such as participation in the rehab process.

There is no doubt in my mind that group behavior, myth, risk-taking behavior and the laissez-faire attitude we associate with lack of helmet laws in many states still drives the overall problem of lack of compliance with rehab in many fire departments, especially those which are volunteer or those which do not have a strong ethic of respect for NFPA guidelines and standards. Where does this come from? I think to some degree it is the term rehabilitation itself.

Even the drug addicts and alcoholics who come to the emergency department pleading for admission to inpatient rehabilitation programs don't seem to relish the thought of actually spending time there. Rehab in the U.S. means something is wrong with you and nobody, especially firefighters, want to admit that.

Despite the fact that in many instances, there is nothing physically or mentally "wrong" with these individuals aside from a predictable and expected exhaustion which follows a dangerous and demanding job such as fire suppression, the mere act of sitting in the rehab sector implies that there is a problem.

Moreover, in departments in which rehab is not mandated, those who choose wisely to rest in a formal fashion are effectively dissociating themselves from the brotherhood. Thus, they become outcasts in the eyes of the nonbelievers.

Here's another analogy. Most volunteer fire departments and some career stations which house reserve apparatus have one or more vehicles that are old, decrepit or otherwise not as attractive as the new technologically sophisticated ones. A common description of such a vehicle which has passed its heyday is the s**t truck.

Box alarm assignment
When the tones drop and the box alarm assignment is announced, how many firefighters who have a choice run towards or vocalize their desire to man and street the s**t truck? None. So does it come as any surprise that firefighters do not jump for joy when they are told that the rehab sector is open for business?

Aside from the desire to have a cold drink of water or take a break, the rehab sector is looked upon by many in exactly the same manner as the emergency department patient asking for admission to inpatient rehabilitation: I would go anywhere else if I had the choice but you force me to go there to get what I want.

By default, medical personnel become the rehab police, an entity that garners dirty looks and harbors animosity from the very people we are trying to help. What an uncomfortable position to be in!

Clearly, an attitudinal shift and a paradigm shift is needed in the fire service so that medical monitoring and rest for firefighters is looked upon as a mechanism to preserve life and the ability to come back and fight the next fire.

To their credit, the IAFF, the IAFC, the NVFC, the National Association of EMS Physicians and others are on the same page when it comes to recommendations for medical evaluation and care of firefighters in the rehab sector. Will the NFPA standard be renamed because of this column? Unlikely. Is there a better term out there to describe what it is that we do to protect the vital resource known as our career and volunteer firefighter workforce? Perhaps.

What may be of most immediate importance is to recognize a concept which my fellowship director first taught me in our nation’s capital 12 years ago. Perception is reality. This is especially true concerning the language and phraseology we use in everyday life. Disagree? Talk to Don Imus and ask him how the radio show is going.

Rehab is vitally important, and I strive to do my best to implement it at every working fire, long duration incident and intense training exercise. But I do so with ever a slight quiver every time I hear the word uttered on scene. The rehab process is a good thing. Surely we can turn the tide and convince the troops that the concept works. What we need is a marketing strategy which starts with an attractive catch phrase.

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.

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