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Challenges of on-site rehab and questions you need to ask

Rehab patients are friends and co-workers, which requires additional awareness for rehab medical personnel and preplanning to administer over-the-counter medications


Medical preplanning is extremely important in the rehab sector. Having confidential lists of responders’ medical histories and current medications can be invaluable.

Photo/John M. Buckman III

This article first appeared on, sponsored by Masimo.

On typical EMS calls we treat strangers. We engage in quick and high-powered critical thinking for short periods of time and use our skills to help the critically ill or injured.

Rehabilitation scenes are a bit different for many reasons. We often know the emergency personnel that we are to care for. Incident scenes tend to be drawn out over a period of hours, often with long periods of inactivity for medical personnel.

Co-worker, friend, patient

“I see you more than my wife” is a regular joke among emergency response personnel. We often see our brothers and sisters on the job more than we see our own family.

Your patient who is also a colleague and friend may be uncomfortable disclosing certain information, and you may be uncomfortable probing for it, which may limit your comfort in performing a thorough physical exam.

These circumstances may be unavoidable, but what is important is that you recognize them. Provide emergency care and treat minor injuries to the best of your ability, but always refer to an impartial provider for anything that requires follow-up.

Awareness is an important assessment tool

Cardiac dysrhythmias, unidentified hypertension, severe hyperkalemia, corneal abrasions, fractured patellas, carbon monoxide toxicity, pregnancy and even inhalation injury requiring intubation are all things we have seen in the rehab area. Awareness is the most important tool you can bring to that role and requires answering questions like:

  • Who has been through rehab and who has not?
  • Who is acting normally and who is not?
  • Who is sweating when they should be, and who is sweating when they shouldn’t be?

While attitudes are slowly changing, many emergency personnel working an incident still feel that they are invincible and that the rules of rehabilitation don’t apply to them. Be prepared to be the voice of reason and not release someone to return to the incident scene unless he or she is medically ready and able to safely perform their duties.

Talk to your chain of command well ahead of time to have their support in this decision-making process. Rehab is not a place where you will make friends, but it is a place where your judgment can ensure that you keep them.

The longer an operation goes, the more diverse the list of medical concerns becomes. Be prepared for sprains and strains. Abnormal blood pressures and pulse rates are common. Complaints of palpitations, splinters, lacerations, headaches and hunger abound.

Other questions need to be answered during assessment and treatment in the rehab area:

  • Who is diabetic?
  • Who has heart disease?
  • Who is on medication(s)?
  • Who would be willing or unwilling to disclose personal medical history?

Medical preplanning is extremely important. Having confidential lists of responders’ medical histories and current medications can be invaluable in the rehab sector.

Administering OTC medications to personnel

Are over-the-counter medications allowed to be distributed in the rehab sectors? If yes, what OTC medications are allowed?

For example, pseudoephedrine is an effective nasal decongestant but may be contraindicated in patients with underlying hypertension or those who are taking certain antidepressants. Here are some important considerations for common OTC medications.

Antihistamines may be extremely beneficial for crew members suffering from environmental allergies, especially when the incident takes place outdoors. Some antihistamines, such as diphenhydramine, can cause users to feel fatigued and uncoordinated, which may affect job performance. Instead, use non-sedating antihistamines like cetirizine. Be aware that all antihistamines can lead to impaired sweating response, which can worsen hyperthermia and predispose users to heat-related illnesses.

Loperamide is effective at treating mild, noninfectious diarrhea, but users should be assessed for more serious causes and complications of diarrhea. The responder’s overall hydration status should be assessed. The medical provider should look for red flags – signs of a serious condition – that may suggest infectious or inflammatory diarrhea such as bloody stools, recent travel, recent antibiotic use, fever or recent hospitalizations.

Providers suffering from diarrhea are at serious risk of dehydration and should be replaced with other personnel. There is also the risk of the spread of infectious disease among providers due to gastroenteritis and poor hygiene conditions on the scene.

Non-steroidal anti-inflammatory drugs such as ibuprofen and naproxen can be useful against minor aches and pains. When these are given, medical personnel should perform a standard patient assessment to rule out life threats. Additionally, an occupational assessment should be performed to evaluate if the crew member will be able to be successful at his or her previous job duties or if these duties will need to be adjusted. Also, the use of NSAIDs should be questioned in responders with underlying kidney disease or dehydration.

Acetaminophen is a useful medication for headaches and muscle aches. Keep in mind that the vast majority of headaches are related to dehydration, so encourage regular and adequate oral hydration. Carbon monoxide should be ruled out as a cause of headaches on the scene as well. Caffeine withdrawal headaches are also a common occurrence we see in the rehab area, and we discourage the use of caffeine due to its diuretic properties.

Encourage appropriate hydration

Participants entering the rehab area should be encouraged to drink liquids to quench their thirst; however, overhydration should be avoided to limit risk of hyponatremia.

Sweat is typically hypotonic, meaning that it has a low concentration of electrolytes that is less than that of the cells. Therefore, sweat should be replaced with hypotonic solutions – either water or sports drinks with a low concentration of electrolytes. Additionally, responders should be encouraged to arrive on shift prehydrated and nourished if possible.

The patient presentations we might encounter in the rehab area are something we need to consider. Keep track of routine issues you encounter to share with your medical director. Having discussions with your medical director about rehab protocols for common issues may have tremendous impact on keeping your responders healthy and working steadily on scene.

When in doubt, if a responder is at risk of deteriorating on scene, contact medical direction or transport the patient for a full medical evaluation.

The EMS Docs Responding column shares EMS physician-led research, describes the implementation of prehospital protocols and discusses how EMS field personnel, as well as their medical directors, can improve patient care. The EMS Docs Responding column is a collaborative effort of the Mercy Health System Corporation (Wis.) EMS physicians, led by EMS medical director Jay MacNeal, MD.

James MacNeal, MPH, DO, NRP began his career in emergency medicine as a paramedic. He holds American Board of Emergency Medicine/Emergency Medical Services certification and completed an EMS fellowship at Yale University. He is assisted by associate medical directors Todd Daniello, Ken Hanson, Mitch Li, Sean Marquis, John Pakiela, Matt Smetana and Chris Wistrom.