By Ken Lavelle, MD, FF/NREMT-P
Anytime we need to do a job, we look for tools to help us do it more efficiently. However, these tools also need to help us do it reliably. If a tool causes us to get wrong information, then it is not a very good tool. This is particularly the case in medicine — and remember, EMS is medicine.
One of the challenges of the EMS provider in rehab is to quickly do intake and assessment as a company or group of firefighters enters the rehab area.
If the firefighters have to wait 10-15 minutes for anyone to see them, they very well may wander away. We need to engage them quickly, not only to make sure there is nothing life threatening occurring with their condition, but also to “get them in the system” and make sure they stay in rehab for the appropriate amount of time.
Usually one person will be getting their name, age and company. This “scribe” can be anyone — it does not need to be an experienced medical provider.
They could be a cadet, a new member to the organization, even a spouse or friend that got sucked into a major event because they were out with an EMS provider that had a responsibility to respond to the incident. Obtaining this information can occur at the same time other activity is going on.
I usually like to get the firefighter to sit down and get their gear off, so the cooling down process can start. Next, we need to get baseline vitals. This is a mildly controversial area.
My former Division Chief, a very experienced EMS and fire physician, prefers to wait 10 minutes and then get a set of vitals. His view is that it does not matter much what the initial vitals are at the start, and that it is much more important what the vitals are at the time that the firefighter may be released.
I think there is some validity to this, however I would prefer to know if there was a problem sooner rather than later. If a firefighter’s heart rate is 200 because he is in a dangerous arrhythmia, I don’t want to miss this, even for only 10 minutes.
If their blood pressure is extremely low or extremely high, I also need to keep a better eye on them. While in most circumstances they should have either a complaint or physical appearance that should clue us into this abnormality, this is not always the case.
I think both approaches are reasonable — discuss with your medical director which is better for your department.
I have found that obtaining vitals is often the bottleneck in the initial rehab evaluation. There are two vital signs I definitely want immediately — heart rate and blood pressure.
A third vital sign that I think is reasonable to obtain sooner rather than later is a carbon monoxide level. I am not concerned about the temperature because it is my opinion that getting an accurate core body temperature is not feasible in the field.
Doing so requires taking a rectal temperature, something neither I nor the firefighter are much interested in doing. The other, non-invasive methods of getting a temperature are not very reliable, and an elevated temperature is almost always associated with a significantly elevated heart rate.
So how can we get these vitals quickly?
The pulse can be obtained by the good old fashioned method of feeling a radial pulse and counting, but we can also use a number of other tools, such as pulse oximetry, a heart monitor or a carbon monoxide monitor.
have found that either feeling and counting the radial pulse, or using CO oximetry, is the most efficient in obtaining a pulse rate. Using CO oximetry allows us to get both a heart rate and a CO level with one action.
The concern is of course is whether it is truly reliable. I believe it is, but if you are concerned, feel for a pulse at the same time and compare the results. This will likely not add much time to the task.
The blood pressure also needs to be obtained quickly and reliably. Now I am generally a fan of automatic blood pressure cuffs. In the hospital, these work fairly well and allow us to trend the blood pressures — follow them over time.
However, in the field, I have found that they are becoming more and more of a problem. Too often the machine pumps up the cuff and then slowly goes down. And up. And down. And down some more. And then back up. And then down. And then fails to give a value.
EMS providers end up staring at the screen awaiting this important vital sign. So, I think the best way to get a BP in the field is the manual sphygmomanometer and stethoscope.
If a firefighter is found to have a significantly abnormal BP, and they become a patient, then using the automatic machine to confirm and trend is reasonable. But I bet most EMS providers can take a manual BP faster.
Once you have these vitals, and assess the firefighter’s appearance and any physical complaints, they can then be sorted into the medical sector or just to the rest and refreshment area.
But we need to have these vital signs to do so, and we need them quickly and to be accurate. Remember we call them vital signs for a reason — they are important.
Stay safe (and hydrated!)