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Rehab and refusals: What you should do

At a large fire, multiple people, many with vitals outside of the normal range, come through the rehab sector

As a Fire/EMS Medical Director, one of the greatest liability risks to me related to the agencies I cover is patient non-transport. This is when an ambulance is called to the scene and, for some reason, the patient is not transported to the hospital.

Most of the time, the reasons for the non-transport are understandable — an extremely minor incident or a refusal are examples. The EMS providers explain the risks to the patient and they obtain a signed refusal of treatment and/or transport.

This occurs even for mild complaints such as a splinter or an abrasion, or even if the symptoms have all resolved and the patient currently has no complaint.

EMTs and most medics are not empowered to treat and release — in general we need to either transport or obtain a refusal. In some systems, contact with a base command doctor is required to approve the refusal.

EMS providers basically must always recommend transport to the hospital, even if we don't think it is indicated. That is the whole concept of the "refusal" — the refusal to follow our recommendations.

With this in mind, let's shift gears to the fire rehab scene. At a large fire, multiple people, many with vitals outside of the normal range, come through the rehab sector and are evaluated by EMTs.

Some of the firefighters may have physical complaints such as shortness of breath or dizziness, but most are simply a bit tired and need little, if any, medical care.

We check vitals to make sure we are not missing anything, they rest a bit, and they are then released from rehab, hopefully based on pre-approved guidelines regarding discharge vital signs and time in the sector.

In essence, these firefighters were evaluated by an EMT or paramedic, and then discharged from the sector. Is that a problem?

The answer to this question lies in the answer to another -- when does the firefighter in the rehab sector become a patient, requiring a refusal to be signed if they are not transported?

There are two aspects to consider, vital signs and complaints. We can break it down into different categories:

Normal vitals/No complaints: These firefighters are simply coming through for rest and refreshment. They are really not patients and I think we all agree that no signed refusal is needed to release them.

If the vitals were abnormal but are now normal, one might think that would be a problem, but it is important to view everything in context. While a heart rate of 125 may not be in the "normal" range, it is certainly expected shortly after exertion such as active firefighting. It does not necessarily elevate this firefighter to the status of a patient.

An 80-year-old member of the fire police who was directing traffic would not be expected to have a heart rate of 125, and this finding should make us search for causes and consider him a patient rather than just someone coming through rehab.

Abnormal vitals/No complaints: This often represents either the individual with vitals that we really do not expect like described above, or more often, the firefighter whose vitals do not return to normal after a significant period of rest.

They often present a quandary for us both on the scene and also in the hospital. Most of the time, in the absence of any physical complaint, there is no major underlying condition — they are usually just a bit out of shape.

However, the EMS provider is put in the middle. On one hand there is little the emergency department is going to do for an asymptomatic patient with a heart rate of 115 or a BP of 180/90, but on the other hand these are abnormal vitals and simply allowing the firefighter to just walk away could increase our liability.

I think the best way to handle this situation is to have a good pre-established algorithm to guide the EMS provider. The firefighter typically stays in the rehab sector until vitals reach a certain level, or they have been in the sector for a certain time period, at which time a decision must be made.

Perhaps the firefighter can be released and just not returned to active firefighting duty. They can follow up with their primary care doctor or the department occupational physician in the near future.

Perhaps the EMS provider can call a base command physician for further guidance, although this is sometimes restricted only to ALS providers in some states.

Or, perhaps a full recommendation for transport might be made. This algorithm should be designed with guidance from the department medical director. Also, consider if the firefighter was really having a productive rest and rehab. Were they walking around in full gear and not drinking any water? This may contribute to a delayed return to baseline vitals.

Complaints: These firefighters have some sort of physical complaint that is either unexpected or serious in nature. These can include chest pain, shortness of breath, severe dizziness or any type of injury that they experienced on the fireground. The presence of these generally elevates the firefighter to that of a patient, and if transport does not occur, a refusal should be obtained.

Mild fatigue and similar complaints are expected, but they should prompt us to take a closer look at the firefighter while they are in the rehab sector.

One last comment on firefighters that become patients. It should not be surprising that often these firefighters do not want to go to the hospital and express their desire to refuse transport.

Then when we tell their Chief, the response is typically, "He can't refuse — he has to go." Certainly we are not going to drag the firefighter to the ambulance.

The firefighter does have the legal right to refuse and the Chief cannot take that away from him or her. The firefighter has to consent to transport. However, the Chief can restrict their occupational activities and otherwise make it unpleasant if the firefighter does not follow the Chief's wishes.

When this happens, I just put the Chief and firefighter together to hash it out. I will usually say something to the effect of: "I can't force him to go — he has to give consent. You talk to him and let me know once you convince him to go."

Summer has finally arrived here in the northeast. Be extra vigilant early in the season as many of us have not become acclimatized to the heat and humidity. Drink water and stay safe.

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