Barriers to an Effective Rehab Sector – Part 4

An Ounce of Prevention is Worth a Pound of Cure

By David Jaslow

There are several factors which act as de facto barriers to the activation and deployment of a functional rehabilitation and medical monitoring sector at prolonged fires, technical rescue operations and similar incidents. Most of these factors, which we’ve outlined in earlier columns, have one thing in common: a failure on the part of command personnel, perhaps unintentional, to understand the importance of this sector as it relates to the overall concept of firefighter health and wellness.

Benjamin Franklin, a Philadelphian and founder of the nation’s first volunteer fire department, coined the famous phrase, “An ounce of prevention is worth a pound of cure” sometime during the 1700s. I often use this quote when I teach emergency services personnel because it acts as a great segue into a discussion of the integration of public health principles into fireground operations.

These principles encourage and promote a proactive approach to health and wellness. This concept is foreign to many emergency services providers whose day-to-day job involves a reactive or reflexive approach to health. When a civilian becomes injured, entrapped or otherwise finds themselves in an emergency situation, the proverbial alarm is sounded and emergency vehicles rush to the person’s aid.

From a public health perspective, it is always more desirable and economically more sensible to prevent an illness or injury from occurring than to await its occurrence and treat the outcome. Furthermore, treatment of the outcome does not in itself reduce the chances of repeat occurrence. This is a commonly overlooked fact in emergency services. Instructions “not to do that (injury producing behavior) again” does not a safer patient make.

Not proactive
Unfortunately, the paradigm of SOP/SOG design in many of this country’s emergency services agencies is still very much reactive rather than proactive. If an event occurs, we will meet that event with a commensurate amount of resources that will eventually arrive and take care of the problem. Agencies of all sizes choose to err on the side of statistics rather than on the side of caution. Too many have the view, “My men probably won’t have a life-threatening emergency so it is probably unnecessary to prepare for such an event.” Coincidently, lack of disaster preparedness is one of the principles upon which all disaster management education is based.

In my experience, it is still quite rare for Incident Commanders to think proactively. It’s still not common for them to request, activate or deploy assets and personnel in such a fashion as to minimize the chances that personnel will find themselves in a position to sustain an injury or illness during the campaign. Ironically, there are NFPA standards (1500 series) which address this very topic, known as risk prevention. The Incident Commander is supposed to be risk averse, which means that he/she should do what is possible to avoid risk and minimize it when complete avoidance is impossible.

How does this discussion relate to an ounce of prevention in the rehab and medical monitoring sector? Well, Incident Commanders may think of rehab as something that only needs to exist if a firefighter is identified as ill or injured. But nothing is further from the truth. In fact, rehab and the treatment sector are two totally different animals.

Main purpose
Rehab does not exist to perform extensive medical treatment nor should that be done in an area primarily established for the rest and recuperation of exhausted but physically healthy personnel. The purpose of this sector is to simultaneously provide an opportunity for rest and hydration and/or alimentation coupled with a brief medical screening exam. This exam is aimed at the detection of a few fireground medical emergencies and several other urgent but non-emergent medical conditions which, if undetected, could pose a threat to the firefighter at some point in the future. Such conditions include uncontrolled hypertension, deconditioning, and cardiac ischemia without typical presentation.

It should come as no surprise that the Incident Commander who does not understand these principles of prevention would deem rehab unnecessary until one of his firefighters keels over or otherwise declares themselves ill. History has shown us time and again that the typical firefighter does not make known their concerns about feeling ill early and that delay in notification of EMS providers correlates with a worse outcome.

The job of EMS personnel staffing the rehab sector is to provide that Incident Commander with the comfort that there is a screening process in place to identify these personnel rapidly. It means appropriate medical interventions may be taken which keep that firefighter not only alive, but medically fit to enable him/her to return to duty, if not immediately, then at some time in the future.

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.