Transcript EMERGENCY INCIDENT REHABILITATION

EMERGENCY INCIDENT
REHABILITATION
Mason County Emergency Medical
Services
Douglas Richardson, EMT-P
Emergency Incident Rehabilitation
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Objectives
• Define rehabilitation in context to
emergency workers.
• Discuss the importance of rehabilitation to
the fire and emergency services.
• Understand situations warranting, and
criteria for initiating rehabilitation.
Emergency Incident Rehabilitation
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Objectives
• Discuss the impact of Heat Stress on
emergency workers.
• Discuss the impact of Wind Chill on
emergency workers.
• List criteria for the appropriate placement of
a rehabilitation area.
Emergency Incident Rehabilitation
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Objectives
• List five (5) reasons to send emergency
workers for medical evaluation.
• List four (4) criteria that should be meet
before emergency workers are allowed to
return to duty.
Emergency Incident Rehabilitation
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Objectives
• List two (2) reasons for not allowing
injured emergency workers to return to
active duty.
• List ten (10) reasons to transport emergency
workers to an appropriate hospital for
further evaluation.
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Objectives
• Discuss the physiological consequences of
fluid loss.
• Define osmolarity and discuss the
importance of osmolarity in the rehydration
of fire / rescue personnel.
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What is Rehab and Why Do We
Need It?
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Background To Rehab
For many years the fire service has treated the
element of job-related danger as a badge of
courage, worn with pride. Firefighters
would boast of this element of danger when
discussing the merits of various
occupations.
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Background To Rehab
In the last 20 years or so, however, the attitude
of the fire service toward safety has
changed dramatically. Firefighters and
department officials began to realize that
needless deaths and injuries of firefighters
were not badges of courage but indicators
of problems.
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Background To Rehab
• If firefighters are extended beyond their
safe operating periods, the results may be:
– Stress- or fatigue-related illness or injury
– The Firefighter, although uninjured, will be
fatigued to a point at which he/she is unable to
continue in the operation
– The mentally and/or physically fatigued
firefighter may make poor decisions in a highrisk environment
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What Is Rehab?
In the Emergency Services, rehabilitation, or
rehab, describes the process of providing
rest, rehydration, nourishment, and medical
evaluation to responders who are involved
in extended and/or extreme incident scene
operations.
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What Is Rehab?
• Note that Rehab operations are not limited
to emergency scenes. Other type of
activities that might necessitate Rehab
include:
– Training exercises
– Athletic events
– Parade or event standbys
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Why Do We Need Rehab
• Over 50% of all firefighter deaths are to
some extent, directly attributed to stress and
overexertion.
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The Functions Of A Rehab
Operation
• Physical assessment
• Revitalization (rest, rehydration, and
nutritional support)
• Medical evaluation and treatment
• Continual monitoring of physical condition
• Transportation for those requiring treatment
at a hospital
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The Functions Of A Rehab
Operation
• Initial critical incident stress assessment and
support.
• Reassignment
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The Functions Of A Rehab
Operation
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Physical Assessment
•
•
•
•
•
General physical assessment
Basic vital signs
Medical evaluation
Revitalization
Reassignment
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Revitalization
• Rest
– An adequate amount of time for core temp and
vital signs to return to normal.
• Fluid replenishment
– Provided with appropriate fluid to replace those
lost
• Nutrition
– Should receive nutritionally sound food
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Medical Evaluation and
Treatment
• Firefighters who appear ill or injured should
be assigned to personnel in the medical
evaluation/treatment area for rehab
• This should not be delayed by providing
with drinks/food unless the medical
evaluation shows this to be a priority.
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Continual Monitoring of Physical
Condition
• Firefighters in the rehab area should have
their condition continual monitored.
• Firefighters who meet the criteria for
release from rehab should be reassigned or
released from care
• Firefighters who do not respond to rest or
medical attention may require more
intensive interventions.
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Continual Monitoring of Physical
Condition
• No one should be released from rehab until
he/she is medically sound or,
• Is transported to a medical facility for
further treatment.
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Knowing When To Establish
Rehab
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Knowing When To Establish
Rehab
The goal of emergency incident rehab
operations is to lessen the risks of injury
that may result from extended operations,
which are sometimes carried out in adverse
conditions, involving weather and other
factors.
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Knowing When To Establish
Rehab
Ideally, rehab operations should commence
whenever emergency operations pose a risk
of pushing personnel beyond a safe level of
physical and mental endurance.
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Knowing When To Establish
Rehab
•
•
•
•
•
•
Extended fire incidents
Hazardous Material Incidents
Prolonged rescue/recoveries
Adverse weather conditions
Crime scene/standoff’s
Search activities
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Extended Fire Incidents
• Structure Fires
• High-rise structural
fires
• Wildland fires
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Weather Conditions
• Hot-Weather
– Ambient temperature
– Relative Humidity
– Direct Sunlight
• Cold-Weather
– Ambient temperature
– Wind chill factor
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Hot-Weather
Even under the “ideal” climatic conditions,
fires, hazmat incidents, and rescue
operations place a variety of thermal
stresses on the responders operating at
them.
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Hot-Weather
Emergency responders must frequently
perform heavy physical labor in heated
atmospheres, while wearing bulky
protective clothing. In those “ideal”
conditions when the responders have
completed their assignments they go to a
safe area such as rehab to remove their
clothing and cool down.
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Hot-Weather
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Hot-Weather
• Ambient air temperature and relative
humidity can be factored together to create
what is often referred to as a “Heat Index”
• Working in direct sunlight can add 10ºF to
the heat index.
• Working in full turn-out gear can add an
additional 10ºF to the heat index.
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Heat Stress Index
Relative Humidity
Temp °F 10% 20% 30% 40% 50% 60% 70% 80% 90%
104
102
100
98
96
94
92
90
88
86
82
80
78
76
74
Note: Add
98
104 110 120 132
97
101 108 117 125
95
99 105 110 120 132
93
97 101 106 110 125
91
95
98 104 108 120 128
89
93
95 100 105 111 122
87
90
92
96 100 106 115 122
85
88
90
92
96 100 106 114 122
82
86
87
89
93
95 100 106 115
80
84
85
87
90
92
96 100 109
77
79
80
81
84
86
89
91
95
75
77
78
79
81
83
85
86
89
72
75
77
78
79
80
81
83
85
70
72
75
76
77
77
77
78
79
68
70
73
74
75
75
75
76
77
10° when protective clothing is worn and add 10° when in direct sunlight.
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Injuries Associated with Heat
Stress Index Conditions
Injuries Associated with Heat Stress Index Conditions
Heat Index, °F
Danger Category
Injury Threat
Below 60°
80° to 90°
None
Caution
90° to 105°
Extreme Caution
105° to 130°
Danger
above 130°
Extreme Danger
Little to no danger under normal circumstances
Fatigue possible if exposure is prolonged and there is
prolonged physical activity
Heat cramps and heat exhaustion possible if exposure is
prolonged and there is physical activity
Heat cramps and heat exhaustion likely and heat stroke
possible if exposure is prolonged and there is physical
activity
Heat stroke is imminent
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Heat Stress Index
• The USFA (United States Fire
Administration) recommends that rehab
operations be initiated whenever the heat
stress index exceeds 90 ºF (32 ºC).
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Cold-Weather Conditions
Often overlooked when determining the need
for rehab operations are the effects of cold
weather on responders who must operate in
low-temperature conditions for long periods
of time.
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Cold-Weather Conditions
Cold weather poses different rehab challenges
to emergency responders then the warmweather scenarios talked about earlier. The
potential threat to the well-being of the
emergency workers from them, however is
just as great.
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Cold-Weather Conditions
An emergency worker insufficiently protected
against the cold may have his/her body’s
core temperature lowered to dangerous
levels under extreme circumstances. This
condition is referred to as hypothermia.
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Cold-Weather Conditions
The most common cold-weather related
injuries among emergency responders are
localized cold injuries, commonly called
frostnip or frostbite. These injuries occur
when particular parts of the body are
exposed to extreme cold for extended
periods of time.
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Wind Chill
Just as heat and humidity combine to increase
the impact of heat, cold and wind combine
to impact the effects of cold upon the
human body.
The combined effect of cold and wind is
referred to as the Wind Chill Factor.
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Wind Chill Factor Index
Wind Speed MPH
45
40
35
30
25
Temperature, °F
20 15 10 5
5
10
15
20
25
30
35
40
45
43
34
29
26
23
21
20
19
18
37
28
23
19
16
13
12
11
10
32
22
16
12
8
6
4
3
2
27
16
9
4
1
-2
-4
-5
-6
22
10
2
-3
-7
-10
-12
-13
-14
16
3
-5
-10
-15
-18
-20
-21
-22
Wind Chill Temperature, °F
Above 25 °F
25°F to -70°F
Below -70°F
11
-3
-11
-17
-22
-25
-27
-29
-30
6
-9
-18
-24
-29
-33
-35
-37
-38
0
-15
-25
-31
-36
-41
-43
-45
-46
0
-5
-10 -15
-5
-22
-31
-39
-44
-49
-52
-53
-54
-10
-27
-38
-46
-51
-56
-58
-60
-62
-15
-34
-45
-53
-59
-64
-67
-69
-70
-21
-40
-51
-60
-66
-71
-75
-76
-78
Danger
Little danger for properly clothed person
Increasing danger, flesh may freeze
Great danger, flesh may freeze in 30 seconds
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Wind Chill Factor
The USFA (United States Fire Administration)
recommends initiating rehab operations
whenever the wind chill factor drops to
10ºF (-12º C) or lower.
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Other Situations Where Rehab
May Be Necessary
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•
•
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Crime scene/standoffs
Search activities
Public events
Training events
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Crime Scene / Standoffs
• Bomb squad members who have been
operating for long periods of time in heavy
protective clothing.
• Police tactical unit teams who have been
operation in forward positions for a long
period of time.
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Search Activities
• Large area searches for person(s) who have
wandered away from their home.
• Urban search and rescue (USAR) incidents
following a natural or manmade disaster,
such as a structural collapse.
• Searches for climbers, hikers, or others
involved in sports or recreation activities.
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Public Events
•
•
•
•
•
•
•
Fairs, carnivals or other festivals
Auto Races
Parades
Concerts
Major sporting events
Political rallies
Large-scale religious ceremonies
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Establishing and Managing A
Rehab Area
The first five minutes of an
incident can dictate the
outcome of the next five hours.
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Establishing and Managing A
Rehab Area
• Once the need for a rehab has been
established the most important decision and
one that must be made almost immediately
is where to locate the rehab operations.
• Making a good initial choice for the
location of rehab is vital. Trying to relocate
rehab later in the incident can be very
difficult to nearly impossible.
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Locating the Rehab
• Close to Incident Command
– More easily keep track of who is in rehab
– Easier to anticipate when people will be ready
– More efficient use of equipment
• Away from Incident Command
– Easier for the personal to relax
– Fewer distractions
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Site Characteristics
• The site for the Rehab must be selected on
several criteria:
– The estimated number of people that will need
to be rehabbed
– The weather at the time of the incident
– The duration of the incident
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Site Characteristics
• The site should be outside, uphill and
upwind of the operational hazard area.
• The site should permit prompt reentry into
emergency operations when personnel have
completed rehab.
• The site should provide maximum
protection from environmental extremes.
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Site Characteristics
• The site should be large enough to
accommodate all those that need rehab.
• The site should be free of vehicle exhaust.
• The site should be as quite as possible.
• Access to the site by the media should
restricted.
• The site should provide SCBA
replenishment/refill.
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Site Characteristics
• The site should have easy entrance and exit
routes for ambulances.
• The site should have a supply of running
and drinking water.
• It is helpful if restroom facilities are part of
the rehab.
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Site Characteristics
• If the incident involves the recovery of
fatalities, the rehab site should be out of
view of the work area.
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Staffing of The Rehab Area
The most highly trained and qualified EMS
personnel on the scene should provide
medical evaluation and treatment in the
Rehab area.
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Roles of the Rehab Staff
• EMT’s must assure that the sector provides
a safe area in which fire and rescue crews
can rest and receive rehydration.
• EMT’s must identify fire and rescue
personnel entering the rehab who are at risk
for heat- and stress-related illness or injury.
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Roles of the Rehab Staff
• EMT’s should have an AED readily
available in the unlikely, but statistically
important, event that a fire or rescue
personnel experiences cardiac arrest.
• EMT’s must assure accountability for fire
and rescue personnel who enter and exit the
rehab
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Roles of the Rehab Staff
• EMT’s must medically monitor crews to
determine whether they:
– Are fit to return to active fire/rescue duty.
– Require additional hydration and rest.
– Require transport to an ED for further.
evaluation and medical treatment.
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Roles of the Rehab Staff
• EMT’s must give regular reports/updates to
the Safety Officer or the Incident
Commander.
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Rehab
• The amount of time that a responder will
require in rehab will vary depending on a
variety of conditions:
– The responders level of physical conditioning.
– The atmospheric conditions.
– The nature of the activities the responder was
performing prior to entering rehab.
– The time needed for adequate rehydration.
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Rehab - Rest
It is recommended that departments establish
a minimum amount of time that fire/rescue
personal spend in rehab. This will vary with
the atmospheric conditions and the number
of personal available but a good rule of
thumb is that each person spend at least 20
minutes in rehab.
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Rehab - Rehydration
• The hydration that occurs in the rehab is
very important to a responders recovery.
• Personnel who perform heavy work under
stressful conditions, while wearing heavy
personal protective clothing are subject to
excessive fluid loss.
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Rehab - Rehydration
• While fluid loss is obvious in hot weather
conditions, do not overlook the fact that
dehydration also occurs in cold climates.
• Maintaining sufficient levels of water and
electrolytes in the body can greatly aid in
the prevention of heat- or stress-related
illness or injury.
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Osmolarity
• Osmolarity can be roughly defined as the
“thickness” of a fluid as determined by the
electrolyte and carbohydrate content of the
beverage.
• The higher the osmolarity the longer the time it
will take to absorb the fluid.
• In general it is recommended that rehydration
solutions do not exceed an osmolarity of
350mOsm/liter.
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Characteristics of Beverages Commonly Used for Rehydration
Beverage
Sugar Concentration
Gatorade
6%
Exceed
7.2%
Body Fuel
4.2%
10-K
6.3%
Quickick
4.7%
Coca-Cola
11%
Sprite
10.2%
Cranberry Juice
15%
Orange Juice
11.8%
Water
---Serving Size 8 fluid ounces.
Sodium
Potassium
Osmolarity
110mg
50mg
80mg
52mg
116mg
9.2mg
28mg
10mg
2.7mg
low
25mg
45mg
20mg
26mg
13mg
trace
trace
61mg
510mg
low
280-360
250
210
350
305
600-715
695
890
690
10-20
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Rehab - Rehydration
• Assure that the rehydration solutions have
an osmolarity of less than 350 mOsm/liter.
• Assure that rehydration solutions are
administered in reasonable rather than
excessive amounts.
• Assure that rehydration solutions are not
carbonated.
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Medical Evaluation
• On entry into the Rehab each fire/rescue
personal should be triaged to determine if
medical treatment or transport is necessary.
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Medical Evaluation
• On entry any rescue fire personal with any
of the following should be sent immediately
to the treatment area of rehab
–
–
–
–
–
A heart rate of greater the 120 BPM
A systolic BP of greater then 200 mm/Hg
A systolic BP of less then 90 mm/Hg
A diastolic BP of greater then 110 mm/Hg
Any Traumatic injury
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Medical Evaluation
• No fire/rescue personal should be returned
to active duty if after 20 minutes of rest if
he/she presents with:
–
–
–
–
A pulse of greater than 100 BPM
A systolic BP of greater than 160 mm/Hg
A systolic BP of less than 100 mm/Hg
A diastolic BP of greater than 90 mm/Hg
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Medical Evaluation
• No fire/rescue personal should be returned
to active duty if he/she presents with:
– An injury that may be worsened by a return to
duty.
– An injury that might in any way impair the
performance of his/her duty.
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Medical Evaluation
• Any fire/rescue personal should be
considered for transport to the hospital if
he/she presents with:
–
–
–
–
–
Chest pain
Shortness of breath
Altered mental status
Skin that is hot and either moist or dry
Irregular pulse
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Medical Evaluation
• Any fire/rescue personal should be
considered for transport to the hospital if
he/she presents with:
– Oral temp of greater than 101ºF
– Pulse of more than 150 BPM at any time
– Pulse of more than 140 BPM after cool down
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Medical Evaluation
• Any fire/rescue personal should be
considered for transport to the hospital if
he/she presents with:
– Systolic BP of greater than 200 mm/Hg after
cool down
– Diastolic BP of greater than 130mm/Hg at any
time
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Medical Evaluation
• Any emergency worker should be
considered for transport to the hospital if
he/she is unable to orally rehydrate due to
nausea and vomiting.
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Application
• Define rehabilitation in context to
emergency workers.
• Discuss the importance of rehabilitation to
the fire and emergency services.
• Understand situations warranting, and
criteria for initiating rehabilitation.
Emergency Incident Rehabilitation
77
Application
• Discuss the impact of Heat Stress on
emergency workers.
• Discuss the impact of Wind Chill on
emergency workers.
• List criteria for the appropriate placement of
a rehabilitation area.
Emergency Incident Rehabilitation
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Application
• List five (5) reasons to send emergency
workers for medical evaluation.
• List four (4) criteria that should be meet
before emergency workers are allowed to
return to duty.
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Application
• List two (2) reasons for not allowing an
injured emergency workers to return to
active duty.
• List ten (10) reasons to transport emergency
workers to an appropriate hospital for
further evaluation.
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Application
• Discuss the physiological consequences of
fluid loss.
• Define osmolarity and discuss the
importance of osmolarity in the rehydration
of fire / rescue personnel.
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Summary
Deciding when and if to initiate rehab, and
deciding where to set up rehab are
decisions that must be made early on in an
incident.
Rehydration and constant monitoring of fire
/rescue personnel is of the utmost
importance.
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Summary
• Following accepted guidelines for returning
emergency workers to duty, will aid in both
returning fit workers to duty while at the
same time keep stressed/injured workers
from the risk of causing further harm to
themselves.
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Bibliography
The material presented in this course was compiled
using Emergency Incident Rehabilitation, Edward
T. Dickson, MD, NREMT-P, FACEP and Michael
A Wieder, MS, CFPS, Brady publishing,
International Fire Service Training Institute.
Photos by Julie Richardson, Kim Wheat, and Valarie
Bell
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