Fire Rehab

liftwithlegs

liftwithlegs

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My service is just starting up a fire rehab team to respond to prolonged fire incidents with our regular ambulance. We are in the very begining stages of planning, and I was curious as to what your service does for fire rehab, if anything?
 
We have just recieved some new training on rehab from Mesa FD. Basically stating that all FF's should report to rehab asap, doff all gear, rehydrate, use either fan's blowing cool mist or forearm dunks in ICE to lower body temp. Also all FF's should recieve a bls medical eval and should not rotate back if there vital signs have not improved during rehab, there are specific numbers that I cannot recall right now. Heart rate is a biggie now. I have came of the nozzel on a 100 plus degree day at 2 in the afternoon on a semi-trailer fire on the freeway and my heartrate was at 170ish for the next 30 minutes barely slowing down. They want it under 100 by the time you get back on the line. Arizona sucks though, and our biggest concern is hydration and electrolyte balance.

Good things are Cliff bar's, tiger's milk bars. Granola. Water, Gatorade, not too cold either it will make you nauseated.
 
Thanks for all the info! Quick question for the last poster....how are you dispatched? Are you called automatically, or do you recieve a page? This is one of the things that we are trying to figure out.
 
Forearm dunks...sure. Also some commonsense.

Have a nice big trashcan full of ice and water. If you dunk your arms into it, that is, what, about 36% body surface area exposure to rapid cooling?It actually hurts, so sticking in your head is not the greatest experience and has far lower BSA exposure, not to mention all sorts of bad vagal stim. and even maybe vestibular stim if it gets into your ears.

The heat victims I treated during chemical warfare defense ensemble exercises (condition BLACK/MOPP Four for you ex-mil's), almost to a person, had these factors in common: they didn't drink unless they felt like it, they stopped drinking when their thirst was slaked, they didn't drink plastic canteen water because it tasted funny, and they didn't eat their meals.

US Army did some studies. Offer water no colder than 70 deg.F, do not use fountains, do what it takes to make it palatable, and enforce water discipline. My observation was that if they ate, they worked better; my supposition was that not only were elecrolytes available, but all the nutrients your body needs, PLUS, if you are catabolyzing to keep going because your food intake's down, you need to use more water to do that and to wash out the wastes, which are also toxic.

My magic rehydration fluid was 1/2 strength gatoraid in a big cup with just a LITTLE ice, and a lecture while I had their attention. I never had to start an IV in eleven years. (I also was out there with them in my gear and pulling people getting into trouble, nagging them to drink, teaching them how to cool themselves, and pounding the buddy system into their helmets).TEACH and be proactive.
 
mycrofft answered about the forearm dunks, some will also dunk there feet or just go all the way to the shoulder in cold/sorta cold water to lower body temp. Its kind of scary to take a core body temp on a firefighter right after working in harsh conditions, so cooling is important.

Yes any working fire assignment will have a utility truck and an extra rescue (ambo) dispatched or depending on where the fire is an actual rehab unit will be dispatched, usually rehab3 from phoenix in my area and they handle rehab operations. But it is also an individual unit responsibility, all apparatus should carry an ice chest with water and some sort of sports drink.
 
Uhhhhh....
Ice?
No.
Ice water?
No.
Cool water?
Yes.
A rapid temp change is not good for the body.
TFG makes a cool chair, albeit much over priced, meant to be filled with cool water in the arms, so the rehabbing FF can relax, and cool down.
If you can, get your hands on the July 2008 copy of EMS magazine. It has an excellent, well written article on rehab procedures, and even ties in NFPA1584 (for once, NFPA does something for the Brothers, not the manufacturers!)

A minimum of a BLS ambulance (transport available) should be dispatched on the first alarm for a working structure fire.
An all hands or above job, confirmed entrapment, activation of FAST, or a Brother showing signs of shock, c/o CP, SOB, or any ALS criteria should get ALS dispatched forthwith.
 
Here's an intro article from JEMS: http://www.jems.com/news_and_articles/columns/Becker/Emergency_Scene_Rehab_Operations.html

We do quite a bit of rehab. To keep things simple, we throw a couple cases of bottled water/gatorade and a couple small fans in the back of the truck and head to scene.

As for criteria, watch for the basics - chest pain, DIB, altered behavior or mental status. Generally cooldown must be for 15-30 mins with required rehydration, pull off the gear and sit in the back of the truck in extremes of heat/cold outside temp, do not release from rehab until spO2 above 92-94%, pulse down to 110, and BP within norms - otherwise, more rehab, reevaluate, consider transport.
 
So. IL Medic said:
As for criteria, watch for the basics - chest pain, DIB, altered behavior or mental status. Generally cooldown must be for 15-30 mins with required rehydration, pull off the gear and sit in the back of the truck in extremes of heat/cold outside temp, do not release from rehab until spO2 above 92-94%, pulse down to 110, and BP within norms - otherwise, more rehab, reevaluate, consider transport.
Click to expand...

Although I HATE NFPA (Not For Practical Application), they did well on their guidelines. They are a tad more stringent for vitals.
Also, look at getting one of these, so you can measure carboxyhemaglobin levels.
http://www.masimo.com/rad-57/index.htm
 
So.IL, roger that

It helps when you pound it into their heads to buddy up and watch each other, and then have a professional out there acting like a ref/coach, and plan/enforce water comsumption and breaks.
I had about forty folks in MOPP4 (groundcrew ensemble, hood, mask, rubber boots) in 85+ degree, 25% humidity weather with little/no breeze. There was a break in the simulated combat support, they were sitting in the shade on a concrete slab. I had them lay down, and the cooling was immediate through the sweat-soaked chem warfare suits to the slab/heat sink. When we got up, the slab was covered with Hiroshima-like silouhettes of the folks who cooled off there. (A couple fell asleep).
 
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Are there similar guideines for cold exposure? (New thread)

...................
 
I have always taught and been taught that rapid cooling of the extremities is more likely to raise core body temp than to lower it. The reasoning behind this is the extremities are the first areas to react to the outside temp. So the temperature of the blood within those limbs is always going to be more extreme than that of the core. When you drastically change the temp of the extremity, the warm blood in the limb is then moved into the core raising its temperature.

In wilderness med, the rule is to cool or warm the core first. Use the cold packs or wet cloths on the area of the carotid, femoral or brachial arteries. Allowing the extremities to adjust more slowly.
 
mycrofft said:
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Click to expand...

As to cold, all our protocols say is that the rehab area should be dry and warm and that hydration is just as important as during hot environments. Watch for frostbite in exposed or wet clothing areas, watch for hypothermia symptoms, get personnel into dry gear, etc.
 
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BLSBoy, Agreed. We're getting co-oximeters in next year's budget....hopefully....if the money is there.....*sigh*
 
Best budget money we spent for rehab was one of those tympanic thermometers. Easy to use, fits in the pocket of my bunker gear. And not as easily broken as the regular thermometer.

I've sent vollies to the sidelines in a fire more than a time or two. They whine and moan but luckily we have a chief who backs me up.
 
Let me recollect the Nebraska heat wave of 1980...the life raft.

Besides losing all radio networking to sunspot skip, we had a sockdollager of a heat wave, old folks dying, etc.

Local trauma center/ER had a protocol for severely overheated pts, including rectal temps Q 10 min and schlepping the pt to and from the PhysTherapy tub for lukewarm to tepid dunking. Pt's weren't making it. The doc went to the local camping/surplus store and bought a "two man raft", inflated it and kept it in the ER behind Curtain # 1. A dike of towels surrounded it. When a heatstroke victim was brought in, one flunky ran (RAN) for a bucket of ice, another put a few buckets of water in the raft, then they plus the pt were quickly united. Rectal temp was taken as soon as was possible, and the cold shoulder tx D/C'ed as soon as the pt seemed to be coming around even somewhat. Pt survival upswung.

It was too bad that in-ambulance cooling was so ineffective because promptness equals life. They would come in with a chem cold pack on either side of their neck, their groin, their axillae...what they needed was a wet sheet and a fan.

Another factor reappears...older folks who can't afford air conditioning in the humid midwest also don't eat and drink the healthiest of meals, plus the effects of age and possibly medications...need those electrolytes, minerals, serum albumin etc. to keep things going in and out, round and round.
 
BC, attagirl.

EMS or at least medical has to be integrated with "overhead" on fires etc. I started recording weather and ambient temps etc in my afteraction reports. My chief nurse told me to edit it out, I refused, and the next year they were made mandatory and in fact were supplemented by environ health techs coming along taking black sphere temps and hygrometery reading for real-time counseling of exercise managers.
 
BLSBoy said:
Although I HATE NFPA (Not For Practical Application), they did well on their guidelines. They are a tad more stringent for vitals.
Also, look at getting one of these, so you can measure carboxyhemaglobin levels.
http://www.masimo.com/rad-57/index.htm
Click to expand...

Not for Practical Application, I like that one!

A couple of thoughts I was having.......................

1. While you are sitting out on a fire scene doing a whole lot of nothing for the most part, what happens if an EMS call drops? Do you leave the fire? Do you send another unit? Do you have another unit to send?

2. CO monitoring is a great idea and all, but who will pay for the equipment?

My point here is why if resources are so thin in some areas, why are we sending and dedicating an EMS unit to babysit firefighters? The reality is that most large fire agencies have firefighters that are also EMT's, many are even Paramedics. Many receive compensation for this training. So why aren't these medically trained firefighter's performing their own rehab? It only takes one person to do and it would eliminate the need of taking an EMS unit out of service needlessly for hours at a time. If someone needs to be transported, then call an ambulance. Major incidents aside, rehab is usually simplistic and can be handled without the need for an ambulance.

Volunteer fire departments and rural agencies are the problem children here. Most do not enforce a physical standard, thus you have a bunch of middle age overweight smokers running around in bunker gear. The sad part is that these are the areas that truly need to preserve their EMS units for emergencies as they are already volunteer staffed with limited resources and usually a large geographic area.

Now if they are just on scene helping out, well more power to them. But dedicating an EMS unit to a working fire simply for rehab is a waste of medical resources. Especially when those resources are needed elsewhere.

Also, if you want CO monitoring to assist you with your high speed rehab operations, get the fire department to foot the bill. Although I am still puzzled exactly what you would do with the carboxyhemoglobin readings. Other than having a cool new toy, there will be no change in your treatment. Not to mention, a minimal assessment can give you a decent idea of if someone has CO poisoning or not. Use your head, not your probe...............................
 
Good, amateurs think tactics, pro's think systems, to steal a phrase.

So the optimal arrangement might be an EMS advisor to the overhead (fire management), think out and prepare fairly robust and simple cooling and monitoring steps integrated into the extant "first aid" feature of the ICP/ECP (incident command post and entry control points) and develop a simple protocol to be used by reserves/auxiliary or trained laypersons (C.E.R.T., local Red Cross?) with one director to manage and give it "spine" enough to bench firefighters who need it. In fact, those firefighters could be pressed into the role of first aid/"rehab" as a means to let them physiologically re-equilibrate while still participating.
 
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