Incident: It is always great to resume training outside as the weather warms. But it was just snowing last week, and now it is up to 70 F. The training sessions were going well and the trainees were all hydrating between evolutions. But then there was a call for help inside the training building and the crews scrambled to drag out a captain who collapsed inside. He was brought to a grassy area and his equipment removed. He was breathing adequately, but was confused and disoriented. He complained about being chilled. His skin was dry. The other instructors had heard him complaining that his vision was blurry, and he gave a couple of commands to the trainees that didn’t make sense. He had been inside most of the afternoo, and no one could remember seeing him drink anything. He seemed to become more confused, and refused to drink anything more then a few sips of water. Someone finally suggested that a medic crew should be called to evaluate the captain and get him to the hospital. When they arrived, he had begun vomiting and then became unresponsive.
What incidents will your department identify as needing rehabilitation services? Bad weather? More than one hour? Fires only? There is now a new set of requirements intended to protect emergency responders in a broad variety of duties from as many physical stresses as can be managed in the emergency environment.
NFPA 1584 was passed in December last year and is being implemented now. This is the Standard on the Rehabilitation Process for Members During Emergency Operations and Training Exercises. The new standard calls for liberal application of rehabilitation services, not just at working incidents but at training operations as well. It establishes minimum criteria for implementation of a rehabilitation process for fire service members during incident operations and at training exercises. This standard calls for application by organizations providing rescue, fire suppression, emergency medical services, hazardous materials mitigation, special operations and other emergency services, including public, military, private and industrial fire departments. The standard states, “Procedures shall be in place to ensure that rehabilitation operations commence whenever emergency operations pose the risk of members exceeding a safe level of physical or mental endurance.”
Who will be there?
For this standard to be applied in such a broad range of circumstances, fire service leaders will need to participate in a new set of planning discussions. These may need to take place with other agencies, including local EMS provider agencies, mutual aid fire companies and the leadership of the fire support agencies that exist in many communities. The resulting program from those planning sessions will need to include a process for implementing rehabilitation programs at all types of incidents across a 24/365 environment. It will also need to be developed for training exercises and other physically-demanding duties. Many departments have even developed screening and surveillance programs for their internal candidate physical ability testing, to protect the candidates and department members who are taking part in these demanding activities.
It is likely that many fire agencies will need to develop their fire rehabilitation program using outside resources. It will be critical to develop the program to include the variety of incidents and training scenarios appropriate for the department, including likely weather events and the training exercises that involve physical stresses that could place members at risk. Many departments may find it helpful to do this planning in tandem with other regional fire agencies and EMS providers, so that the program has similar elements and consistency in applications, training, equipment and documentation.
Who Takes Your Pulse?
In a recent poll by FireRehab.com, readers were asked who performed rehabilitation operations in their department?
The poll resulted in more than 300 responses, with the following percentages:
- Fire Personnel: 14 percent
- EMS Personnel: in the FD 32 percent
- EMS Personnel: outside the FD 36 percent
- Fire auxiliary or support unit: 12 percent
- No one: 6 percent
These results indicate that EMS personnel are going to need to be trained and equipped to perform fire rehabilitation services, as well as personnel that respond with fire support units. Proper planning will include training, equipment, methods of deployment, collection of information and documentation and integration with other critical responsibilities at an incident scene. If EMS personnel are to establish and maintain the rehabilitation program, how will that be done at incidents where there are civilian victims? Who covers the operation if there is a firefighter who suddenly gets injured and needs to be transported to the hospital? How will rehabilitation crews be rotated in incidents that are very prolonged?
Many departments face issues related to warm weather operations, including live incidents and training. Fire service leaders need to be able to recognize heat illness and be able to intervene at a point where personnel can be protected from life-threatening events. As we head into the danger time for heat illness, we have the opportunity to develop programs that are consistent with other high-risk groups. For instance, there have been high-profile deaths of professional football players from heat illnesses. And last year, there were many heat illnesses related to marathons in Atlanta and Chicago. Some departments may have access to the training staff for professional teams and college athletic programs, and they may have valuable information on how they develop programs for hot weather operations and safety of their personnel.
The programs that have been developed for all these groups include proper preparation for hot weather events; strategic use of hydration, sunshading, cooling techniques and clothing; and observation for the physical changes that indicate an individual is at risk.
Springtime is clearly the highest risk time of year, before personnel are able to acclimate to warmer conditions. The highest risk is early in the season, especially if there is rapid change to warm temperatures. When those climate conditions occur, many fire leaders will strongly encourage personnel to change out clothing, conduct all training operations at cooler parts of the day, call for extra resources for any “working incidents” to allow more personnel rehabilitatio, and prioritize the use of shading, cooling fans and extra hydration. When departments have crews that are performing multiple working incidents in the same day or shift, they are should be particularly careful with crew maintenance in the afternoon and evening hours.
Training is as dangerous as live incidents, so rehabilitation is a safe practice for training involving recruits, volunteers, career personnel, EMS providers and whoever else is on the training grounds. As demonstrated in the example scenarios at the start of the article, instructors are equally at risk, if not more so. All those responsible for training should be educated in evaluating personnel for heat illness and apply this to both the instructors and the “students.” Many departments also mandate the presence of ALS resources when weather conditions are dangerous, with their responsibility being the monitoring of trainers and trainees. Although rehabilitation operations at training exercises may not seem as important as operations at a live incident, there is a clear need. It is also a great opportunity to train new members on the program and to utilize new equipment or processes.
Recognizing severe heat illness
The worst forms of heat illness — heat stroke — occur when the body is unable to regulate its temperature. It can cause permanent disability or death if emergency care does not begin promptly.
The earliest signs of heat stroke are in the person’s ability to think clearly. The victim will often get confused, disoriented or act in a way inappropriate for circumstances, such as trying to put clothing on because they feel cold. Some patients get very agitated and violent, sometimes appearing very much like they are having an insulin reaction. Their skin temperature may not be warm and many heat stroke patients appear very pale or ashen in appearance. A few have the classic red, hot and dry skin and are not sweating. If they are able to complain of anything, they may report throbbing headache, nausea, vomiting and dizziness. In later stages, the victim will be unconscious or have a seizure and not wake up.
Skin temperature in these cases will be misleading, so do not rely on a temperature probe on the skin And it is very difficult for these patients to hold an oral thermometer in their mouth, as they are typically breathing very fast and/or vomiting. The hospital will rely on a rectal temperature to get an accurate reading on heat stroke patients. This is not available in the field.
Managing a severe heat illness patient
- Immediately begin cooling the victim.
- Get the victim to a sun-shaded location.
- Remove whatever clothing you can and maintain modesty.
- Put the victim on their side, as they are usually nauseated and may vomit.
- Cool the victim rapidly using anything available. Spray with cool water and a fan is a very effective technique.
- Use cold compresses to the forehead, axilla, and groin areas, where blood flow is highest.
- If available, immerse the victim in a pool or tub of cool water or place him/her in a cool shower.
- If the victim is awake enough, allow a few sips of fluid. Do not give the victim large volumes of fluids to drink, as this will likely result in vomiting.
- If ALS is available, start an IV and give a bolus of fluids. Be aware that large volumes of IV fluids are rarely needed, and may be dangerous. Get medical control guidance as soon as possible.
Summary
With fire rehabilitation now a mandate under NFPA 1584, fire leaders may need to look for regional resources to assist in the implementation of this standard and be active in getting EMS organizations and fire auxiliary units trained and equipped for these operations. Remember, it is important to implement this for training exercises, too.
This time of year requires all fire and EMS responders to prepare for heat illnesses and to develop an operation plan to deal with potential victims.
Incident Resolution: The captain never woke up. His temperature at the hospital was 106 degrees. He was cooled aggressivelyl and, even taken to the operating room. But his kidneys failed, his heart faile, and he arrested and died two days later.
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