1. Rehab Revised: Changes to NFPA 1584 Mike McEvoy, PhD, NRP, RN, CCRN EMS Chief – Saratoga County, New York

2. Rehab Revised: 2015 Changes to NFPA 1584
Mike McEvoy, PhD, NRP, RN, CCRN
EMS Chief – Saratoga County, NY
EMS Editor – Fire Engineering magazine
Board Member – IAFC EMS Section

3. Rehab Resources

4. Disclosures I am on the speakers bureau for Masimo Corporation
I do not intend to discuss any unlabeled or unapproved uses of drugs or products

5. McEvoy’s Philosophy: Creation of 1584 (2008 version) Prescriptive
Evidence basis

6. McEvoy’s Philosophy: Creation of 1584 (2008 version) Real world rehab
Prescriptive
Evidence basis
Real world rehab
Historical perspective (baggage)
Who needs it?

7. McEvoy’s Philosophy: Creation of 1584 (2008 version) Real world rehab
Prescriptive
Evidence basis
Real world rehab
Historical perspective (baggage)
Who needs it?
Effect on manpower / personnel scene

8. McEvoy’s Philosophy: Creation of 1584 (2008 version) Real world rehab
Prescriptive
Evidence basis
Real world rehab
Historical perspective (baggage)
Who needs it
Effect on manpower / personnel scene
Firefighters = adults = performance athletes

9. NFPA Rehab Standard Comment period open through 11/15/2013

10. But we’re adults…
Firefighters should know as much as professional athletes about rest, hydration, and endurance.

11. Education on proper hydration, nutrition and diet
But we’re adults…
Firefighters should know as much as professional athletes about rest, hydration, and endurance.
Education on proper hydration, nutrition and diet

12. Firefighting
Greatest short surge physiologic demands of any profession.
10% firefighter time spent on fireground
50% of deaths & 66% of injuries occur on scene.

13. Firefighter LODDs – Likely Culprits:
Medical condition
Fitness
Rehab

14. What is Rehab? “Restore condition of good health”
Mitigate effects of physical & emotional stress of firefighting:
Sustain or restore work capacity
Improve performance
Decrease injuries
Prevent deaths

15. Firefighter Rehab – NFPA 1584
National Fire Protection Association 1584 “Standard on the Rehabilitation Process for Members During Emergency Operations and Training Exercises”
Originally issued in as recommendation in 2003, became a Standard in 2008, revision due for release in 2015.
Every department responsible to develop and implement rehab SOGs

16. Elements of Compliance
SOGs outline how rehab will be provided at incidents and training exercises (where FF expected to work 1 hour or more)
Minimum BLS level equipment on scene (= ambulance equipment)
Integrated into IMS

17. Elements of Compliance
SOGs outline how rehab will be provided at incidents and training exercises (where FF expected to work 1 hour or more)
Commence whenever potential safety or health risk to members or risk exceeds safe level of physical or mental endurance.

18. NFPA 1584: 2015 Revisions Roles and Responsibilities delineated: IC CO
Rehab Manager
Members (FF)

19. NFPA 1584: 2015 Revisions Incident Commander: Establish rehab
Assure staffing & supplies
Rotate members
Mental health services available to all members
If crew member seriously injured or killed, remove all crew members as soon as possible

20. NFPA 1584: 2015 Revisions Company Officer:
Awareness of FF physical/mental condition
Assure hydration
Assess his/her company every 45 min
Wildland: evaluate heat stress conditions

21. NFPA 1584: 2015 Revisions Rehab Manager: Operation, supplies Food
Release
Records

22. NFPA 1584: 2015 Revisions Member: Use rehab Hydrate
Advise CO when performance affected
Awareness of others

23. NFPA 1584: 2015 Revisions Science Updates:
De-emphasis on sports drinks
Caffeine permitted up to 400 mg/day
Energy drinks banned
Passive cooling before active
Medical monitoring parameters are a local decision

24. Hydration and Prehydration
Firefighters are often dehydrated
Prehydrate for planned activities:
500 ml fluid within 2 hours prior to event
Hydrate during events:
Water appropriate most of the time
Sports drinks after first hour of intense work or 3 hours total incident duration
Best to consume small amounts ( ml) very frequently - Typical gastric emptying time limits fluid intake to no more than 1 liter per hour.

25. Hydration and Prehydration
Firefighters are often dehydrated
Prehydrate for planned activities:
500 ml fluid within 2 hours prior to event
Hydrate during events:
Fluids: consume regardless of thirst, continue post incident
Sports drinks offered, consumed at FF discretion
Goal of completely replacing sweat loss deleted
Best to consume small amounts ( ml) very frequently

26. Sports Drinks Usually contain electrolytes and carbohydrates
Osmolarity (concentration) formulated for maximal absorption
Absorption limited by gastric emptying time (COH)
Dilution will extend gastric emptying time and lead to nausea / vomiting

27. Sports Drink Investigation
BMJ investigative report
1035 web pages (listed in magazine ads), 431 performance-enhancing claims on 104 different products
47.2% had references, none referred to systematic reviews (level 1 evidence)
84% judged at high risk of bias
Only 3 (of 74) studies judged to be high quality and low risk of bias
Heneghan C, Howick J, O’Neill B, Gill PJ, et al. The evidence underpinning sports performance products: a systematic assessment. BMJ Open 2012; 2:e doi: /bmjopen

28. Sports Drink Investigation
Conclusions: The current evidence is not of sufficient quality to inform the public about the benefits and harms of sports products. There is a need to improve the quality and reporting of research, a move towards using systematic review evidence to inform decisions.

29. Not to be confused with Sports Drinks
Energy Drinks
Definition: “A type of beverage containing stimulant drugs (caffeine, and other ingredients such as taurine, ginsign, guarana) that is marketed as providing mental or physical stimulation.”
Not to be confused with Sports Drinks

30. NFPA 1584 - Overview Ongoing education on when & how to rehab.
Provide supplies, shelter, equipment, and medical expertise to firefighters where and when needed.
Create a safety net for members unwilling or unable to recognize when fatigued.

31. Who’s Responsible for What?
Department: develop and implement SOGs
Company Officer:
Assess his/her crew every 45 minutes
Suggested after 2nd 30-min SCBA bottle
Or single 45- or 60-min bottle
Or after 40 min intense work without SCBA
Company Officers can adjust time frames to suit work or environmental conditions

32. What about informal rehab?
Was acceptable previously, now encouraged, particularly 1st round
Company or crew level rehab:
SCBA cylinder changes
Work transitions (firefighting to overhaul)
Small or routine incidents
When IC fails to recognize need for rehab

33. Informal Rehab Requirements:
Fluids
Shelter
Place to remove PPE
Seating for members

34. Nine Key Components of Rehab
Relief from climatic conditions
Rest and recovery
Cooling or rewarming
Re-hydration
Calorie and electrolyte replacement
Medical Monitoring
EMS tx according to local protocols
Member accountability
Release

35. 1. Relief from Climatic Conditions
An area free from smoke and sheltered from extreme heat or cold is provided

36. 1. Relief from Climatic Conditions
Rehab unit or air conditioned vehicle/room
Portable heaters, enclosed unit
Removed, but not too far from incident
Vestibule area for removal and storage of PPE

37. 2. Rest and Recovery
Members afforded ability to rest for at least 10 minutes or as long as needed to recover work capacity

38. 2. Rest and Recovery If not rested, rest for 10 more minutes.
Rest 20 min. on second rehab

39. 3. Cooling or Rewarming Better definition
Shaded or air conditioned area
Remove PPE
Gloves, helmet, hood, coat, open bunker pants (pull down to knees when seated)
Cool fluids
Rest

40. 3. Cooling or Rewarming Passive cooling initially
Active cooling when passive ineffective or member exhibits heat related illness

41. Active Cooling: Cold Drinks
Serves dual purpose of hydration and cooling
Ability to cool may be limited on scene
Drinks usually stored warm - must be cooled or only benefit is hydration

42. Cold Towel – 3 Bucket System
Bucket 1: sanitizing solution
¼ cup bleach/gallon
Bucket 2: rinse
Clear water removes any left over bleach
Bucket 3: regeneration
Ice water restores cooling effect

43. 4. Re-hydration Potable fluids to satisfy thirst on scene
Guidelines on beverages revised to allow caffeine up to 400 mg per day and prohibit energy drinks

44. 4. Re-hydration The truth about caffeine: Increases urine output
Does not usually dehydrate (compensatory decline)
Consumption < 400 mg appears safe for firefighters
Reference: EFO paper Stephen Abbott: Assessing the effect of energy drinks on firefighter health and safety

45. 4. Re-hydration
Fluid losses will often exceed gastric emptying limitations
No reliable method of assessing hydration status on scene
Weights
Urine specific gravity
? Saliva testing

46. 4. Re-hydration
Encourage continued hydration post-incident

47. 5. Calorie and electrolyte replacement
Rather than time (3+ hour event), now consider duration, exertion, time of last meal and individual conditions.
Whenever food is available, means to wash hands and faces must also be provided.

48. Food Fruits, meal replacement bars, carbohydrate drinks (15 gm COH)
30-60 grams carbohydrate per hour
High fat foods inappropriate

49. Medical Monitoring vs. Emergency Care
Medical monitoring: observing members for adverse health effects (physical stress, heat or cold exposure, environmental hazards)
Emergency Care: treatment for members with adverse effects or injury.

50. 6. Medical Monitoring in Rehab

51. 6. Medical Monitoring in Rehab
Specifies minimum 6 conditions be screened:
CP, dizzy, SOB, weakness, nausea, h/a
General c/o (cramps, aches, pains…)
Sx heat or cold-related stress
Changes in gait, speech, behavior
Alertness and orientation x 3
Any VS considered abnormal locally

52. 6. Medical Monitoring in Rehab
Local (FD) medical monitoring protocols:
Immediate EMS treatment and transport
Close monitoring in rehab area
Release

53. 6. Medical Monitoring in Rehab
Vital signs now required: (For all members entering rehab)
Temperature
Heart rate
Respiratory rate
Blood pressure
Oxygen saturation
Members exposed to fire smoke shall be assessed for CO poisoning

54. Vital Sign Parameters
NFPA 1584 Annex includes suggested vital sign parameters
Each department must:
Set vital sign parameters
Specify if and when reassessment of vital signs should occur

55. Vital Signs Many departments do not measure
No evidence or published studies:
Determine when treatment necessary
Predict type or duration of rehab needed
Vitals may help set parameters for monitoring, treatment, transport, release
Must be evaluated in context

56. Temperature Core temp most accurate Oral or tympanic used in field
NL = °F ( °C)
Best measured rectally or temp transmitter
Oral or tympanic used in field
Oral 1°F (0.55°C), tympanic 2°F (1.1°C) less
Errors common in measuring firefighters
Oral falsely low from rapid resps or fluid consumption
Tympanic less accurate with significant environmental influences (hot/cold)

57. Pulse NL = 60-80, many influences.
Very important to interpret in context of individual.
Recovery rate may be more significant than actual heart rate.
If > 100 after 20 min rest, further eval needed before release
Pulse ox offers accurate measure

58. Respiratory Rate NL = 12 – 20, should  with fever and exercise
Should return to normal with rest

59. Blood Pressure Most measured Least understood Very contextual
Tremendous potential for error

60. Blood Pressure Sources of error: Cuff size Arm placement NIBP
Potential for cross contamination:
Need to decon between each use

61. Blood Pressure
NFPA suggests members with SBP > 160 or DBP > 100 not be released from rehab.
Mike McEvoy editorial commentary:
Several studies have suggested hypotension (SBP < 80) may be of far greater concern than high blood pressure during rehab.

62. Pulse Oximetry Non-invasive measurement of oxygen and blood flow
NL = %
Most oximeters cannot differentiate oxyhemoglobin from carboxyhemoglobin
Members with SpO2 < 92% should not be released from rehab

63. CO Assessment
Carbon monoxide is present at all fires and a leading cause of death
CO monitoring during rehab has become standard of care
Exhaled CO meter or pulse CO-Oximeter are two detection devices

64. Carbon Monoxide

65. Smoke Characterization Study

66. Smoke Characterization Study
Carbon Monoxide

67. Live Fire Study Chicago Fire Dept. – February through May, 2009
Rescue Squad Company No. 5
44 fires (40 residential and 4 commercial)
Measurements during all phases of fire through overhaul:
Air monitoring (direct air monitoring and personal monitors)
Measurement of smoke particle sizes and content
Gloves and hoods sent to lab for analysis

68. Peak Gas Concentrations at Fires
NIOSH – IDLH
(ppm)
Max (ppm)
Mean
HCN 50
30.0
7.0
NH3
300
4.0
1.8
SO2
100
150.0*
31.0*
NO2 20
2.3
0.7
H2S
133.9
18.4 CO
1200
1500*
774*
* sensor limited values – true values would be higher

69. Total Gas Concentrations at Fires
NIOSH -STEL
(ppm)
TWA (ppm)
Mean
HCN
4.7
10b
27.4
NH3 35 25
8.8
SO2 5 2
200.2*
NO2 1 5b
0.9
H2S
10a 10
146.2 CO
200a
5,313*
X number fires = your exposure
a 10 minute exposure limits
b OSHA limit (in general, NIOSH limits are more conservative)
* sensor limited values – true values would be higher

70. Firefighter Health: the Obvious

71. New Fire Ground CO Study
Sacramento Fire: September 2010 through June 2011
Baseline SpCO at start of each shift for every firefighter
Remeasured at conclusion of overhaul, apparatus position noted
48 fires with 201 paired measurements
Baseline %
Following overhaul %
10 occurrences of SpCO > 5% after overhaul
No difference
p =
Mackey K, Filbrun T, Schatz D, Hostler D, Ogan L. Do carbon monoxide levels rise in firefighters during overhaul operations following a structure fire? [Abstract]. Prehosp Emerg Care 2012; 16:

72. IAFF Statement January 2008
Routine testing of any firefighter potentially exposed to CO using a CO-oximeter

73. Firefighter Rehab

75. Cyanide Consider at all fire scenes All patients in cardiac arrest
Any patient in shock, especially if low CO level
Treat with cyanide antidote kit

76. Paris Fire Brigade ROSC = 50%
In addition to carbon monoxide exposure, cyanide should always be suspected in smoke inhalation victims of a closed-space fire, such as the recent incident in the Chicago subway system.
References
Alcorta R. Smoke inhalation & acute cyanide poisoning. JEMS. 2004;29:suppl 6-15.
Babwin D. Chicago derailment highlights vulnerability of transit systems. Associated Press, July 11, 2006.

77. 7. EMS Tx according to local protocol
Documentation changes
Rehab log minimum:
Unit #
Member name
Time in and out
Disposition
When EMS Tx given, defer to HIPAA and local laws, rules, regs

78. NFPA Sample Rehab Log

79. 8. Member Accountability
Track members assigned to rehab
IC must know whereabouts (i.e.: when they enter rehab and when they leave)

83. 9. Release
Prior to leaving rehab, EMS must confirm that members are able to safely perform full duty.

84. Wildland Firefighter Rehab
Placeholder inserted
Potential concerns:
Acclimatization, hydration, hourly assessment of environmental conditions (includes wet bulb globe temp to alter work/rest cycle to prevent heat- related illness)

85. Rehab Research Needed…

86. Thanks for your attention!
LEAD. EDUCATE. SERVE.