4Disclosures I am on the speakers bureau for Masimo Corporation I do not intend to discuss any unlabeled or unapproved uses of drugs or products
5McEvoy’s Philosophy: Creation of 1584 (2008 version) Prescriptive Evidence basis
6McEvoy’s Philosophy: Creation of 1584 (2008 version) Real world rehab PrescriptiveEvidence basisReal world rehabHistorical perspective (baggage)Who needs it?
7McEvoy’s Philosophy: Creation of 1584 (2008 version) Real world rehab PrescriptiveEvidence basisReal world rehabHistorical perspective (baggage)Who needs it?Effect on manpower / personnel scene
8McEvoy’s Philosophy: Creation of 1584 (2008 version) Real world rehab PrescriptiveEvidence basisReal world rehabHistorical perspective (baggage)Who needs itEffect on manpower / personnel sceneFirefighters = adults = performance athletes
9NFPA Rehab Standard Comment period open through 11/15/2013
10But we’re adults…Firefighters should know as much as professional athletes about rest, hydration, and endurance.
11Education 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
12FirefightingGreatest short surge physiologic demands of any profession.10% firefighter time spent on fireground50% of deaths & 66% of injuries occur on scene.
13Firefighter LODDs – Likely Culprits: Medical conditionFitnessRehab
14What is Rehab? “Restore condition of good health” Mitigate effects of physical & emotional stress of firefighting:Sustain or restore work capacityImprove performanceDecrease injuriesPrevent deaths
15Firefighter 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
16Elements 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
17Elements 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.
18NFPA 1584: 2015 Revisions Roles and Responsibilities delineated: IC CO Rehab ManagerMembers (FF)
19NFPA 1584: 2015 Revisions Incident Commander: Establish rehab Assure staffing & suppliesRotate membersMental health services available to all membersIf crew member seriously injured or killed, remove all crew members as soon as possible
20NFPA 1584: 2015 Revisions Company Officer: Awareness of FF physical/mental conditionAssure hydrationAssess his/her company every 45 minWildland: evaluate heat stress conditions
22NFPA 1584: 2015 Revisions Member: Use rehab Hydrate Advise CO when performance affectedAwareness of others
23NFPA 1584: 2015 Revisions Science Updates: De-emphasis on sports drinksCaffeine permitted up to 400 mg/dayEnergy drinks bannedPassive cooling before activeMedical monitoring parameters are a local decision
24Hydration and Prehydration Firefighters are often dehydratedPrehydrate for planned activities:500 ml fluid within 2 hours prior to eventHydrate during events:Water appropriate most of the timeSports drinks after first hour of intense work or 3 hours total incident durationBest to consume small amounts ( ml) very frequently - Typical gastric emptying time limits fluid intake to no more than 1 liter per hour.
25Hydration and Prehydration Firefighters are often dehydratedPrehydrate for planned activities:500 ml fluid within 2 hours prior to eventHydrate during events:Fluids: consume regardless of thirst, continue post incidentSports drinks offered, consumed at FF discretionGoal of completely replacing sweat loss deletedBest to consume small amounts ( ml) very frequently
26Sports Drinks Usually contain electrolytes and carbohydrates Osmolarity (concentration) formulated for maximal absorptionAbsorption limited by gastric emptying time (COH)Dilution will extend gastric emptying time and lead to nausea / vomiting
27Sports Drink Investigation BMJ investigative report1035 web pages (listed in magazine ads), 431 performance-enhancing claims on 104 different products47.2% had references, none referred to systematic reviews (level 1 evidence)84% judged at high risk of biasOnly 3 (of 74) studies judged to be high quality and low risk of biasHeneghan 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
28Sports 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.
29Not to be confused with Sports Drinks Energy DrinksDefinition: “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
30NFPA 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.
31Who’s Responsible for What? Department: develop and implement SOGsCompany Officer:Assess his/her crew every 45 minutesSuggested after 2nd 30-min SCBA bottleOr single 45- or 60-min bottleOr after 40 min intense work without SCBACompany Officers can adjust time frames to suit work or environmental conditions
32What about informal rehab? Was acceptable previously, now encouraged, particularly 1st roundCompany or crew level rehab:SCBA cylinder changesWork transitions (firefighting to overhaul)Small or routine incidentsWhen IC fails to recognize need for rehab
33Informal Rehab Requirements: FluidsShelterPlace to remove PPESeating for members
34Nine Key Components of Rehab Relief from climatic conditionsRest and recoveryCooling or rewarmingRe-hydrationCalorie and electrolyte replacementMedical MonitoringEMS tx according to local protocolsMember accountabilityRelease
351. Relief from Climatic Conditions An area free from smoke and sheltered from extreme heat or cold is provided
361. Relief from Climatic Conditions Rehab unit or air conditioned vehicle/roomPortable heaters, enclosed unitRemoved, but not too far from incidentVestibule area for removal and storage of PPE
372. Rest and RecoveryMembers afforded ability to rest for at least 10 minutes or as long as needed to recover work capacity
382. Rest and Recovery If not rested, rest for 10 more minutes. Rest 20 min. on second rehab
393. Cooling or Rewarming Better definition Shaded or air conditioned areaRemove PPEGloves, helmet, hood, coat, open bunker pants (pull down to knees when seated)Cool fluidsRest
403. Cooling or Rewarming Passive cooling initially Active cooling when passive ineffective or member exhibits heat related illness
41Active Cooling: Cold Drinks Serves dual purpose of hydration and coolingAbility to cool may be limited on sceneDrinks usually stored warm - must be cooled or only benefit is hydration
42Cold Towel – 3 Bucket System Bucket 1: sanitizing solution¼ cup bleach/gallonBucket 2: rinseClear water removes any left over bleachBucket 3: regenerationIce water restores cooling effect
434. 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
444. Re-hydration The truth about caffeine: Increases urine output Does not usually dehydrate (compensatory decline)Consumption < 400 mg appears safe for firefightersReference: EFO paper Stephen Abbott: Assessing the effect of energy drinks on firefighter health and safety
454. Re-hydrationFluid losses will often exceed gastric emptying limitationsNo reliable method of assessing hydration status on sceneWeightsUrine specific gravity? Saliva testing
464. Re-hydrationEncourage continued hydration post-incident
475. 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.
49Medical 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.
516. Medical Monitoring in Rehab Specifies minimum 6 conditions be screened:CP, dizzy, SOB, weakness, nausea, h/aGeneral c/o (cramps, aches, pains…)Sx heat or cold-related stressChanges in gait, speech, behaviorAlertness and orientation x 3Any VS considered abnormal locally
526. Medical Monitoring in Rehab Local (FD) medical monitoring protocols:Immediate EMS treatment and transportClose monitoring in rehab areaRelease
536. Medical Monitoring in Rehab Vital signs now required: (For all members entering rehab)TemperatureHeart rateRespiratory rateBlood pressureOxygen saturationMembers exposed to fire smoke shall be assessed for CO poisoning
54Vital Sign ParametersNFPA 1584 Annex includes suggested vital sign parametersEach department must:Set vital sign parametersSpecify if and when reassessment of vital signs should occur
55Vital Signs Many departments do not measure No evidence or published studies:Determine when treatment necessaryPredict type or duration of rehab neededVitals may help set parameters for monitoring, treatment, transport, releaseMust be evaluated in context
56Temperature Core temp most accurate Oral or tympanic used in field NL = °F ( °C)Best measured rectally or temp transmitterOral or tympanic used in fieldOral 1°F (0.55°C), tympanic 2°F (1.1°C) lessErrors common in measuring firefightersOral falsely low from rapid resps or fluid consumptionTympanic less accurate with significant environmental influences (hot/cold)
57Pulse 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 releasePulse ox offers accurate measure
58Respiratory Rate NL = 12 – 20, should with fever and exercise Should return to normal with rest
59Blood Pressure Most measured Least understood Very contextual Tremendous potential for error
60Blood Pressure Sources of error: Cuff size Arm placement NIBP Potential for cross contamination:Need to decon between each use
61Blood PressureNFPA 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.
62Pulse Oximetry Non-invasive measurement of oxygen and blood flow NL = %Most oximeters cannot differentiate oxyhemoglobin from carboxyhemoglobinMembers with SpO2 < 92% should not be released from rehab
63CO AssessmentCarbon monoxide is present at all fires and a leading cause of deathCO monitoring during rehab has become standard of careExhaled CO meter or pulse CO-Oximeter are two detection devices
67Live Fire Study Chicago Fire Dept. – February through May, 2009 Rescue Squad Company No. 544 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 contentGloves and hoods sent to lab for analysis
68Peak Gas Concentrations at Fires NIOSH – IDLH(ppm)Max (ppm)MeanHCN5030.07.0NH33004.01.8SO2100150.0*31.0*NO2202.30.7H2S133.918.4CO12001500*774** sensor limited values – true values would be higher
69Total Gas Concentrations at Fires NIOSH -STEL(ppm)TWA (ppm)MeanHCN4.710b27.4NH335258.8SO252200.2*NO215b0.9H2S10a10146.2CO200a5,313*X number fires = your exposurea 10 minute exposure limitsb OSHA limit (in general, NIOSH limits are more conservative)* sensor limited values – true values would be higher
71New Fire Ground CO Study Sacramento Fire: September 2010 through June 2011Baseline SpCO at start of each shift for every firefighterRemeasured at conclusion of overhaul, apparatus position noted48 fires with 201 paired measurementsBaseline %Following overhaul %10 occurrences of SpCO > 5% after overhaulNo differencep =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:
72IAFF Statement January 2008 Routine testing of any firefighter potentially exposed to CO using a CO-oximeter
75Cyanide Consider at all fire scenes All patients in cardiac arrest Any patient in shock, especially if low CO levelTreat with cyanide antidote kit
76Paris 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.ReferencesAlcorta 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.
777. EMS Tx according to local protocol Documentation changesRehab log minimum:Unit #Member nameTime in and outDispositionWhen EMS Tx given, defer to HIPAA and local laws, rules, regs