1. Firefighter Rehab: An Introduction to NFPA 1584
Rehabilitation Practices and Medical Monitoring
Mike McEvoy, PhD, NRP, RN, CCRN
EMS Coordinator – Saratoga County, NY
EMS Editor – Fire Engineering magazine
EMS Section Board Member – International Association of Fire Chiefs
Chair – Resuscitation Committee – Albany Medical Center Hospital/College
Chief Medical Officer – West Crescent Fire Department

2. INTRODUCTION
MEDICAL monitoring

3. Medical Monitoring
Medical Monitoring: Ongoing evaluation of members who are at risk of suffering adverse effects from stress or from exposure to heat, cold, or hazardous environments.

4. Medical Monitoring
Recovery: The process of returning a member’s physiological and psychological states to levels that indicate the person is able to perform additional emergency tasks, be reassigned, or released without any adverse effects.

5. Best Practices in Rehab
MEDICAL MONITORING vs. TREATMENT
Medical monitoring and medical treatment are different. Not all EMS providers are experienced at medical monitoring in the rehab operation. There must be specific protocols for medical monitoring that differ from standard EMS treatment protocols. To avoid confusion, the medical monitoring area and the medical treatment area must be separate.

6. Medical Monitoring
Emergency Medical Care: Treatment or stabilization of an emergency condition (possibly including ambulance transport).

7. REHAB CRITERIA
Firefighter rehab

8. Firefighter Rehabilitation
Rehab criteria:
Personnel shall be provided with rehab following use of:
A second 30 or 45-minute SCBA bottle.
A single 60-minute SCBA bottle.
Or 40 minutes of intense work without SCBA.

9. Firefighter Rehabilitation
Rehab criteria:
Personnel shall be provided with rehab following use of:
A second 30 or 45-minute SCBA bottle.
A single 60-minute SCBA bottle.
Or 40 minutes of intense work without SCBA.
A supervisor (CO) shall be permitted to adjust time frames depending on work or environmental conditions.

10. Best Practices in Rehab
WORK-TO-REST RATIOS
Company officers know their crews. It is important for company officers to stop and periodically assess all crew members for the need to undergo rehab (at least every 45 minutes). In severe conditions, the assessment interval should be decreased accordingly.

11. Firefighter Rehabilitation
Rest and recovery:
Personnel entering rehab for the first time shall rest for at least 10 minutes—longer when practical.
A member should not return to active operations if they do not feel they are adequately rested.

12. Firefighter Rehabilitation
Personnel shall rest for a minimum of 20 minutes following:
A second 30 or 45-minute SCBA bottle.
A single 60-minute SCBA bottle.
40 minutes of intense work without SCBA.
A supervisor shall be permitted to adjust time frames based on work or environmental conditions.

13. Best Practices in Rehab
PRE-DETERMINED WORK PREDICTION
Fire departments that have a comprehensive work health program will often have a complete work prediction profile for each firefighter. This information can be made available to the rehab sector personnel to allow them to make more informed decisions about work-to-rest ratios. It takes some of the guessing out of the equation.

14. ACCOUNTABILITY
Firefighter rehab

15. Medical Monitoring
Each crew or company should stay together when entering rehab.
Individual crew members have the responsibility to alert their supervisor as to the need for rehab.

16. Firefighter Rehabilitation
Accountability and tracking is an essential component of firefighter rehab.
The accountability system should be a part of the overall NIMS scheme used in the region.

17. Firefighter Rehabilitation
Commercial tracking systems are available.
The tracking system should have interoperability with neighboring departments and agencies.

18. Rehab Tags

19. Medical Monitoring
A rehab documentation report shall be created to include:
Unit number
Member name
Time in/out
Disposition
Medical monitoring records are part of the incident records.
Emergency care is documented on a PCR.

20. MEDICAL MONITORING
Firefighter rehab

21. Medical Monitoring EMS shall be alert for the following: Chest pain
Dizziness
Shortness of breath
Weakness
Nausea
Headache
General complaints (cramps, aches and pains)
Symptoms of environmental stress (heat or cold)
Mental status changes
Behavioral changes
Changes in speech
Changes in gait (ataxia)
Abnormal vital signs (per departmental guidelines)

22. Medical Monitoring EMS shall be available for eval/tx Minimum BLS
EMS shall evaluate members arriving at rehab for s/s suggestive of a health or safety concern

23. Medical Monitoring
The following vitals shall be obtained for all members entering rehab:
Temperature
Heart rate
Respiratory rate
Blood pressure
Pulse oximetry
Members exposed to fire smoke shall be assessed for carbon monoxide poisoning

24. Medical Monitoring
EMS shall assess and treat in accordance with protocols developed by the FD physician or medical authority

25. REHAB MEDICAL DECISION-MAKING SCHEME
Medical Monitoring
INITIAL REHAB MEDICAL EVALUATION
Immediate transport to an emergency medical facility
Close monitoring and treatment in the rehab area
Release from rehab
REHAB MEDICAL DECISION-MAKING SCHEME

26. MEDICAL TREATMENT
MEDICAL monitoring

30. VITAL SIGNS
MEDICAL monitoring

31. Medical Monitoring Vital signs: Pulse rate Respiratory rate
Blood pressure
Temperature
Oxygen saturation (SpO2)
Carboxyhemoglobin (SpCO)

32. Medical Monitoring
While many fire departments measure vital signs in rehab, not all have chosen to in the past.

33. Medical Monitoring
Vital sign measurement can help with medical decision-making (monitoring, treatment and transport) and can help establish a baseline.
However, they must be interpreted within the context of the general appearance and ongoing health status of the individual.

34. Medical Monitoring Utility of vital sign measurement:
Objective assessment (contextual).
Help identify medical conditions requiring treatment or follow up.
Objective determination of recovery/release.

35. Abandoned Tire Dump Fire
Saratoga County, NY (Waterford)
June 2002 – 10 million tires in abandoned tire dump caught fire
15 departments on scene, 8 days
Rehab for 2,882 firefighters
Pulse ox at door, TPR/BP inside

36. Retrospective Review
100% of firefighters with abnormal temp, respirations or BP had abnormal pulse ox (O2 sat or HR)
Upstate NY rehab protocol now measures only: HR
Oxygen saturation
Carbon monoxide (SpCO%)

37. TEMPERATURE REGULATION
MEDICAL monitoring

38. Medical Monitoring
Humans must maintain their body temperature within a relatively narrow range.
Normal temp is 98.6°F (37.0°C) although there is some variation between individuals.

39. Medical Monitoring
Heat stress is a major occupational hazard for firefighters.
Heat stress is the development of ill-effects or injury secondary to exposure to hot temperatures.

40. Medical Monitoring Heat-generating mechanisms:
Metabolic (biochemical) activity
Muscles at work
Shivering

41. Medical Monitoring
Environmental extremes, especially heat waves, are common.
Heat wave deaths outnumber all other types of weather-related emergencies.

42. Medical Monitoring
The more uncommon the environmental emergency for a community, the more likely it will be problematic.
day Chicago heat wave killed over 600 people.

43. Medical l Monitoring Limited FF heat studies.
Regular heat related FF deaths, often in training.
FF temps continue to rise for 20 minutes regardless of cooling interventions.

44. Medical Monitoring
The core temperature is the temperature deep within the body (usually in a great vessel such as the pulmonary artery or vena cava).
The core temperature is a more accurate measure of body temperature.

45. Medical Monitoring
For healthy individuals, when blood flow is good, an oral temperature is usually an accurate reflection of the core temperature.

46. Medical Monitoring
For abnormal states (hypothermia, hyperthermia) blood flow through the body may be impaired rendering oral temperature readings unreliable and erroneous.
In these situations, a rectal reading is preferred.

47. Medical Monitoring Core body temperature assessment:
Pulmonary Artery (PA) Catheter temp
Esophageal
Urinary Bladder (UBT) – if making urine
Rectal

48. Medical Monitoring
Most departments use tympanic or oral thermometers to measure temperature
NL core temp °F ( °C)
Oral 1°F, tympanic 2°F less than core
Caution: devices may be offset

49. Medical Monitoring Temporal Artery Thermometer (TAT)
Offset to display core temp

50. Medical Monitoring Diaphoresis Temporal Artery Thermometer (TAT)
Offset to display core temp
Diaphoresis

51. Medical Monitoring Temperature Concerns: Measurement error; accuracy
Interference from hydration, sweating, cooling, clothing, helmet, environment.
Considerations:
Touch is highly accurate and may suggest heat related illness
Never use a measured temp to exclude heat related illness!

52. Medical Monitoring Firefighting can be physically intense.
The core temperature will quickly rise triggering temperature control centers in the brain:
Increased respirations
Shunting of blood to the skin
Sweating

53. Medical Monitoring Sweating:
When sweat glands are activated, the first secrete a fluid called the primary secretion.
Similar to plasma
High sodium and chloride
Low potassium
The water evaporates and cools the body.
During low-sweat states the sweat glands slowly reabsorb the electrolytes.

54. Medical Monitoring
In hot environments, the difference between an individual’s core temperature and the environmental temperature is relatively small (low thermal gradient).
The smaller the thermal gradient, the more difficult it is to cool.

55. Medical Monitoring
A firefighter with a core temp of 101°F (38.3°C) will cool more effectively when the environmental temperature is 50°F (10°C) compared to an environmental temperature of 95°F (35°C).
Heat must flow from the firefighter to the environment.

56. Medical Monitoring Cooling can be accomplished two ways:
Passive cooling: Facilitating the body’s cooling mechanisms, such as removing clothing, moving the subject to a cooler environment, and removing the subject from direct sunlight.
Active cooling: Using external methods or devices (e.g., hand and forearm immersion, misting fan, cold towels) to reduce the elevated body temperature.

57. Medical Monitoring Passive Cooling:
Helmet, hood, gloves, SCBA, and coat should be removed and stowed prior to entering rehab.
Pants should be opened at the top (20% greater cooling)

58. Medical Monitoring
Passive cooling: move to a cooler area

59. Medical Monitoring
Members entering rehab should consume enough fluids to satisfy thirst.
Rehydration helps lower body temperature.
There is no risk to firefighters from consuming chilled fluids.

60. Medical Monitoring
Active cooling is recommended when passive cooling is ineffective or signs/symptoms of heat stress are present.

61. Active Cooling:

62. Medical Monitoring Forearm immersion: Effective cooling mechanism.
Increased blood flow to the forearms and hands facilitate heat transfer to the cold water.
More effective than misting fans in humid environments.

63. Medical Monitoring Misting fans:
Effective in dry environments (the drier, the more effective is cooling).
In humid environments (where evaporation is slowed), water can remain on skin possibly leading to steam burns when the member returns to firefighting.

64. Medical Monitoring Wet towels: As effective as forearm immersion.
Sometimes more practical and less expensive.

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

66. Medical Monitoring
Often, a combination of techniques is used on the fire ground to prevent heat stress.
Importantly, no one strategy (including an air conditioned room) is superior to any other cooling method.
Except…
Espinoza M, Contreras M. “Safety and performance implications of hydration, core body temperature, and post-incident rehabilitation.” Orange County Fire Authority (CA). December, 2007

68. Cold Towels…(preferred by FF)

69. Vests…

70. Best Practices in Rehab
ACTIVE COOLING
Wet or cold towels provide active cooling through conduction and evaporation. Conductive cooling occurs when the skin comes in contact with a cooler object. Conductive cooling is effective in all environments. Ice water and cold towels are inexpensive and can cool multiple members at the same time. Wet, cold towels are generally more comfortable for members.

71. Medical Monitoring When entering rehab on warm days:
Remove protective clothing
Drink plenty of fluids
Cooling should be started as soon as possible:
Passive cooling initially
For severe conditions, switch to active cooling immediately.

72. Medical Monitoring During active cooling:
Be careful not to overcool a member as shivering may start which will cause body temperature to again rise.
When body temperature reaches 1-2°F above normal, switch to passive cooling to prevent overcooling the member.

73. Medical Monitoring
Personnel should not be released from rehab until core temperature is normal.

74. Medical Monitoring
In cold environments, personnel are at increased risk of losing heat to the environment.

75. Medical Monitoring
When the core temp falls below normal, hypothermia can develop.
The greater the thermal gradient, the greater will be the subsequent heat loss.
Exposure to water during firefighting can hasten cooling and worsen the situation.

76. Medical Monitoring Hypothermia: Core temp <95°F (35°C).
Pose a significant risk to members.

77. Medical Monitoring Warming can be accomplished two ways:
Passive warming: Application of measures (e.g., removal of wet clothing, use of blankets or additional clothing, or movement to a warmer environment) that slow heat loss to the environment.
Active warming: The actual application of heat to a victim (e.g., heat packs, warming blankets, warmed IV fluids). Heat is transferred from the heat source to the victim.

78. Medical Monitoring
Both passive and active warming should be used as needed on the fire ground.
Only warm the member until the core temperature returns to normal—avoid overshoot an hyperthermia.
When body temperature reaches 1-2°F below normal, switch to passive warming to prevent over warming the member.

79. MEDICAL MONITORING
Heart Rate

80. Medical Monitoring Pulse rate: Normal is 60-100 beats per minute.
Common to exceed 100 during exertion.
After resting for a period of time, heart rate should return to normal.
Heart rate must be interpreted within the context of the individual (baseline recorded resting heart rates are helpful).

81. Medical Monitoring Pulse rate:
Pulse rate can be easily measured by palpation.
Pulse oximetry or CO-oximetry can also be used.
Oximetric pulse rates are more accurate than palpated rates.

82. MEDICAL MONITORING
Respiratory Rate

83. Medical Monitoring Respiratory rate:
Normal is breaths per minute.
In rehab, most firefighters will have a higher than normal respiratory rate.
Respiratory rates should fall to normal before discharge from rehab.

84. MEDICAL MONITORING
Blood Pressure

85. Medical Monitoring Blood Pressure (BP):
One of the most frequently measured and least understood vital signs.
BP measurement is extremely prone to error.
Because of the extreme variability and difficulty interpreting blood pressure changes, many authorities in the past had chosen not to routinely measure BP in rehab.

86. Medical Monitoring Blood Pressure (BP): Potential for errors:
Wrong cuff size:
Too large (falsely low readings)
Too small (falsely elevated readings)
Malpositioning:
Above heart (falsely low readings)
Below heart (falsely elevated readings)
BP cuffs and stethoscopes are often dirty and can spread antibiotic-resistant bacteria.

87. Best Practices in Rehab
THE BLOOD PRESSURE CONTROVERSY
Blood pressures measurements are prone to error and interpretations can be controversial. Members of ethnic and racial groups respond differently to physiological stress. If BP is measured, NFPA 1584 suggests that members with a SBP >160 or a DBP >100 NOT be released from rehab. Recent studies actually suggest hypotension (SBP < 80) may be more significant than hypertension. Additional research is needed to define the role of BP in rehab.

88. MEDICAL MONITORING
Pulse oximetry

89. Medical Monitoring Pulse Oximetry:
Noninvasive measure of oxygen saturation (SpO2) and pulse rate.
Good assessment tool prior to and during oxygen administration and medical treatment.
NFPA suggests that firefighters with SpO2 < 92% on room air should not be released from rehab.

90. PULSE OXIMETRY INTERPRETATION
Medical Monitoring
PULSE OXIMETRY INTERPRETATION
SpO2 READING (%)
INTERPRETATION
95 – 100
Normal
91 – 94
Mild Hypoxemia
86 – 90
Moderate Hypoxemia
< 85
Severe Hypoxemia

91. Carbon Monoxide poisoning assessment
MEDICAL MONITORING
Carbon Monoxide poisoning assessment

92. Medical Monitoring Carbon Monoxide (CO)
Members exposed to fire smoke shall be assessed for carbon monoxide poisoning

93. 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 (or blood gases)

94. Exhaled CO Meters
Estimation COHb from alveolar CO concentration first described in (Sjostrand T. Acta Physiol Scand 16:201-7)
Predominantly used to monitor smoking cessation
Compact, portable, well validated
Requires 20 second breath holding (awake, alert patient)
Disposable mouthpieces, regular gas calibration
Despite widespread availability since 1970’s utilization very low

95. Pulse CO-Oximetry FDA approved January 2006
Compact, portable, well validated
Continuous carboxyhemoglobin measurement
Can be used on any patient (even unconscious)
No disposables, no calibration needed
Wider adoption than exhaled devices after shorter time in marketplace
Also measures oxyhemoglobin (SpO2), methemoglobin (SpMet), perfusion index (PI), hemoglobin (SpHb) and Pleth Variability Index (PVI).

96. Hemoglobin Signatures:
Extinction coefficients comparable to Absorption wavelengths of each analyte (in mm-1). Invisible spectrum range 660 to 940 nm.

97. Medical Monitoring Pulse CO-Oximetry: Normal values: SpCO 10-15%:
0-5% (non-smokers)
5-10% (smokers)
SpCO 10-15%:
Assess for signs and symptoms of CO poisoning.
SpCO > 15%:
Treat with 100% oxygen
Member must have a normal SpCO to be released from rehab.

98. CO Assessment in FF Rehab?
It’s in NFPA 1584 (industry standard practice)
CO induces death 2º to VF in lab animals
VF initial rhythm in 90% interior FF deaths
Should not leave rehab if > 5% COHb

100. < 5%

101. Paris Fire Brigade Protocol
Known smoke exposure in enclosed space
Altered mental status
Soot in nares or mouth
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.

102. Paris Fire Brigade Protocol
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.

103. Cyanokit® (hydroxocobalamin)
5 grams IV over 15 minutes
Second dose if needed (clinical condition)

104. RELEASE
MEDICAL monitoring

105. Medical Monitoring Release from rehab:
EMS personnel should evaluate members prior to release from rehab.
EMS personnel must assure there are no contraindications to returning to work.

106. MENTAL HEALTH
MEDICAL monitoring

107. Medical Monitoring
As personnel rotate through rehab, they should be observed for signs of psychological or emotional stress.
Personnel experiencing psychological and/or emotional stress should not be allowed to return to the fire ground and should be evaluated by a licensed mental health professional who has knowledge of the fire service and fire operations.

108. Medical Monitoring
If one or more members of a crew or company are seriously injured or killed during an incident, all members of the company or crew should be removed from emergency responsibilities as soon as possible.

109. Medical Monitoring
The provision of mental health services should be voluntary and not mandated.
Psychological first aid (providing comfort needs and information) may be provided.

110. SUMMARY
MEDICAL monitoring

111. Medical Monitoring
The health and well being of our personnel should be our primary concern.

112. Medical Monitoring
Rehab should be included in all operations where environmental, physical, and psychological stress can occur.

113. Summary Just Do It… Define who will do what…
IC must establish a rehab branch/area
Define who will do what…
Medical monitoring
Emergency Medical Care & Treatment
Bring supplies (cooling, shelter, water)
Record keeping
Accountability

114. Rehab Research Needed…

115. Thank You!
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