1. Establish Procedures Utilized for the Rehabilitation of Personnel at Emergency Scenes

A.  PURPOSE

1.  Establish procedures utilized for the rehabilitation of personnel at emergency scenes, search and rescue operations, and training evolutions. The goal is to prevent climate and fatigue-related injuries / illnesses, and to ensure all personnel are physically capable of safely performing tasks during emergency operations in compliance with NFPA 1584 standards.

B.  RESPONSIBILITIES / DEFINITIONS

1.  At all times, the Incident Command System structure (ICS) maintains an organized response and accountability during emergency operations. Dependent upon the scale of the event, the ICS may be minimally staffed, or have multiple layers in the Chain of Command (see Appendix A).

2.  Incident Commander (IC): The Incident Commander considers circumstances of each incident and makes adequate and early provisions for the rest and rehabilitation of all personnel operating at the scene.

3.  Company Officers: All company officers must maintain awareness of the condition of personnel operating within their span of control and ensure steps are taken to provide for each individual’s safety and health. ICS utilized to request relief and reassignment of fatigued crews.

4.  Safety or Logistics Officer (SO or LO): Ensures EIR established and maintained per departmental policy. The SO / LO ensures provisions are made for the safety and health of all personnel on scene (including Rehab personnel).

5.  Rehab Officer: An EMT-B or EMT-P is designated as "Rehab Officer" (RO). The RO may be pre-assigned to the Rehab Sector, or be a medical provider already on-scene without other specific responsibilities. The RO typically reports to the IC, although they may report to the SO / LO on larger-scale incidents. RO responsibilities include: designating Rehab Sector location (if IC has not already done so), securing and providing necessary Rehab Sector resources, maintaining accountability; remaining at the Rehab Sector until completion of all incident operations, and serving as liaison with EMS personnel and the IC.

6.  Rehab Team: Sufficient personnel to monitor Rehab Sector operations for the maximum number of personnel on scene at any given time. A ratio of 1 Rehab medical personnel for every 10 personnel on scene is recommended. The Rehab Team may include non-EMS personnel (i.e. volunteers serving food).

7.  Individual Responsibilities: During periods of hot weather, personnel encouraged to drink water and electrolyte beverages throughout the day. During an emergency incident or training evolution, personnel should advise their supervisor(s) when their level of fatigue or environmental exposure approaches a level that could affect them, their crew, or the operation. Personnel should remain aware of the health and safety of other personnel and company members. Operating outside the ICS is a serious safety and policy violation.

C.  ESTABLISHING THE REHABILITATION SECTOR

1.  The IC will establish a Rehab Sector when conditions indicate that rest and rehabilitation are required for personnel operating at an incident scene or training evolution. This determination should be made based upon the duration of the operation, level of physical exertion, and environmental conditions. Additional guidelines include:

a.  Personnel anticipated to utilize more than 2 air bottles, or SCBA for >45 mins (including overhaul).

b.  Working fire scenes > 20 minutes, including overhaul operations.

c.  One or greater alarm fires or other long duration incidents.

d.  Extended labor intensive incidents, including hazardous materials responses or multiple casualty incidents.

e.  Climatic or environmental conditions that indicate the need to establish a rehabilitation section include temperature extremes, a heat index >90oF (heat alert or emergency), or a wind chill index <10oF.

f.  Any other time deemed appropriate by the IC.

D.  PERSONNEL AND RESOURCES

1.  The RO is in charge of all Rehab Sector activities. The Rehab Sector is often placed under the Safety Section or the Operations / Logistics Section, and therefore the RO reports to the SO, LO or IC (see “Section B Responsibilities”). When companies are assigned to Rehab, they are under the direct control of the RO who determines total time spent in Rehab and disposition. The RO is in constant communication with IC, SO, LO and / or company officer.

2.  For extended operations, the Medical Director should be notified and may assist in Rehab Sector operations. The Medical Director reports to the RO.

3.  IC determines the number of ALS and BLS units assigned to the incident and Rehab Sector. If additional resources required, the RO requests these resources through the IC, i.e. additional personnel / transport units, large-scale shelter vehicles (i.e. transit buses), Salvation Army or Red Cross for fluid and food replenishment if Rehab vehicle not on site.

4.  The company officer assigns individuals or the entire company to the Rehab Sector. When companies have completed Rehab, the RO advises the company officer that personnel are ready for reassignment or require further evaluation and management, including transport to a medical facility. Individuals never self-assign or leave Rehab without the knowledge and approval of the RO.

5.  The RO (or LO in large-scale operations) will secure resources to properly supply the Rehab Sector (see Appendix B), including:

a.  Fluids: water, electrolyte-replacement beverages, warm beverages, beverage dispensers, ice, hot/cold beverage cups.

b.  Foods: low salt, low fat choices, warm foods (i.e. soup), fruit, meal-replacement bars, snacks, utensils.

c.  Medical: BP cuffs, stethoscopes, oxygen equipment, cardiac monitor, tympanic thermometers, IV solutions / supplies, tracking and treatment forms, pens, clipboards, white-boards, and baseline vital sign information (see Appendix C).

d.  Miscellaneous: Fans, tarps, smoke heaters, dry clothing, floodlights, blankets, towels.

6.  An ALS “Stand-By” Crew (at least one EMT-P, with additional EMT-P or EMT-B) dispatched on all single or greater-alarm responses to provide immediate triage and treatment of injured and ill personnel or patients. The ALS Stand-By Crew is not primarily assigned to the Rehab Sector, though may assist in Rehab operations if not actively involved in patient care.

7.  The ALS crew reports directly to the IC or Triage Officer and must be immediately available to the IC in the event personnel needs medical attention. ALS personnel shall not perform firefighting functions which may divert them from their primary function.

8.  In the event the ALS crew transports an ill or injured patient to the hospital, they should be immediately replaced by another ALS crew. If the ill or injured patient only requires BLS transport, one can be requested by IC or the Triage Officer to keep the ALS crew on scene for life threatening emergencies.

9.  All EMS personnel should be located outside the active perimeter. In the event of a large incident where EMS required to stage in a forward or advanced location, EMS personnel must wear the level of PPE required for that area.

10.  In the event of a MAY DAY the ALS crew and ambulance will report to a location in proximity to the anticipated exit of the injured firefighter. The ALS ambulance will not be utilized for any other function during a MAY DAY incident.

11.  The ALS stand-by crew may be utilized for Rehab functions if the incident has de-escalated or during overhaul. ALS will not leave the incident until all emergency and overhaul activities are complete, and only by direct dismissal by the IC.

E.  REHAB SECTOR LOCATION

1.  The Rehab Sector must be located in a safe area appropriate for incident and environmental conditions, chosen either by the IC or RO. The area should be outside the immediate incident zone, but in reasonable proximity to the Command Post where the IC can get rehabilitated companies quickly redeployed back to the incident. The location should not expose companies to extreme environments, fumes or exhaust, is up-stream and up-wind, and can provide ample rest by promoting camaraderie while limiting stress and distractions (including from media to allow patient privacy).

2.  There may be both interior and exterior staging areas; in these cases the Rehab Sector may be co-located with interior staging.

3.  In a Hazardous Materials situation, the Rehab area must not be located in Red or Yellow Zones, only Green Zones.

4.  Rehab should be far enough away from the incident that personnel may safely remove their SCBA, turnout gear and PPE.

5.  There must be access for emergency medical personnel and vehicles with a clear entrance and egress, possibly including establishing a landing zone.

6.  The Rehab Sector should provide suitable environmental protection, i.e. during hot weather it should be in a cool, shaded area; during cold weather, it should be in a warm, dry area.

7.  It should be large enough to accommodate multiple crews, based on the size of the incident

F.  DETERMINING REHABILITATION NEEDS

1.  Early in the incident, the IC and RO will make provisions for the appropriate rest, rehabilitation, and medical treatment of all personnel. These provisions include:

a.  Restoration of Core Temperature: A primary goal of EIR is the restoration of core body temperature. The most effective method(s) are by active cooling through forearm/hand immersion, cold wet towels to neck, passive cooling through hydration, removal of turnout gear, and rest. Personnel should not be moved from a hot environment directly into a cold area as the body's cooling system can shut down in response to the external cooling. An air-conditioned environment is acceptable after a cool-down period at ambient temperature. Certain drugs impair the body's ability to sweat and extreme caution must be taken if the firefighter has taken antihistamines, diuretics or stimulants (including caffeine).

b.  Rehydration: A critical factor in the prevention of heat injury is maintenance of water and electrolyte balances. During heat stress, personnel should consume at least 1 quart of water / hour and a minimum of 8 ounces while SCBA cylinders are being changed while in Rehab. Rehydration important even during cold weather operations where, despite cold temperatures, heat stress may occur during any strenuous activity when protective equipment is worn. Caffeinated / carbonated beverages should be limited or avoided as both interfere with the body's water conservation mechanisms. Outside of the Rehab Sector, personnel encouraged to drink water or an electrolyte drink throughout the work-day. Company officers and / or the RO should ensure that water coolers are continuously replenished with water and/or ice.

c.  Refueling: Food necessary at extended incidents when units are engaged for >3 hour or with environmental extremes. Soup / broth recommended as they are rapidly digested. Apples, oranges, and bananas provide supplemental forms of energy replacement as do commercial protein / meal replacement bars and drinks. Fatty and/or salty foods should be avoided.

d.  Rest and Recovery: The 2 air bottle rule, or 45 minutes of work time without SCBA (i.e. exterior overhaul), recommended as maximum times prior to mandatory rehab. Subjective and objective evaluation of a firefighter's fatigue level is additional criteria for rehabilitation time. Rest shall not be less than 10 minutes and may exceed an hour as determined by the R and may be accompanied by active cooling. Rest periods should last until normalization of vital signs within 20% of baseline1, and dependent upon working environment and medical evaluation by Rehab personnel. Crews shall not be signed out from the Rehab Sector until they adequately rested, evaluated, and released by the RO to the company officer.

2.  The IC responsible for assigning personnel to the Rehab Sector and must ensure adequate personnel available. The RO ensures appropriate rehabilitation procedures are followed and communicates any resource requests to the IC. Though the IC is responsible for the well-being of all personnel, the RO’s recommendations for rest and medical treatment (i.e. not returning to fireground operations) is penultimate.

3.  Companies are assigned to the Rehab Sector by the IC, SO or LO. Company officers should advise the IC when their personnel are in need of rehabilitation. Whenever possible, the entire Company should be assigned to the Rehab Sector as a group. Personnel should remain in the Rehab Sector for a minimum of 20 minutes before returning to duty and do not leave until directed by the RO.

G.  MEDICAL EVALUATION DURING REHABILITATION

1.  The Rehab Team must identify and treat medical problems early to reduce the main cause of firefighter morbidity and mortality: cardiovascular pathology.

2.  When arriving at the Rehab Sector, personnel remove all PPE practical for the circumstances and immediately have their vital signs obtained and documented. Even if vitals are within normal limits, they must be rechecked and documented prior to discharge from the Rehab Sector. Any abnormal vital sign needs to be rechecked at or near the 10 minute mark.

3.  The following criteria used in the evaluation personnel to determine release from Rehab or if there is a need to transport for further evaluation1:

a.  Systolic Blood Pressure: Ideally 150mmHg

b.  Diastolic Blood Pressure: Ideally <100mmHg

c.  Heart Rate: Ideally regular and <110bpm. Measured for 30 seconds early in the rest period. If 110bpm, immediately obtain a temperature. If <110bpm, there is minimal likelihood of heat stress.

d.  Respiratory Rate: Ideally: Unlabored and <24.

e.  Tympanic Temperature: Ideally <100.6o. If <100.6 but HR >110, increase Rehab Sector time. Temp >100.6oF requires reassessment after passive body cooling (removal of gear, fanning, cool water or mist application) If temp remains elevated, medical evaluation and transport are required.

f.  Carbon Monoxide: Ideally <5% (non-smoker), <10% (smoker)

g.  Mental Status: Ideally alert and oriented, able to have a brief conversation

4.  If vitals or clinical complaint / condition are concerning, a full evaluation is necessary, ideally by ALS personnel as treatment and transport is likely necessary.

5.  Medical treatment and transportation to the hospital is required:

a.  Vitals outside acceptable limits >20 mins or accompanied by clinical complaint(s).

b.  Chest pain

c.  Shortness of breath that does not resolve while in Rehab, hypoxia (O2 <95%) or elevated carbon monoxide (CO >10%).

d.  Evidence of heat or cold-induced injuries.