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Home My WebLink About203.005 - Rehabilitation for Fire Personnel STANDARD OPERATING PROCEDURES MANUAL HEALTH AND SAFETY 203.005 REHABILITATION FOR FIRE PERSONNEL EFFECTIVE: FEBRUARY 2019 Current Revision Date: 9/9/19 Next Revision Date: 9/9/22 Author’s Name/Rank: Kevin Reynolds, Fire Captain Review Level: 1 Administrative Support: Sherrie L. Badertscher, Management Analyst II Section 203.005 Page 1 of 10 PURPOSE To establish a standard and consistent method for the Fresno Fire Department (FFD or Department) members to identify, prevent heat-related emergencies, and carbon monoxide exposure. APPLICATION Rehabilitation (Rehab) will be a tactical requirement during emergency operations as well as training exercises, providing cooling, rehydration, rest, recovery, medical monitoring, and nutrition where strenuous physical activity and exposure to the elements occurs. OPERATIONAL POLICY 1. A formal Rehab unit will be established whenever the Adjusted Heat Index is 95 degrees or more and the anticipated operational period exceeds two (2) hours. 2. Members shall undergo rehabilitation following the use of a second 30- minute or 45-minute self-contained breathing apparatus (SCBA) cylinder, a single 60-minute SCBA cylinder, or 40 minutes of intense work without SCBA. 3. An Incident Commander shall have the ability to modify this policy under “extraordinary circumstances” (i.e., ongoing rescues, RIC deployment, building collapse, rapidly expanding uncontrolled incident). 4. According to the attached flow chart, when rehab is completed, no member shall be released to return to full duty without a medical provider’s evaluation when any one (1) of the following readings persists: Section 203.005 Page 2 of 10 • ANY symptoms including: chest pain, difficulty breathing, heat illness, and/or irregular heartbeats. • Temperature: > 100. • Pulse oximetry: < 95. • Heart rate: > 100 BPM. • BP: Systolic > 160 and/or Diastolic > 100. • CO oximeter reading if available: > 15% or greater. OPERATIONAL GUIDELINES All treatment and transport decisions should be based upon Central California EMS Policies and Procedures and the vital signs within the Rehab Flow Chart. While the establishment of a Rehab unit is based upon the Adjusted Heat Index and operational period, the incident commander (IC) may establish a Rehab group at a lower Adjusted Heat Index. The IC should consider assigning personnel to less strenuous work activities when limited resources are present to establish proper rehab within the first two (2) hours. This may require a change in strategy and/or operational mode. The Department recognizes two forms of rehab: 1. Self-Rehabilitation: Company Officers are responsible for the health and readiness of all crew members under their supervision. Self-Rehab and personal assessment should be performed both during and after strenuous activity or use of personal protective equipment (PPE) when the anticipated operational period is less than two (2) hours or the Adjusted Heat Index is less than 95°. Self-Rehab ensures all company members are given the opportunity to rehydrate and obtain nourishment as needed. Dehydration is preventable through consistent intake of water throughout a member’s shift as well as several hours prior to a shift as referenced on the attached hydration chart. Crew members should perform a brief personal assessment on one another ensuring the following: • No signs or symptoms of heat illness are present. Section 203.005 Page 3 of 10 • No prolonged fatigue or weakness is present that would affect operational readiness. Crew members exhibiting ANY of the above signs or symptom are to be assessed and treated immediately. 2. Formal Rehabilitation: All officers and ICs are to anticipate the need for Rehab during the initial planning stages of all incidents and training evolutions. A Formal Rehab is established in the following circumstances: • Whenever the Adjusted Heat Index is 95 degrees or more. • The operational period is anticipated to exceed two (2) hours. In addition to the EMS resources assigned to the operations section, the IC should assign a medical unit leader and sufficient EMS personnel to address the rehab needs of fire personnel. The IC should consider resources needed for extended rehab operations where multiple operational periods will occur or the incident covers a large geographic area. Community Emergency Response Team (CERT) or other fire personnel may be utilized to assist in establishing Formal Rehab for emergencies or training evolutions. These guidelines should be applied in accordance with Standard Operating Procedures Manual, Section 203.005a, Heat and Cold Stress Management. PROCESS Rehab begins at the lowest level incident or activity with Self-Rehab and progresses into a more formalized and extended operation to match the needs of an incident or training evolution. Goals: • Relief from climatic conditions. • Rest and Recovery. • Active and/or passive cooling or warming as needed for incident type and climate conditions. Section 203.005 Page 4 of 10 • Rehydration (fluid replacement). • Calorie and electrolyte replacement, as appropriate, for longer duration incidents. • Medical monitoring. • Member accountability. • Address any signs of acute emotional trauma. • Release. Steps: 1. Establish Rehab. a. Select a site at sufficient distance from the effects of the operation where members can safely remove their PPE and can be afforded physical and mental rest. b. Apply the Adjusted Heat Index from Chart 1 to determine Self or Formal Rehab. c. Determine work rest periods based on heat, projected incident duration, operational needs, and resource availability. 2. When Formal Rehab is utilized, companies report to Rehab with all members. a. Rehab personnel document members’ initials as well as vital signs utilizing an electronic fillable form or a Rehab Tracking Log. b. Rehab personnel triage companies using the Rehab Flow Chart 2. c. Rehab includes: i. Doff PPE. ii. Hydration. iii. Active and passive cooling. iv. Vital signs. Section 203.005 Page 5 of 10 v. Rest and recovery. d. Rehab chairs are to be placed in shade, close to cooling devices, battery-operated-electric fans, air-tube, or hood-cooling boxes. i. NO internal combustion powered fans are to be utilized to provide moving air. ii. CERT can provide cooling towels to be worn around the neck, and head, further allowing the decrease of a member’s core temperature. e. Members drink both water and electrolyte replacement drinks for the purpose of hydration. f. While in Rehab chairs, members should consider pulling PPE bottoms down past knees to allow more effective cooling. Vital signs are taken and members are treated following the Rehab Flow Chart. g. Nutritional snacks can be distributed at the incident by CERT or other assigned personnel and should be applicable to the season. Full meals may be provided by FFD personnel when incidents run through normal meal periods. h. The Rehab unit leader is to utilize the chain of command to notify the IC when a member must be evaluated by a physician. DEFINITIONS Self-Rehabilitation: One-company or member completion of a personal assessment utilizing the Rehab Flow Chart for vital signs. Formal rehabilitation: Multi-company Rehab involving the establishment of a Rehabilitation unit and the completion of an on-scene medical evaluation with documentation. Temperature: A temperature related to the mass of actual heat contained within a body. Tympanic temperature: A temperature reading taken within the ear using a non- invasive thermometer. Passive cooling measures: Steps taken to lower core temperature by removing PPE, moving out of direct sun light and heated environment, and provide cool drinks. Section 203.005 Page 6 of 10 Active cooling measures: Steps taken to rapidly decrease a person’s core temperature e.g., fans with misting water, cold towels around the neck, cooled IV fluids, cooled- air tubes, and cooled-air hood. Heat illness: Signs and symptoms related to heat exhaustion or heat stroke, including but not limited to: cramping, nausea, vomiting, lethargy, absence of sweating, and decreased mental status. Carbon monoxide oximetry: Similar to pulse oximetry, this is a means to measure the total amount of carbon monoxide within the blood. Heat index: A measure of heat and humidity the body feels. Adjusted Heat Index reading: The combination of outside air temperature plus humidity plus addition of PPE. Rehab personnel: Department members or EMS personnel assigned to Rehab unit with a minimum of one assigned ALS unit. Vital signs: As applied within this policy consist of; pulse, respiratory rate, blood pressure, and tympanic temperature and pulse oximetry. Carbon monoxide oximetry may be added. Cold weather conditions: The exposure of members to cold environments, wind chill, precipitation, perspiration, and wet PPE. Community Emergency Response Team (CERT): The Department’s response preparedness group who, as one of its responsibilities, responds to requests for incident support providing rehab for incident personnel. Personal assessment: A brief self-check performed by personnel, which includes assessment of dehydration based on the urine chart, fatigue, and vital signs in accordance with the Rehab Flow Chart. Return- to- work limits: Limits based on vital signs and symptoms found on the Rehab Flow Chart, which allow a member to continue working post rehab. Rehab chairs: Portable chairs with a mesh back and bottom to allow maximum air flow. Hood or tube cooling device: A supplemental device, which produces cooled air pumped thru hoods or tubes worn by members to increase cooling. Battery- operated- electric fans: Fans used to provide air movement over Rehab area to increase cooling of members. Section 203.005 Page 7 of 10 CROSS-REFERENCES California Code of Regulations (CCR) Title 8, Section 3395, General Industrial Safety Orders, Heat Illness Prevention. Central California EMS Policies and Procedures EMT protocols- 510.19 (BP low) 510.11 (Resp. Distress) 510.04 (O2 use) 510.27(hyperthermia) EMT-P protocols- 530.11 (PSVT) –non symptomatic treatment- sets parameters for HR> 100 and < 160(PSVT) <150, SVT 160-220) 530.16 Resp. Distress http://www.dir.ca.gov/title8/3395.html Standard Operating Procedure Manual Section 203.005, Heat Stress Management Protocol National Fire Protection Association (NFPA) 1584: Standard on the Rehabilitation Process for Members During Emergency Operations and Training Exercises (2015 Edition) Occupational Safety and Health Administration (OSHA) Heat Index Using the Heat Index: a guide for employers (colored charts with temp ranges) https://www.osha.gov/SLTC/heatillness/heat_index/ https://www.osha.gov/SLTC/heatillness/heat_index/pdfs/monitoring_workers. pdf Occupational Safety and Health Administration (OSHA) - Work/Rest Cycles https://www.osha.gov/SLTC/heatillness/heat_index/protective_measures.html URINE CHART: Perrier, E.T., Johnson, E.C., McKenzie, A.L. et al. Eur J Nutr (2016) 55: 1943. https://doi.org/10.1007/s00394-015-1010-2 Section 203.005 Page 8 of 10 Chart 1 Heat Index Reading for REHAB ADJUSTED HEAT INDEX = the Heat Index + 15 degrees if working in direct sunlight in PPE (i.e., temperature is 90 degrees + 30% RH = 105° ADJUSTED). HEAT INDEX = chart below, used to determine temperatures by adding the ambient temperature and the relative humidity. * Use of PPE will increase Heat Index reading by 10 degrees * Use of PPE in direct sunlight increases Heat Index by 15 degrees * All chart readings are based on temperatures taken in shade with light winds *CDC and Cal OSHA publications Section 203.005 Page 9 of 10 Chart 2 Flow Chart Formal Rehab Flow Chart Initial Actions Check in to rehab station Remove PPE Check vitals and record baseline Asymptomatic Temp 98-99.9o F Pulse 60-99 BP 160/100 ↓ SPO2 96-100% SPCO 0-15% Symptomatic Temp 100o F+ Pulse 100+ BP 160/100+ SPO2 ↓ 95% SPCO >15% Asymptomatic Temp 100o F+ Pulse 100+ BP 160/100+ SPO2 ↓ 95% SPCO >15% Activate passive cooling measures Initiate 20 minutes rest cycle Round 1: Retake vitals (record) Yellow Yellow Rest for 20 minutes Round 2: Retake vitals (record) Rest for 20 minutes Round 3: Retake vitals (record) Yellow Transport to Medical Provider Vitals not stabilized after 60 minutes of rest Green Green Green Return to Work Return to Work Return to Work Section 203.005 Page 10 of 10 Chart 3 Hydration Chart by Urine Color • Hydration begins THE NIGHT BEFORE GOING ON SHIFT. • Generally accepted guidelines dictate it takes TWICE as much water to rehydrate than what is being lost. • 6-8 ounces of water every hour at a MINIMUM will assist in proper hydration. • Once hydrated, individuals should expect to urinate every 60 minutes at a minimum. • If hydrating and urination has not occurred, continue hydrating until urination occurs. 1 Colors 1, 2, or 3 - might be Properly Hydrated Colors 4 or greater - DRINK MORE WATER! Colors 5 -8 - DANGER of dehydration, DRINK MORE WATER!!! 2 3 4 5 6 7 8