1 Developing an Emergency 1 Running head: DEVELOPING AN EMERGENCY INCIDENT FIREFIGHTER Developing an Emergency Incident Firefighter Rehabilitation Procedure for the Middletown, Connecticut Fire Department John Woron Middletown Fire Department Middletown, Connecticut
2 Developing an Emergency 2 Certification Statement I hereby certify that this paper constitutes my own product, that where language of others is set forth, quotation marks so indicate, and that appropriate credit is given where I have used the language, ideas, expressions, or writings of another. Signed:
3 Developing an Emergency 3 Abstract Firefighting is a strenuous and arduous profession. In the discharge of their duties, firefighters are routinely exposed to emotional, physical, physiological, and psychological stressors. Emergency incident firefighter rehabilitation programs are designed to mitigate or alleviate the effects of the fore mentioned stressors. Several studies have shown that proper firefighter rehabilitation during the active phases of emergency incident operations reduce both injuries and or death caused by thermal, mechanical or psychological insult on the body. As fore mentioned, although several studies have shown the positive benefits of a properly implemented emergency incident rehabilitation program, currently the Middletown Fire Department does not utilize a formal program. Through action research, the purpose was to investigate best practices used by area fire departments and develop a Standard Operating Procedure to address emergency incident firefighter rehabilitation in the Middletown Fire Department. The research answered the following questions: a) How are area fire departments conducting emergency incident firefighter rehabilitation? b) What standards and recommendations exist for emergency incident firefighter rehabilitation? c) What discrepancies currently exist in the method the Middletown Fire Department utilizes to conduct emergency incident firefighter rehabilitation? d) How can the existing emergency incident rehabilitation procedures utilized by the Middletown Fire Department be incorporated into a comprehensive Standard Operating Procedure? Utilizing a comprehensive literature review, internal and external questionnaires, and peer interviews, the research concluded that not only was there a need for a comprehensive emergency firefighter incident rehabilitation Standard Operating Procedure, but also a change in the department s culture concerning rehabilitation. A draft Standard Operating Procedure was developed and presented to the Fire Chief for consideration for approval.
4 Developing an Emergency 4 Table of Contents Certification Statement 2 Abstract 3 Table of Contents.4 Introduction..5 Background and Significance..6 Literature Review.9 Procedures..19 Results 21 Discussion and Implications..28 Recommendations..37 References..39 Appendix A 41 Appendix B 45 Appendix C 47 Appendix D 48 Appendix E 53 Appendix F 55 Appendix G 62 Appendix H 63
5 Developing an Emergency 5 Introduction Firefighting is a strenuous and demanding profession that often times leads to injuries due to environmental stressors and over exertion. Firefighters are required to operate in combative conditions while wearing several additional pounds of protective clothing and equipment. Increased emotional, physical, and psychological stress coupled with increased exertion levels can quickly lead to over-exertion related medical emergencies or injuries. Advancements in protective firefighting clothing have become a double edged sword to the fire service. While this state of the art protective clothing provides better protection, it also has a tendency to trap a firefighter s body heat and sweat which becomes a cumulative physiological stressor. The fire service is steeped in tradition. For years firefighters have accepted injury and even death as an inherent part of their job, even a badge of courage. Fire departments largest fixed cost is its personnel. Beyond the empathetic and compassion aspects of firefighter injuries lies the financial impact to a department and municipality as a result of firefighter injuries and deaths. In 2010, 85 firefighters died in the line of duty, 61% of these deaths were attributed to stress and overexertion related activities (United States Fire Administration, 2010). The National Fire Protection Association identified 32,205 firefighter injuries on the fire ground during the 2009 calendar year with 2,650 or 8.4% of the total injuries being attributed to stress and overexertion. The problem is that the Middletown Fire Department does not currently possess a Standard Operating Procedure addressing emergency incident firefighter rehabilitation. Currently firefighter rehabilitation at emergency scenes is accomplished in a very inconsistent manner. The purpose of this research study is to investigate best practices used by area fire departments and develop a draft emergency incident firefighter rehabilitation operating procedure.
6 Developing an Emergency 6 This research project will utilize action research to assist in answering the following questions: a) How are local fire departments conducting emergency incident firefighter rehabilitation? b) What standards and recommendations exist for emergency incident firefighter rehabilitation? c) What discrepancies currently exist in the method the Middletown Fire Department utilizes to conduct emergency incident firefighter rehabilitation? d) How can the existing emergency incident rehabilitation procedures utilized by the Middletown Fire Department be incorporated into a comprehensive Standard Operating procedure? Background and Significance The Middletown Fire Department provides a diversified all hazards response to a city of 60,000 residents and visitors each day. The City of Middletown is centrally located in the State of Connecticut, is bordered to the east by the Connecticut River and is transected by two Interstate Highway Systems. The City of Middletown is comprised of 42 square miles and is diversified to include urban, suburban and rural areas. Middletown is located in the Hartford- Springfield Metropolitan Region which includes a population of 1.9 million people. The Middletown Fire Department (MFD) staffs four shifts of fourteen personnel per shift. The MFD is a fully career fire department. All members are certified Emergency Medical Technicians and are contractually required to be trained to the NFPA 1001 Firefighter II level. The MFD provides service from two fire stations. Services include fire, rescue, emergency medical services, fire prevention, education, technical rescue, dive rescue, and marine operations. Emergency responses are handled by one Battalion Chief, three Engine Companies,
7 Developing an Emergency 7 one Truck Company, and one Assistant Chief/Safety Officer. The Middletown Fire Department (MFD) runs close to 5,000 emergency calls each, approximately 60% which are medical based in nature. The City of Middletown enjoys a distinct four season climate. Winter temperatures average 25 degrees Fahrenheit with extreme low temperatures below zero at times, while summer temperatures average in the mid 80 degree Fahrenheit range with typically 10 or more days above 90 degrees. Average precipitation is 55 inches where winters typically average around seventy inches of snowfall. Weather extremes can create year round firefighter rehabilitation challenges for MFD personnel operating at incidents that are labor intensive. These include but are not limited to; structural fires, motor vehicle extrications, technical rescue incidents, hazardous materials incidents, long duration EMS incidents, and long term deployments. At the present time the Middletown Fire Department does not possess a formal emergency incident firefighter rehabilitation Standard Operating Procedure (SOP). Without a formal SOP in place, firefighter rehabilitation is completed at the discretion of the Incident Commander or immediate supervisor. Because there is no SOP in place, rehabilitation is never performed in a consistent manner from shift to shift. In the warmer months rehabilitation takes the form of firefighters taking a break, removing their protective clothing, and re-hydrating with water. In the colder months rehabilitation consists of getting cold, wet, or tired firefighters out of the cold and into a warm environment. Although the Middletown Fire Department possesses a hazardous materials decontamination trailer which can be utilized as a warming or cooling vehicle, it is not a front line manned apparatus and must be special called. In
8 Developing an Emergency 8 most instances on scene engine and truck company apparatus are utilized as the vehicles to warm or cool the firefighters during rehabilitation. Not possessing an adequate and consistent rehabilitation SOP is potentially putting Middletown Fire Department personnel at risk of injury or even death from stress or overexertion. At many emergency incidents, firefighter rehabilitation becomes an after thought. Because of pre-established cultural norms, firefighters tend to look at rehabilitation as a weakness, thus they attempt to avoid rehabilitation whenever possible. Without an SOP to utilize as a benchmark and a policy to enforce, many Shift Commanders and Company Officers will look the other way and not activate or enforce rehabilitation for the personnel resources assigned to them. Firefighters do not want to take needed work breaks, thus they can overexert themselves which can jeopardize their health and safety. As fore mentioned, the (United States Fire Administration) reported that 61% of the 2010 Firefighter Line Of Duty Deaths were attributed to stress and overexertion. Bledsoe (2008) states: Rehabilitation should be an integral part of the IMS for both the fire ground and training exercises. Rehabilitation should commence anytime emergency or training operations pose the risk of department members exceeding a safe level of mental or physical endurance. (p. 3) While the safety culture in the fire service can be slow to change, there are several agencies and organizations which have championed firefighter safety. One such group is the National Fire Academy s (NFA) Executive Fire Officer Program (EFOP). The Executive Development Course identifies three primary curriculum themes; leadership, research, and change. Translated into a safety message, true fire service leaders champion research and positive change to ensure
9 Developing an Emergency 9 firefighter health and safety is always the highest priority for their organizations. The United States Fire Administration (USFA) is another strong proponent of firefighter health and safety. In a 2008 report to Congress, the USFA identifies one of its key objectives is to significantly reduce the nation s loss of life from fire, while also achieving a reduction in property loss and non-fatal injury due to fire (p. 1). This reduction in the loss of life from fire and injuries includes the fire service. With over 50% of line of duty deaths and over 2,600 injuries annually contributed to stress and overexertion, possessing a comprehensive emergency incident firefighter rehabilitation procedure is imperative. Literature Review A literature review was conducted to research current emergency firefighter rehabilitation programs and rehabilitation program recommendations. The information gathered in this literature review was used to assist the author in preparing a draft Standard Operating Procedure (SOP) for emergency incident firefighter rehabilitation in the Middletown Fire Department (MFD). The idea to create this new SOP to address emergency incident firefighter rehabilitation was presented to MFD Fire Chief Ouellette; the selling point was current documentation of several agencies linking overexertion and stress on the fire ground with an increased risk of injury or even death. Knowing that any fire department s greatest asset is its personnel, the chief agreed to allow the author to research and create a draft SOP. The greatest benefit of a new rehabilitation SOP would be a consistent model to follow for each of the four platoons of the MFD. Firefighting can be compared to the scene from the 1994 movie Forrest Gump. While waiting for a bus, Forrest quotes (IMDb, 1994) how his momma always said, life was like a box of chocolates, you never know what you re gonna get (p. 3). Each and every day, firefighters
10 Developing an Emergency 10 are required to respond to a myriad of emergency calls. Emergency incidents have no bounds; they take place day or night, holidays, week days and weekends. Firefighter stressors can come in the form of physical, physiological, environmental or a combination of each. The United States Fire Administration (USFA) publication Emergency Incident Rehabilitation (2008) speaks to these issues: Unlike many jobs, firefighters cannot pick the time or conditions these jobs must be carried out. When you combine the inherent stresses of handling emergency incidents with the environmental dangers of extreme heat and humidity or extreme cold, you create conditions that can have an adverse impact on safety or health of the individual emergency responder. Members who are not provided adequate rest and rehydration during emergency operations or training exercises are at increased risk for illness or injury, and may jeopardize the safety of others on the incident scene. (p. 3) Why do firefighters resist being sent to emergency incident rehabilitation? The fire service is a tradition driven fraternity, many times you hear firefighters quote the fire service, 200 years of tradition unimpeded by progress. Many in the fire service live by the macho creed that injuries and even death are collateral risk of being a firefighter. Dickinson and Wieder (2004) refer to this phenomenon as a badge of courage that is worn with pride. While this might have been an acceptable practice and attitude at one time, the safety culture of the fire service finally seems to be shifting away from this type of behavior. Many fire service organizations including the United States Fire Administration (USFA), National Fire Protection Association (NFPA), International Association of Fire Chiefs (IAFC), and International Association of Firefighters (IAFF) have produced research studies and supporting documentation championing the benefits of emergency incident firefighter rehabilitation.
11 Developing an Emergency 11 In the foreword section of the Bledsoe (2008) Rehabilitation and Medical Monitoring Standard, Gary Ludwig points out that annually approximately 50% of firefighter deaths continue to be attributed to heart attack and strokes. Line of Duty Death (LODD) research has begun to show a correlation between heavy exertion, stress, fatigue and smoke inhalation and cardiac based LODD s and injuries. Whether career or volunteer, many fire departments operate with limited power and staffing levels. This translates into fire departments having to juggle sending firefighters to rehab while having enough manpower available to continue to handle the given emergency. Many times these limited manpower situations force Incident Commanders to push their personnel to extremes, thus exposing firefighters to possible overexertion or stress related emergencies. Wolf (2007) writes: NORMal leaders subject their two or three person companies to more physical punishment and greater risk of injury because of a lack of sufficient staffing to perform the many tasks required on the fireground. Fire fighters on understaffed departments go through three or four air bottles before the fire is knocked down because insufficient staffing prevents rotating crews through rehab or distributing the workload among more engine companies. (p. 1) Many different professions require their personnel to properly prepare themselves for exertion based activities. Professional sports teams are a good example. These teams assign trainers, doctors, and other wellness based personnel to ensure their athletes are properly stretched, hydrated, receive proper caloric intake and are mentally and physically ready for the ensuing event. Many fire departments have realized the benefits associated with health and safety programs and practices directed at ensuring on duty personnel are fit for duty at any given time.
12 Developing an Emergency 12 Bledsoe (2008) summarizes health risks can be reduced through sufficient hydration, diet, limited outdoor physical exercise on hot days, acclimatization, and monitoring of weather conditions. This will help department members understand the dangers associated with working in varying climatic conditions (p. 6). One of the most important aspects of a quality rehabilitation procedure is knowing when to establish it. The Incident Commander must walk the fine line between waiting too long and running the risk of overexerting personnel or removing line personnel and sending them to rehab and creating a manpower shortage. Many fire departments that utilize an emergency incident rehabilitation program front load emergency incidents with adequate levels of manpower. This is achieved through extra stand-by companies or through the use of automatic or mutual aid. Another important initial decision is where to locate the rehabilitation sector. This area needs to be close enough to the emergency incident to facilitate the needs for on scene resources that need to be utilized but far enough away from the emergency incident to ensure that emergency personnel are not attempting to leave rehab to re-enter the hot zone to work again. Once the decision to formally establish emergency incident rehabilitation is made, a strict accountability system must be implemented. Dickinson and Wieder (2004) explain Responders staffing rehab must understand how their department s accountability system operates and must make sure that all personnel in rehab strictly adhere to accountability procedures. (p. 16) One of the most efficient systems to track personnel in and out of rehab is with the use of an accountability document or form. Although most individual departmental accountability forms differ, certain generic information should be standard. This would include; name, organization represented, rank, crew or individual assignment, time in, time out, numbers of self-contained
13 Developing an Emergency 13 breathing cylinders used, time of initial medical evaluation, heating or cooling interventions, hydration or nourishment, medical complaints, medical interventions, and any recommended hospital transport. Lindsey (2009) suggests that when being sent to rehab that crews remain intact both entering and leaving. This ensures that individuals do not get separated from their assigned work group. Although many emergency incident firefighter rehabilitation models exist, most are tailored to each individual organization. With that being said, there still remains specific benchmarks that should be met regardless of the template used. These include; accountability, medical monitoring, relief from climatic conditions, active and/or passive warming or cooling, rest and recovery, rehydration, caloric and electrolyte replacement, initial critical incident stress debriefing, EMS treatment or transport, and release or reassignment. Medical monitoring is one of the gray areas of emergency incident firefighter rehabilitation. Predominately there are two methods for medical monitoring. It can be done by EMS trained department personnel or EMS personnel from outside the organization. Most firefighters when asked about medical monitoring prefer to have members from their own organizations performing this assignment. The first and most important step in medical monitoring is documentation. Bledsoe (2008) clearly identifies the delineation between medical monitoring and emergency medical care documentation. When a firefighter enters rehab and undergoes medical monitoring, this information is maintained as part of the incident record in the department s data collection system. If a firefighter receives emergency medical care, this information must be kept by the entity providing the care and a copy put in the individuals medical file.
14 Developing an Emergency 14 Medical monitoring must include an initial assessment of the firefighter s vital signs beginning with heart rate. It appears that the consensus threshold is 100 beats per minute at the twenty minute rehab mark. If the firefighter s heart rate has not dropped to under 100 beats per minute after 20 minutes of rest, then the firefighter should not be released from rehab and should undergo further medical evaluation. While many studies recommend body core temperature readings, this becomes very impractical during rehab. Oral and tympanic methods of measurement are the only practical options, but can be anywhere from one to three degrees cooler than the core body temperature. For this reason, many organizations do not utilize temperature monitoring during rehab. Respiratory rate is another suggested vital sign that should be monitored in rehab. While a normal adult respiratory rate is 12 to 20 breaths per minute, firefighters entering rehab will most likely have respiratory rates above 20 breaths per minute. After adequate rest and rehab these respiratory rates should return to normal levels prior to the firefighter being released from rehab. Many fire departments check their members pulse oximetry. Normal oxygen saturation runs between 95% and 100%. Members who fall under 95% oxygen saturation should be checked for hypoxemia, and may require oxygen therapy to restore their oxygen levels to normal. While being considered relatively new technology, many fire departments are beginning to also check personnel for carbon monoxide saturation and cyanide exposures. Both blood gases have been linked to sudden cardiac events in stressed and overexerted firefighters. The last vital sign that most departments check during medical monitoring is blood pressure. Blood pressure measurement is one of the most controversial rehab monitoring medical checks. Bledsoe (2008) states: Blood pressure measurement has a significant potential for error, especially in the noisy
15 Developing an Emergency 15 and tumultuous prehospital environment. Blood pressure cuffs, like other medical devices applied repeatedly to multiple, often sweaty and grimy people, are implicated in spread of antibiotic-resistant bacteria between individuals. Members of ethnic and racial groups respond very differently to physiological stress, sometimes with dramatic increases in blood pressure blood pressure can be affected by cardiac rhythm, physical conditioning, pain, temperature, age, sex and a variety of internal and external stimuli. (p. 34) It is for these reasons that many fire departments are no longer measuring blood pressures. For those who continue to monitor blood pressure, individuals with systolic readings above 160 and diastolic readings above 100 after 20 minutes are not released from rehab and are referred for continued medical monitoring. Most firefighter rehabilitation models recommend vital signs being checked every 10 minutes. When performing emergency incident firefighter rehabilitation, it is important to assess how personnel will be sheltered or removed from climatic conditions. These conditions can occur in the form of heat, humidity, cold, rain, snow, and ice to name a few. Facilities, vehicles or other areas that firefighters will be removed to becomes dependent upon the availability of these resources and the duration of the emergency. USFA Emergency Incident Rehabilitation (2008) states The use of fixed facilities is especially helpful on long-term incidents and in wet or otherwise extreme climatic conditions. Buildings with large, open spaces immediately adjacent to entrance/exit doors make the best rehab areas. (p. 96) Many times these types of structures provide the benefit of climatic controlled areas, running water, restroom facilities, and kitchen facilities. When fixed facilities are not an option, most fire departments will utilize fire apparatus or vehicles as an avenue to remove their personnel from adverse climatic conditions. Examples of
16 Developing an Emergency 16 apparatus are; fire pumpers, aerial apparatus, heavy rescue apparatus, ambulances, or other ancillary fire department vehicles. One option that seems popular is to utilize buses. A bus works well for several reasons, several firefighters can be housed in a single bus, the interiors are usually rugged enough to handle dirty or wet protective clothing, and an open aisle way makes medical monitoring easier for EMS personnel assigned that task. USFA Emergency Incident Rehabilitation (2008) points out Most of these buses are equipped with heating and air conditioning systems that allow the interior climate to offset adverse exterior weather conditions and allow firefighters to doff their equipment for maximum rest and recovery (p. 101) Many fire departments have carried this idea forward and utilize converted busses as their organizations rehab vehicle. Active/passive heating and cooling relates to the methods used to heat or cool firefighters in rehabilitation. Passive heating or cooling is defined as allowing the firefighter to reheat or cool on their own with no intervention. This can be as simple as bringing firefighters into the rehab area and having them doff their gear to begin to cool off or enter a warm environment to supplement rewarming. Active heating and/or cooling requires intervention to assist the firefighters achieve the desired results. Smith and Haigh (2006) describe active cooling as implying external means of lowering core body temperature and includes cold towels, hand and forearm immersion, misting fans and tents, and ice vests. The most effective are cold towels and forearm immersion. (p.3) Active heating can be achieved by removing firefighters from their wet gear, applying warm blankets, and providing warm foods or beverages. Both active heating and/or cooling may take longer to achieve, thus requiring the firefighter to remain in rehab for a longer period of time.
17 Developing an Emergency 17 Rest and recovery periods are dynamic to the given emergency. Most rehabilitation programs recommend rest and recovery times to be driven by SCBA cylinder use or periods of intense work. Bledsoe (2008) recommends: Personnel entering rehab for the first time should rest for at least 10 minutes-longer when practical. A member should not return to operations if he or she does not feel adequately rested. Personnel should rest for a minimum of 20 minutes following use of a second 30- minute SCBA cylinder, a single 45 minute SCBA cylinder, a single 60-minute SCBA cylinder, or 40 minutes of intense work without an SCBA. (p. 16) Hydration, electrolyte, and caloric replacement becomes imperative during firefighter rehabilitation. While caloric replacement may be tied to longer term emergency incidents, basic hydration and electrolyte replacement takes place during all emergency firefighter rehabilitation periods. The USFA Emergency Incident Rehabilitation (2008) report discusses how the human body can lose as much as a liter of sweat per hour when being subject to extreme exertion related activities. Bledsoe (2008) takes this theory further by discussing how firefighter gear interferes with the body s heat exchange by trapping moisture between their skin and the inner most level of protective clothing, this causes an even greater fluid loss Firefighters can easily lose 32 ounces of sweat in less than 20 minutes of strenuous firefighting activities. In addition, sweating will continue even after a firefighter stops working and enters rehabilitation. (p. 26) Smith and Haigh (2006) recommend that plain water be the choice of fluid replacement during firefighter rehabilitation. Tracking how many bottles of water each firefighter consumes affords a simple method of tracking consumption. For longer work periods, electrolyte replacement needs to be considered. This is usually accomplished with sports drinks. When used as a replacement fluid during rehabilitation, sports drinks should not be diluted. Dilution of
18 Developing an Emergency 18 sports drinks causes them to lose their osmolarity which in return causes them to lose their absorption qualities. This can lead to nausea or vomiting which will accelerate dehydration. Caffeinated and carbonated drinks should also be avoided, as they have a tendency to accelerate fluid loss in the firefighter. Most studies agree that caloric replacement should be considered for long duration incidents or extreme work periods of over an hour. Bledsoe (2008) suggests that firefighters in rehabilitation requiring caloric intake consume between 30 and 60 grams/hour of carbohydrates. Smith and Haigh (2006) point out that foods used for caloric replacement should be low in fat and appropriate for the activity. Foods like pizza, donuts, and fast food should be avoided. To reduce the chance of contamination, water or waterless hand cleaner and towels should be available to anyone required to eat during rehab. Firefighter well being and mental health should also be assessed during emergency incident rehabilitation. Personnel should be closely observed for any contraindicated behaviors. Bledsoe (2008) suggests: If one or more members of a crew or company are seriously injured or killed during an incident, all members of the crew or company should be removed from emergency responsibilities at the incident as soon as possible. Again, services of competent, licensed mental health personnel should be made available to members of the department. (p. 38) As firefighters have spent the appropriate amount of time in rehabilitation, they must receive a final medical monitoring check. At this point three options are available for personnel in rehabilitation. They can be eligible for release and reassignment, a need for more time in rehabilitation, or medical transport to a hospital due to medical contraindications. All of the emergency firefighter rehabilitation models researched concurs that a sufficient amount of
19 Developing an Emergency 19 transport ambulances should be available on scene. If a firefighter needs to transported to the hospital, all medical information generated during rehabilitation and at the hospital must be included in the member s personal medical file. Whether released from rehab or sent to the hospital, member accountability must be thoroughly maintained throughout the rehabilitation process. At the conclusion of the emergency incident, all information generated during rehab should be retained and cross referenced to the incident documentation. Through several firefighter health and safety initiatives, the fire service has proactively tackled the issue of emergency incident firefighter rehabilitation. Researching materials for this literature review, the author found a wealth of firefighter rehabilitation procedures, reports, and recommendations. It is the charge of the fire service to utilize these resources to research, develop and implement emergency incident firefighter rehabilitations programs for their own individual organizations. Procedures Research for this project was conducted utilizing action research and an extensive literature review. The goal of this action based research and literature review was to seek, review and collect data to assist in producing a draft Standard Operating Procedure (SOP) for emergency incident firefighter rehabilitation for the Middletown Fire Department. Two feedback surveys were prepared; one survey was distributed to nineteen fire officers within the Middletown Fire Department (MFD). The goal of this internal survey was to determine what parameters each officer utilizes when making the decision to provide emergency firefighter rehabilitation even though the department presently operates without a formal SOP.
20 Developing an Emergency 20 The second survey was designed to obtain information from twelve other fire departments and the Connecticut State Fire Academy (CFA) as to how they provide emergency firefighter rehabilitation for their organizations. The literature review looked at several articles found both on the Internet and fire department trade journals. Three specific documents were extremely helpful in providing relevant rehabilitation information, these include; Emergency Incident Rehabilitation by Dickinson and Wieder (2004), Bledsoe, A Guide for Best Practices Rehabilitation and Medical Monitoring (2008) and United State Fire Administrations Emergency Incident Rehabilitation (2008). The three fore mentioned publications are specifically designed to address and make recommendations for the implementation of emergency incident firefighter rehabilitation. The survey that was developed for dissemination within the MFD was hand delivered to each officer by the author. Each member given a survey was briefed on the background of this Executive Fire Officer Research Paper and how the information obtained from the survey would be used to help construct a new emergency firefighter rehabilitation program for the MFD. Although the survey was distributed to nineteen fire officers, only eleven of these officers typically have the authority to initiate emergency rehabilitation. The other eight officers were allowed to participate in the survey because during extreme emergencies, they could have the potential to cover as an Acting Shift Commander or Incident Commander. The author received nineteen surveys back which created a 100% participation rate. Because the eight junior Fire Lieutenants had not yet worked in the capacity of Incident Commander or Shift Commander at emergencies requiring emergency firefighter rehabilitation, they did not participate in the survey. A copy of this internal survey is shown in Appendix B of this paper. A total of seven questions were asked, Appendix E lists the complete results of the survey.