How To Develop A Draft Fdny Emergency Incident Rehabilitation Sop

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1 Developing a Standard 1 Running head: DEVELOPING A STANDARD OPERATING PROCEDURE FOR Leading Community Risk Reduction Developing a Standard Operating Procedure for Emergency Incident Rehabilitation in the City of New York Fire Department Toni M. Lanotte New York Fire Department New York, New York February 2006

2 Developing a SOP 2 CERTIFICATION STATEMENT I hereby certify that this paper constitutes my own product, that where the 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 a SOP 3 Abstract The National Fire Protection Association (NFPA), the International Association of Firefighters (IAFF) and the United States Fire Administration (USFA) have addressed the need for emergency incident rehabilitation in order to reduce firefighter illness and injuries. The problem was the City of New York Fire Department (FDNY) did not have a standard operating procedure for emergency incident rehabilitation. The research purpose was to develop a draft FDNY Standard Operating Procedure (SOP) for emergency incident rehabilitation. Action research was employed to answer the following questions: Why is there a need for emergency incident rehabilitation? What aspects of emergency incident rehabilitation currently used by other fire departments would be applicable to an SOP for FDNY? What independent actions do FDNY chief officers currently do at emergency incidents to try and rehabilitate personnel? The procedures included literature review, a review of emergency incident rehabilitation SOPs from other fire departments, and interviews with FDNY EMS chief officers. The results identified deficiencies in how rehab was being conducted at FDNY and provided information for developing a draft FDNY SOP for rehabilitation at emergency incidents. The draft SOP provided FDNY with guidelines for proper operation of a rehab sector. The main functions included rest, hydration, medical monitoring, active cooling and accountability. It was recommended to implement the new SOP prior to the next summer season in conjunction with station house training. A study should also be conducted to measure the effectiveness of the rehabilitation SOP in reducing fire ground injuries and/or cardiac incidents. Fire departments that currently have SOPs in place for emergency incident rehab should periodically update those policies as new research becomes available.

4 Developing a SOP 4 Table of Contents Certification Statement 2 Abstract 3 Table of Contents.4 Introduction..5 Background and Significance...5 Literature Review.7 Procedures..16 Results 18 Discussion..22 Recommendations..23 References..25 Appendix A 27

5 Developing a SOP 5 Developing a Standard Operating Procedure for Emergency Incident Rehabilitation in the City of New York Fire Department Emergency response and operation at incidents for a firefighter is a mentally and physically demanding profession. Firefighters are often required to work long hours while carting and operating heavy tools and equipment. Bulky protective clothing and self contained breathing apparatus (SCBA) place additional stress on the body. These factors are often coupled with environmental dangers of extreme heat and humidity. These conditions can result in fatigue, which can impact the health and safety of the firefighter (Federal Emergency Management Agency [FEMA], 1992). The National Fire Protection Association (NFPA), the International Association of Firefighters (IAFF) and the United States Fire Administration (USFA) have addressed the need for emergency incident rehabilitation in order to reduce firefighter illness and injuries. The problem is the City of New York Fire Department (FDNY) does not currently have a standard operating procedure for emergency incident rehabilitation. The research purpose is to develop a draft FDNY Standard Operating Procedure (SOP) for emergency incident rehabilitation. Action research was employed to answer the following questions: Why is there a need for emergency incident rehabilitation? What aspects of emergency incident rehabilitation currently used by other fire departments would be applicable to an SOP for FDNY? What independent actions do FDNY chief officers currently do at emergency incidents to try and rehabilitate personnel? Background and Significance FDNY covers the 900 square miles of New York City providing service to a population of 8,000,000 residents. The department responds to over 1,000,000 emergency incidents per year. These incidents include working fires, hazardous materials incidents, motor vehicle

6 Developing a SOP 6 crashes and medical emergencies. Temperatures in the summer can exceed 90 degrees Fahrenheit with a heat index over 100 when factoring in relative humidity. During the operation of their duties, the firefighters are at increased risk for heat stress due to their heightened level of activity. This causes a marked increase in their cardiorespiratory rates and metabolic heat production (Baker, Grice, Roby, & Matthews, 2000). It is necessary for firefighters to wear firefighting protective clothing (FPC) and SCBA while operating at many of these incidents, in order to provide protection from fire, sharp objects, flying debris and toxic substances. This clothing is heavy, multilayered, and bulky, and limits the firefighter s ability to maintain a normal body temperature. While the design of the clothing offers an increased protection from extreme environmental heat for short periods of time, it exacerbates the challenge of thermoregulation because the design of the FPC hampers the firefighter s normal cooling mechanism of evaporating perspiration (McLellan, Jacobs, & Bain, 1993). This has a direct impact on the ability of the firefighter to maintain his/her core body temperature which can result in heat stress. Signs and symptoms of heat stress can vary from mild to life threatening and begin with fatigue. This can reduce the firefighter s reaction time and diminish their ability for critical decision making; thus, putting them at greater risk for illness and injury (FEMA, 1992). An emergency incident rehabilitation SOP provides guidelines to officers for properly operating a rehabilitation sector at emergency incidents, and provides a clear scope and purpose. The FDNY does not currently have an emergency incident rehabilitation SOP. This results in inconsistency as to how or when an emergency incident rehabilitation sector is set up. This was demonstrated in interviews I conducted with numerous chief officers regarding rehabilitation sector operations at emergency incidents. There is a lack of familiarity of all the resources

7 Developing a SOP 7 available, and the importance the rehabilitation sector provides in decreasing injury to department personnel. The rehabilitation sector is seen more as a rest and relaxation area where the American Red Cross (ARC) and the Salvation Army (SA) provide coffee and donuts, and chaplain services provide counseling. Only a few of the chiefs interviewed understood the most important aspect of the rehabilitation sector should be the medical monitoring and oversight of the personnel to ensure proper hydration, nutrition and body temperature. Even fewer chiefs discussed how the rehabilitation sector should work hand in hand with the incident commander to ensure proper rotation of resources and prevent over exertion of the personnel. The Leading Community Risk Reduction course of the National Fire Academy s Executive Fire Officer Program is intended to prepare the fire service executive to be personally committed to the philosophy of prevention (Federal Emergency Management Agency [FEMA], 2004, p. SM0-17 unit 0). In order to set the example for the community we serve, it is important to demonstrate those same risk reduction strategies within our own department. My research will examine emergency incident SOPs and current practices from other fire departments. The procedures that are applicable to FDNY will be utilized to provide a draft SOP which will aid the department in its effort to be more proactive than reactive in promoting firefighter safety (Department of Homeland Security U.S. Fire Administration National Fire Academy, 2003, I-3). The emergency incident rehabilitation recommendations of FEMA and USFA will also be reviewed to ensure they are included in the FDNY draft SOP. Literature Review A literature review was conducted to provide a summary of findings of others as it relates to emergency incident rehabilitation. The review would also provide perspectives from other fire departments regarding their SOPs for emergency incident rehabilitation. Interviews

8 Developing a SOP 8 with FDNY chief officers would provide insight as to their experience with emergency incident rehabilitation as it currently exists in FDNY. A systematic approach for the rehabilitation of fire department members at emergency incidents should be outlined in a SOP (Foley, 1998, p. 76). This will provide the necessary guidelines for fire service personnel to follow, in setting up an emergency incident rehabilitation sector. The primary goal of incident rehabilitation is to prevent injuries by providing crew rest, hydration and nourishment in a timely, organized fashion (Dodson, 1999, p. 166). The main objectives of rehabilitation are to provide an on-scene screening process to help determine if any personnel operating there are in danger of collapsing because of cardiovascular complications, and to monitor how firefighters are reacting physiologically and emotionally to the stress of the particular operation (Sachs, 2001, p. 75). Establishing a rehabilitation SOP can be established with minimal impact on human, fiscal, and equipment related sources (FEMA, 1992). This will foster the firefighter life safety initiatives of enhancing the organizational accountability for health and safety in the fire service (National Fallen Firefighters Foundation, 2004). A number of studies were conducted on the effects of heat stress to firefighters while operating in FPC and encapsulated hazardous materials suits. The thick, bulky garments which are designed to protect the firefighter from external heat sources and hazardous materials, also prevent the body from being able to dissipate the metabolic heat generated from exertion. The McLellan study in Toronto (2001), examined firefighters operating in controlled conditions, similar to the warm weather they experience in the summer. This study occurred over a period of two years. He found that in temperatures exceeding 25 degrees Celsius (77 degrees Fahrenheit), a firefighter s tolerance for increase in heart rate and body temperature was greatly decreased. He also discovered that a firefighter s subjective feelings of comfort cannot be used

9 Developing a SOP 9 as indicators of heat stress being experienced by the firefighter. Even when heart rates decreased after 30 minutes of passive recovery, their core body temperatures were found to still increase by as much as 0.5 degrees Celsius. This could put them at risk for collapse if they were to redon their FPC and return to an active work status. The second part of the study focused on cooling and hydration strategies that would optimize firefighter s performance. It examined the effects of no fluid to full fluid replacement in addition to either passive cooling, active cooling with either a fan or mister, or forearm and hand submersion in 18 degrees Celsius (64.4 degrees Fahrenheit) water. The results showed that full fluid rehydration with fluids by mouth increased performance by 15%. However, rehydration coupled with passive cooling did not stop the body s core temperature from rising 0.2 degrees Celsius. When active cooling was conducted where the hands and forearms were submersed in water, the body s core temperature dropped 0.5 degrees Celsius and performance was increased by almost 100%. The submersion technique out performed the fan and mister cooling, because in humid weather, the body does not receive the benefits of the evaporative cooling effect provided by the fan and misters. This study demonstrated that based on the increase in heart rate and body core temperature after a short duration, it is important to employ the rehabilitation procedures to include rehydration and submersion of the hands and forearms in water to assist the body in returning to its normal temperature (McLellan, 2004, p ). Another study was conducted (Smith, Manning, & Petruzzelo, 2001) that examined the amount of strain placed on the cardiovascular system during firefighter activities. The cardiovascular demands of heavy muscular work, and increased body temperature result in competing demands for blood flow to the muscles, the skin in an attempt to dissipate the

10 Developing a SOP 10 metabolic heat buildup within the muscles, and the vital organs including the brain and heart. While many studies in the past have shown heart rate to meet maximal rates quickly and remain elevated during firefighting activities, this study concentrated on the effect of the pumping capacity of the heart. This is known as stroke volume (SV) and is defined as the amount of blood ejected from the heart with each beat. The firefighters were put through a series of three trials of standardized firefighting tasks in a hot environment. Each trial lasted seven minutes and they performed the tasks in FPC and SCBA. An air bottle change was conducted after the first trial, rested for ten minutes after the second trial and rested completely after the third trial. The results showed that their heart rate increased immediately and SV decreased after the second trial by approximately thirty-five percent, and did not return to normal even after ten minutes of rest. It was determined that the decrease in SV was due to a combination of decreased venous return caused by vasodilation of the vessels and a reduction in plasma volume due to the increased sweating. This study showed the importance of cardiac monitoring for firefighters as part of the emergency incident rehabilitation in addition to sending firefighters to the rehabilitation sector at an incident after working through no more than two air bottles. This coupled with keeping firefighters hydrated and re-hydrated at all times will decrease the chances of cardiovascular collapse during or right after an emergency incident. Another study was conducted in 1997 on Royal Naval fire fighting personnel to measure the effects of hand and forearm immersion in water to prevent heat strain (House, Holmes, & Allsop, 1997). This study examined the effects of increased metabolic heat production during thirty minutes of physical work until the test subject s body core temperature reached 38.5 degrees Celsius (101.3 degrees Fahrenheit). Evaporative heat loss was impaired when wearing

11 Developing a SOP 11 impermeable or semi-permeable protective clothing such as FPC. Under these circumstances, unless sufficient heat can be dissipated through conduction, convection and radiation, the body s core temperature would continue to rise. This would eventually result in heat exhaustion or heat stroke, with potentially life threatening consequences. The study evaluated the effectiveness of using a passive (rest only) versus an active (hand and forearm submersion in water) cooling method. When the test subjects rested without any active cooling measures, their core temperature cooled down very slowly, or not at all. Even after 30 minutes of passive cooling with rest and rehydration, their body core temperatures were still elevated slightly above normal. When the active cooling of hand and forearm submersion was added, the body core temperature of the test subjects began to decrease within five minutes. Within twenty minutes of submersion, all participants had their body core temperature return to normal at 36.9 degrees Celsius (98.5 Fahrenheit). Three different temperatures of water were used to find the best temperature for the most beneficial effect. The water temperatures were 10 degrees Celsius (50 degrees Fahrenheit), 20 degrees Celsius (68 degrees Fahrenheit) and 30 degrees Celsius (86 degrees Fahrenheit). While it was found that the colder water had a more rapid cooling effect in the first ten minutes on increased body core temperatures, even the warmest water had the same cooling effects after twenty minutes. This study also proved that the effects of peripheral vasoconstriction in the hands was not affected by the colder water when the body core temperature was elevated. The results of this study supported the importance of rest periods with active cooling and rehydration after twenty to thirty minutes. The hand and forearm submersion should be the method of choice for active cooling. Anyone who overworks or exercises too much in the heat is at an increased risk for

12 Developing a SOP 12 developing hyperthermia (increased body core temperature). When the body becomes overheated, the brain sends signals that dilate blood vessels in the skin, delivering much more blood to the surface of the body and provides the fluid to produce sweat. As the perspiration dries, it cools the surface of the body and lowers body temperature. If the outside air is also very humid, sweat does not evaporate as quickly, and slows down the cooling process (Rosenfeld, 2005). When firefighters add FPC to the equation, it further increases their risk of developing hyperthermia. The number of annual firefighter deaths from on-scene stress has not decreased in more than ten years (Becker, 2005). Emergency incident rehabilitation is aimed at early detection of cardiovascular problems and the prevention of a fatal heart attack or other serious medical events. Even Governor Arnold Shwarzenegger recognized the importance of implementing emergency regulations to protect outdoor workers from heat-stress illnesses (Mendel, 2005). When firefighters are extended beyond their safe operating periods they may suffer a stress- or fatigue-related illness and have an increased potential for making poor decisions in a high risk environment (Dickinson & Weider, 2000, p. 3-4). Establishing an emergency incident rehabilitation sector will provide proper medical monitoring, rest and re-hydration in order to return the firefighters safely back to duty or back to the station. The leading cause of fatal firefighter injuries during the ten year period was overexertion/strain. This is consistent with the high incidence of deaths from heart attacks and accounts for nearly half of firefighter deaths (Federal Emergency Management Agency United States Fire Administration, 2002, p. 23). The USFA and IAFF have committed to making emergency incident rehabilitation an essential element on the incident scene to prevent serious and life-threatening conditions such as heat stroke and heart attacks from occurring (Olshanski,

13 Developing a SOP ). In evaluating the protocols used by other fire departments in the United States, it was found that most protocols followed the template provided by FEMA (FEMA, 1992), which stresses rest, nourishment, re-hydration, passive cooling and medical monitoring. The exception was the heat stress advisory utilized by the Toronto Fire Department which also included active cooling utilizing hand and forearm submersion (Stewart, 2003). All of the protocols reviewed also stressed the importance of accountability and tracking of personnel as they entered and exited the emergency incident rehabilitation area (Dickinson & Weider, 2000, p ). The protocols also placed Basic Life Support personnel as the minimum level care provider to be responsible for the medical evaluation component (Sachs, 2001, p. 110). The medical evaluation needs to include constant monitoring of vital signs with emphasis on heart rate and temperature. FEMA states the two air bottle rule or forty-five minutes of work time is recommended as an acceptable level prior to mandatory rehabilitation (1992). This was the standard followed in most of the department protocols reviewed. However, that is based on average temperature working conditions. When firefighters are faced with hot, humid temperatures in addition to their work load factor, the working time length prior to rehab should be reduced. The personnel should be rehabbed after twenty to thirty minutes of physical activity at an emergency scene, or after one air bottle (Selkirk & McLellan, 2004, p. 210). While most protocols made reference to setting up a rehab sector once temperatures exceeded 90 degrees Fahrenheit, they did not make reference to rehabbing their personnel after a shortened work time. Twelve FDNY Emergency Medical Service (EMS) chief officers from assignment areas throughout New York City were interviewed to examine what independent actions they have currently been performing at emergency incidents to rehab firefighting personnel. They were interviewed under the protection of confidentiality. The EMS chiefs are designated with the

14 Developing a SOP 14 Medical Branch responsibilities under the Incident Command System model for FDNY. The care and treatment of firefighters at these incidents falls under the responsibility of this branch. Each of them utilized the size, scope and duration of the incident as primary factors in deciding whether or not to set up a rehab sector at emergency incidents. However, the guidelines they provided were subjective and individualized as to how quickly they would set up the area. None of the chiefs interviewed had the experience of having a fire company rotate through a rehab sector together. They relied upon the individual firefighter to decide if they needed rest, rehydration, cooling or medical attention. Rehydration and nourishment were provided by the Red Cross and Salvation Army at large scale incidents, without any monitoring or oversight by the EMS chief. Medical monitoring is usually performed by a BLS crew only if the firefighter has a medical or injury complaint. Three of the chiefs interviewed who have a background in hazardous materials, also mentioned that they would provide Advanced Life Support (ALS) medical monitoring to any firefighter who is operating on the scene in a Level-A (fully encapsulated) Haz Mat suit. They all had a good sense of what items could be special called for long term incidents, such as metro buses which could be used for shelter and provide passive cooling (air conditioning), cots for resting, and tents for shade. They were also familiar with the Rehabilitation and Care truck (RAC) that carries large canteens of water and Gatorade. Only four chiefs knew that the RAC also carries fans and water misters that can be used for active cooling. Ten of the twelve chiefs also said they would call in chaplain services and/or the FDNY counseling unit to provide on-scene critical stress defusing, if necessary. None of the chiefs interviewed were aware of the Kore Kooler chairs carried on the RAC which could be used for hand and forearm water submersion. All of the chiefs mentioned use of the Mobile Respiratory

15 Developing a SOP 15 Treatment Unit (MRTU) and Mobile Emergency Room Vehicle (MERV) as part of the rehab sector when necessary. However, the main purpose of these specialized vehicles, is to be used as medical treatment areas. In summary, all of the literature resources examined stressed the importance of rest and cooling periods following physical work in heated conditions. The technical publications dealing specifically with personnel working in bulky, non-breathable clothing added that active cooling should be employed to return body core temperatures to normal. Without active cooling, the body s core temperature could continue to rise even during the rest and passive cooling phase. The differences existed in the amount of time that the work cycle should occur prior to entering the rest and cooling phase. In normal conditions, most references agreed that the maximum amount of time worked should be 30 minutes or after two air bottles. However, for those that examined working in environments where the air temperature was over 90 degrees Fahrenheit with high humidity levels, the work time should be decreased to 20 minutes or one air bottle. Most literature sources noted the benefit of medical monitoring as a standard practice in rehabilitation. It was noted that decreased SV occurred during the working phase which could affect judgement. Relying on the firefighter s perception to decide if they need medical treatment was not recommended. This was also supported by the firefighter fatality study. The fire department protocols demonstrated adherence to most of the recommendations found in the literature review. They followed the template provided by FEMA in 1992 which did not have the benefit of the most recent studies supporting the importance of active cooling or shortened work times in hot, humid weather conditions. Toronto Fire Services was the exception

16 Developing a SOP 16 because they updated their protocol following the study conducted within their department. The FDNY EMS chief interviews demonstrated the need for an emergency incident SOP to provide objective parameters for setting up and operating rehab. This is important to ensure rotation of personnel through rehab that will include medical monitoring and active cooling. There was no identifiable differences in their responses as to the geographic area they cover within the FDNY response area. Procedures Action research was the method used in developing a draft Emergency Incident Rehabilitation SOP for the FDNY. My research began with a literature review at the Learning Resource Center (LRC) at the National Fire Academy in April The literature review was continued at the FDNY Mand Library in July and November I examined book, periodical and technical journal publications in addition to internet resources. I met with FDNY Battalion Chief Jerry Tracey in June 2005 to discuss a joint fire suppression/ems proposal to develop a FDNY SOP for emergency incident rehabilitation. He provided me with copies of recent studies supporting the use of active cooling which were included in my literature review, along with a copy of the heat stress advisory protocol for the Toronto Fire Service and references on active cooling studies. He also provided me with a list of available equipment on the RAC which could be used as part of a rehab SOP. In July 2005, I sent s to fellow Executive Fire Officer students requesting copies of their department s emergency incident rehabilitation protocols. A number of respondents advised their department did not have a SOP. However, I did receive copies of SOPs from Florence Fire and EMS, Johnson County Kansas EMS, Lincoln Fire and Rescue, Honolulu Fire Department, and Houston Fire Department. All copies were received via between July

17 Developing a SOP 17 and October Telephone Interviews were conducted with twelve FDNY EMS chiefs. These chiefs were selected based on geographic distribution between the five boroughs of the FDNY response area. Two were from the Bronx, two were from Queens, two were from Manhattan, two were from Brooklyn and two were from Staten Island. The other two chiefs are assigned to FDNY headquarters in Brooklyn. The chiefs agreed to be interviewed under the protection of confidentiality. The interviews were conducted in October and November 2005 and lasted between fifteen and twenty minutes. The following questions were asked: 1. What factors do you utilize in determining the need for a rehabilitation sector at an emergency incident? 2. What resources are you aware of that are currently available to assist you in setting up a rehabilitation sector at an emergency incident? 3. Describe the actions you take, if any, in setting up a rehabilitation sector at an emergency incident. 4. What type of personnel do you use to staff the rehabilitation sector and what are their primary functions? 5. What process is used in determining what firefighters go to rehab at an emergency incident? 6. When someone goes to rehab at an emergency incident, how is it decided when they are able to leave? FDNY is the largest fire/ems department in the world, and there were no other fire departments close in size who submitted emergency incident rehabilitation protocols for review. This limited my information gathering from smaller sized agencies that would not necessarily

18 Developing a SOP 18 apply to a large department, however, the principles still apply. Another limitation was the amount of literature available regarding rehabilitation after physical work in the non-fire/emergency setting. Most references found dealt specifically with muscle rehab and rehydration after intense physical fitness workouts. Results Why is there a need for emergency incident rehabilitation? Firefighting has been demonstrated to be a physically demanding job that results in increased workload on the heart which is further exacerbated by an increase in body core temperature. The decrease in SV and fatigue can impair a firefighter s decisional capacity and ability to recognize that they are in distress. These stresses on the body can be reduced by providing rest and rehabilitation periods following twenty to thirty minutes of intensive work. Medical monitoring is a key component of the rehab period to assess the cardiovascular functions of the firefighter in addition to providing rehydration, nourishment and active cooling. If a firefighter receives the proper rest and rehabilitation, their cardiac workload will be reduced and their body core temperature will return to normal. This will enable them to return to the work rotation or station safely. There is a need for emergency incident rehabilitation to preserve the health and fitness of our firefighters by preventing serious and life-threatening conditions from occurring. The studies and books examined in the literature review support this. What aspects of emergency incident rehabilitation currently used by other fire departments would be applicable to a SOP for FDNY?

19 Developing a SOP 19 All of the procedures examined would be applicable to the FDNY SOP. Each of the departments followed the FEMA template and included rest, nourishment, re-hydration, cooling and medical monitoring. The Toronto fire department s addition of active cooling using hand and forearm submersion would also be applicable, since climatic conditions in New York City are similar to those in Toronto. The other items outlined in the protocols were general as to the locations for establishing emergency incident rehabilitation sectors. The approach to set up the rehab area in close proximity to, but away from the incident was consistent and applicable to New York City operations. References to types of resources and equipment that needed to be requested through mutual aid sources, would not apply to FDNY, except in catastrophic incidents. FDNY has the majority of the resources needed within the department. Other resources such as transit buses can easily be obtained through the New York City Office of Emergency Management. The amount of time worked at an emergency incident varied from twenty to thirty minutes or after two air bottles. This timeframe would also be applicable to FDNY, since there are enough personnel resources available to continue operations while a company enters rehab. One area not addressed in most protocols is reducing the amount of work time prior to rehab when outside air temperature is elevated. Toronto was the exception; once the heat index (combination of heat and humidity) exceeded 40 degrees Celsius (104 degrees Fahrenheit), heavy work should be limited to 15 minutes prior to rehab and active cooling will be mandatory. This would also be applicable to FDNY because of similar summer climatic conditions.

20 Developing a SOP 20 The medical monitoring part of the protocols indicated that a minimum level of BLS would staff that function. This would also be applicable to FDNY since EMS resources are part of the department. The department protocols that addressed accountability used PASS tags as firefighters entered the rehab area. This would not apply to FDNY as conditions currently exist. A tracking form is used that collects information which can be entered into a database. What independent actions do FDNY chief officers currently do at emergency incidents to try and rehabilitate personnel? The factors utilized in determining the need for a rehabilitation sector at an emergency incident were consistent among the chiefs interviewed. The main three listed were the size, scope and length of the incident. They would consider setting up rehab if the job were extensive requiring multiple apparatus, or if operations would extend beyond a couple of hours. Extreme weather conditions were also mentioned as a factor; however, no specific parameters for temperature were noted. Two of the chiefs also mentioned the emotional impact of the job as being a criteria. All of the chiefs were aware of what resources are available to them in setting up a rehab sector. They knew most of the equipment carried by the RAC such as water coolers and Gatorade. Only four chiefs knew the RAC also carried fans and water misters. They were unaware the RAC carried Kooler chairs that can be used for hand and forearm submersion. They were all aware of the MERV and MRTU in addition to tents and cots. They also mentioned transit buses and generators available through the New York City Office of Emergency Management.

21 Developing a SOP 21 The actions taken by the chiefs in setting up a rehab area included good access/egress areas to facilitate delivery of supplies and allow ambulance transport for any member requiring definitive medical care. They also considered the types of resources required and put in special calls for items when necessary. All of the chiefs included firefighter medical treatment areas inside of the rehab area. The chiefs were unanimous in their answers that the rehab area staffing would include an EMS officer for oversight with BLS and ALS providers. They saw the main role of the BLS and ALS providers as medical care givers when firefighters had complaint of injury or illness. In addition, they all mentioned placing the RAC unit there along with the Red Cross and Salvation Army. These organizations would be responsible for providing hydration and nourishment. There was no mention of monitoring how or what the firefighter s intake was. Ten of the chiefs also mentioned providing chaplain and counseling services if needed. There did not appear to be any process as to determining how or when firefighters would report to the rehab sector. The answers were consistent in stating that firefighters drank when they were thirsty or ate when they were hungry. Most times, firefighters would only report to the rehab sector if they were complaining of illness or injury. This demonstrated the blurring of the definition between rehab and medical treatment areas. As to how long firefighters stay in rehab, there was no definitive time or measurement. It was when they feel rested enough, or they need to be transported to the hospital. These interview results demonstrate the EMS chiefs are familiar with the concept of rehabilitation, but do not have specific guidelines to follow during an operation. It also shows the fire suppression companies do not direct their personnel to rehab as part of an operation. Only when the firefighter has already suffered an injury or is feeling ill, do they seek assistance.

22 Developing a SOP 22 This effectively turns the rehab sector into a reactive setting as opposed to a proactive one with proper monitoring of their status. Attached (Appendix A) is a copy of an emergency incident rehabilitation SOP I have drafted based on my research findings. This SOP along with a copy of this research paper will be submitted to the Chief of Department for review, comment and consideration of implementation. Discussion Instituting an emergency incident rehabilitation SOP in fire departments has been a USFA recommendation for more than ten years to promote firefighter health and safety (FEMA USFA, 2002). FDNY still requires the implementation of a SOP. It was demonstrated in the FDNY EMS chief interviews that the recommended rotation of firefighting personnel through the rehab sector (Dickinson & Weider, 2000) does not occur. The proactive approach to medical monitoring of firefighting personnel in the rehab sector is beneficial in catching potential cardiovascular collapse before it occurs (Sachs, 2001). Providing a systematic approach for the FDNY chief officers to follow in emergency incident rehab operations will ensure that all firefighters receive the necessary preventive care during an operation (Dodson, 1999). The literature review was unanimous in its support to include the following FEMA recommended guidelines when developing a SOP for emergency incident rehabilitation: hydration, nourishment, rest, recovery (including cooling), medical monitoring/ evaluation, and accountability (FEMA, 1992). When firefighters are faced with hot, humid temperatures in addition to their work load factor, the amount of physical activity should be reduced to twenty minutes or one bottle change (Selkirk & McLellan, 2004). Active cooling should also be employed to lower core

23 Developing a SOP 23 body temperatures (Stewart, 2003). The addition of this to the SOP recommended by FEMA is a simple fix. The FDNY already has the equipment necessary to provide this service during recovery, including the recommended hand and forearm submersion (McLellan, 2004). As a result of this study, I found FDNY was deficient in all areas of rehabilitation recommended by the literature. There is currently no crew rotation, preventive medical monitoring or active cooling instituted on a regular basis. Nutrition and hydration are handled by the Red Cross and Salvation Army, but there is no monitoring of their intake. Accountability was only performed on those firefighters seeking medical attention. However, to expect FDNY personnel to perform all of the necessary functions without guidelines set forth in a SOP is unrealistic. The FDNY will benefit from the development of an emergency incident rehabilitation SOP. Once the chief officers have an established set of guidelines to follow (Foley, 1998), they will be able to provide the utmost in preventive and rehab care to our personnel. This will allow for a continuous rotation of fresh personnel to operate safely at the emergency scene. In addition, it should have a positive impact on reducing the number of injuries to our personnel by reducing strain and stress. Most importantly, it would allow our medical personnel to identify potential medical problems early on and begin treatment before more serious problems present themselves (Becker, 2005). Recommendations The FDNY should include the emergency incident rehabilitation SOP as part of its procedure manual before the summer season in Familiarization training of the new procedure should be conducted at each EMS and fire station in the city prior to implementation.

24 Developing a SOP 24 Emphasis needs to be placed on this procedure by the chief officers, and company officers need to be held accountable for ensuring this policy is adhered to. Consideration should be given in getting the firefighter unions involved to disseminate the safety purpose behind the SOP. The FDNY RAC unit currently has six Kore Kooler chairs to provide active cooling (hand and forearm submersion). I recommend the department order an additional thirty chairs, so that six can be placed on the logistical support unit (LSU) trucks in each borough. This would allow the rehab sector to employ hand and forearm submersion cooling to more than one fire company at a time on large or extended operations. Fire departments that currently have SOPs in place for emergency incident rehabilitation should periodically re-examine those policies. As new research becomes available, their procedures could be updated to incorporate new recommendations, such as active cooling techniques. FDNY should consider a study to measure the effectiveness of the rehab SOP to see if fire ground injuries and/or post incident cardiac incidents are reduced. Continuous monitoring of the policy is also recommended, to keep up with current trends.

25 Developing a SOP 25 References Baker, S. J., Grice, J., Roby, L., & Matthews, C. (2000). Cardiorespiratory and thermoregulatory response of working in fire-fighter protective clothing in a temperate environment. Ergonomics, 43, Becker, D. S. (2005, May 10). Emergency scene rehab operations. Journal of Emergency Medical Services, 2005, May,. Retrieved May 28, 2005, from Department of Homeland Security U.S. Fire Administration National Fire Academy (2003). Executive fire officer program Operational policies and procedures Applied research guidelines. Emmitsburg, MD: DHS USFA. Dickinson, E. T., & Weider, M. A. (2000). Emergency incident rehabilitation. Upper Saddle River, NJ: Prentice Hall, Inc.. Dodson, D. W. (1999). Fire department incident safety officer. Albany, NY: Delmar Publishers. Federal Emergency Management Agency (1992). Emergency incident rehabilitation FA-114. Washington, DC: United States Fire Administration. Federal Emergency Management Agency (2004). Leading community risk reduction student manual (1st ed.). Emmitsburg, MD: FEMA. Federal Emergency Management Agency United States Fire Administration (2002). Firefighter fatality retrospective study Emmitsburg, MD: FEMA. Foley, S. N. (1998). Fire department occupational health and safety standards handbook (1st ed.). Quincy, MA: National Fire Protection Association. House, J. R., Holmes, C., & Allsop, A. J. (1997). Prevention of heat strain by immersing the hands and forearms in water. J Royal Naval Medical Service, 83(1),

26 Developing a SOP 26 McLellan, T. M. (2004). Current firefighter occupational medicine issues Approaches for firefighter rehabilitation. Toronto, Ontario: author. McLellan, T. M., Jacobs, I., & Bain, J. B. (1993). Influence of temperature and metabolic rate on work performance with Canadian forces NBC clothing. Aviation Space Environmental Medicine, 64, Mendel, E. (2005, August 3). Rules to protect outdoor workers from heat OK'd. The San Diego Union Tribune. Retrieved August 23, 2005, from +outdoor+workers+from+heat+ok'd.html National Fallen Firefighters Foundation (2004). Firefighter life safety initiatives. Retrieved July 15, 2005, from Olshanski, T. (2005, June 2). USFA and the International Association of Firefighters to examine emergency incident rehabilitation for firefighters and other emergency responders. FEMA Press Release, 05-91,. Retrieved June 2, 2005, from Rosenfeld, I. (2005, July 24). How to beat the heat. Parade,, Sachs, G. M. (2001). The fire and EMS department safety officer. Upper Saddle River, NJ: Prentice Hall. Selkirk, G. A., & McLellan, T. M. (2004, April). Physical work limits for Toronto firefighters in warm environments. Journal of Occupational and Environmental Hygiene, 1, Smith, D. L., Manning, T. S., & Petruzzelo, S. J. (2001). Effects of live fire training on recruits. Chicago, IL: University of Illinois Fire Service Institute. Stewart, W. A. (2003). Heat stress advisory. Toronto, Ontario: Toronto Works and Emergency Services.

27 Developing a SOP 27 Appendix A Draft FDNY Standard Operating Procedure for Emergency Incident Rehabilitation 1. Purpose To provide guidance on the implementation and use of rehabilitation at an emergency scene or training exercise. The intention is to provide a proactive approach in managing the effects emergency personnel experience during physical activity in bunker gear and SCBA. These effects include metabolic heat build-up (increase in body core temperature), dehydration, and increased cardiac stress. 2. Scope This procedure applies to all personnel operating at the scene of an emergency incident or training exercise. 3. Responsibilities Incident Commander The incident commander shall consider the circumstances of each incident and direct the Medical Branch Director or Logistics Sector Chief to initiate a rehab sector with an EMS officer. The rehab sector shall be set apart from the medical treatment area for civilians. Any incident requiring extended operations, or when extreme climactic conditions exist, shall be definitive reasons for initiating rehab. Company Officers Company officers shall maintain an awareness of the condition of their members and the time they are operating on the scene. The command structure shall be utilized in requesting relief for fatigued firefighters. When

28 Developing a SOP 28 directed by incident command to report to the rehab sector, ensure all members report as a unit. Personnel During periods of hot weather, members shall be encouraged to drink water and activity beverages throughout the day. Caffeinated and carbonated beverages should be avoided. During emergency incidents and training exercises, all members should advise their company officer when they feel fatigued or overheated. Members should also remain aware of the health and safety of other company members. 4. The Rehabilitation Sector Officer shall: Wear a rehab officer vest for identification Select a location for the rehab sector according to the following site characteristics: An area large enough to accommodate personnel and equipment The site should be away from the immediate incident scene in an area free of hazardous atmospheres such as apparatus exhaust fumes, smoke or other toxins. Good access and egress for members to report to area and if needed, allow for ambulance transport of a member requiring definitive medical care. The site should provide shelter from the elements. Consider use of MTA buses which can provide climactic controlled conditions and provide maneuverability if the rehab sector must be relocated. DO

29 Developing a SOP 29 NOT use the MRTU or MERV, since these resources are reserved for medical treatment areas. If possible, set up close to a water supply. Consider areas close to rest room facilities. A separate area adjacent to the rehab sector to allow for removal of personal protective equipment (PPE) prior to entering into the rehab area. If weather and location allow, also rinse off PPE prior to removal. NOTE: The rehab area must be reserved for personnel rehab functions only. Members requiring medical attention should be handled in the medical treatment area. This can be a sub area of rehab, but should be located in a separate designated area. Set-up the rehab area with the following resources: Fluids: potable water, activity beverages diluted to a 50% solution, and ice (when available). These items can be obtained from RAC, Red Cross and Salvation Army. DO NOT serve caffeinated or carbonated beverages in the rehab area. Food: soups, broths, stews, and fruits are the preferred items to be served. Arrange for these items through FOC to be delivered by Red Cross and Salvation Army for extended operations lasting longer than 2 hours. Means for personnel to wash or clean hands and face. This must be done prior to eating or drinking.

30 Developing a SOP 30 Kore Kooler chairs to be used for rest and active cooling. Cool or tepid water should be used to fill the troughs in these chairs for the purpose of active cooling through hand and forearm submersion. Note: water should be changed for each personnel use. When possible, set up fan and misting stations to assist with active cooling. At least one ALS crew with medical monitoring equipment. There should be one ALS crew for every 6 members being monitored in the rehab area. Blankets for use during extreme cold conditions FDNY chaplain or counseling unit services should be considered if the emergency incident has a high potential for emotional impact on the personnel Patient tracking sheets to record personnel treated in the rehab unit. Coordinate with the Incident Commander to rotate personnel through the rehab sector. In normal climactic conditions, companies shall be rotated through the rehab sector after minutes of work or 2 air cylinder changes. They should not wait until they feel fatigued. When the heat index (combination of heat and humidity) exceeds 90 degrees, the work time shall be shortened to minutes or 1 cylinder. NOTE: Heat index readings can be obtained by contacting FOC (Fire Operations Command). Ensure that personnel are tracked as they enter and leave the rehab sector. Accountability is a key component to maintaining safety.

31 Developing a SOP 31 When companies are rotated to rehab, the following shall be performed 1. When possible, personnel shall be rinsed down while still in PPE. They will then dress down in the designated area adjacent to the rehab area, by removing their bunker coats, helmets, hoods and open their bunker pants to promote core body cooling. 2. Upon entering the rehab area they will clean their hands and face and proceed to the Kore Kooler resting chairs with hand and forearm submersion to initiate the active cooling process. 3. The ALS crew will begin medical monitoring to include physical assessment, temperature, heart rate, respiratory rate and blood pressure. Special attention should be paid to those members with a sustained heart rate above 110 and/or a temperature exceeding 100 degrees. These members may require further treatment in the medical treatment area. Certain drugs impair the body s ability to sweat and extreme caution must be exercised if the member has taken antihistamines, diuretics or stimulants. Note: It is still possible for personnel to have increased body temperatures even when working in cold environments, due to the insulating properties of the fire protective clothing. 4. During the rest period, personnel must rehydrate with fluids including water and activity drinks diluted to a 50% solution. The amount of fluid intake should be at least 8 oz. in 15 minutes. Record the amount ingested on the tracking sheet.

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