Running head: ANALYSIS OF FIREFIGHTER REHAB AND RESPIRATORY

Transcription

1 Analysis of firefighter 1 Running head: ANALYSIS OF FIREFIGHTER REHAB AND RESPIRATORY Analysis of Firefighter Rehab and Respiratory Protection during Fireground Operations Barry G. McLamb Chapel Hill Fire Department Chapel Hill, North Carolina May 2007

2 Analysis of firefighter 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 use the language, ideas, expressions, or writings of another. Signed:

3 Analysis of firefighter 3 Abstract The Chapel Hill Fire Department was operating at incident scenes without formal policies to support firefighter rehab, and operated with procedures for respiratory protection that were potentially harmful for firefighters. The purpose of the research was to describe current practices, procedures, and cultural issues related to rehab and respiratory protection within the department, and to seek out benchmarks and areas for improvement. Descriptive research methods were used for analysis. Questionnaires were constructed to develop internal data on cultural and compliance issues, and external data for program benchmarks. Recommendations were made for various improvements to policy and procedure, as well as careful implementation of any changes due to the significant cultural influences.

4 Analysis of firefighter 4 Table of Contents Certification Statement 2 Abstract 3 Table of Contents 4 Introduction 6 Background and Significance 7 Literature Review 10 Procedures 17 Results 19 Discussion 25 Recommendations 27 Reference List 28 Appendix A 30 Appendix B 31

5 Analysis of firefighter 5 List of Tables Table 1 20 Table 2 21 Table 3 23

6 Analysis of firefighter 6 Analysis of Firefighter Rehab and Respiratory Protection during Fireground Operations Introduction The hazardous nature of firefighting operations is a universally recognized fact that even the general public can comprehend and appreciate. However, firefighters and fireground commanders often fail to follow the best risk management principles which can lead to firefighter death and injury resulting from exposure to workplace hazards. Often, exposure to the hazards does not inflict immediate or significant damage, nor produce recognizable symptoms; but the repeated exposure, over time, can lead to substantial consequences for firefighter health. Additionally, while the potential for fireground exposure has increased, our use of tools and techniques to reduce the risk has not kept pace. Over the last two decades, there have been rampant changes in building construction, materials, and contents, but very often, fire departments are still operating with the same practices for firefighter rehabilitation and respiratory protection that were in place 20 years ago. In order to maximize the health and safety of firefighters, the fire service must put in place policies and practices that minimize the risk to firefighters working in the fireground operations workplace. Within the Chapel Hill Fire Department (CHFD), the problem faced by the organization is that personnel on the fireground have the potential to be exposed to hazards and yet, the policies and practices regarding firefighter rehabilitation (rehab) and respiratory protection may not be enough to adequately protect our members. The purpose of this research is to first, describe the current practices, procedures, and cultural issues related to respiratory protection,

7 Analysis of firefighter 7 and second, to determine benchmarks for improvement including the National Fire Protection Association (NFPA) recommended practice for firefighter rehabilitation. To examine how the organization can respond, current issues and trends regarding firefighter rehab and respiratory protection will be investigated through a literature review. The existing practices and policies governing rehab and respiratory protection will be analyzed through policy review and the impact of the organizational culture through questionnaires. A survey of other organization s practices will help establish how the CHFD is doing in comparison. Finally, CHFD practices will be examined against the recommend practices established in NFPA Background and Significance The Chapel Hill Fire Department provides fire, rescue and medical first responder services to a growing and diverse population in the central North Carolina piedmont. Comprised of 92 employees, the fire department operates 5 stations, 6 front-line apparatus, and 3 reserve/support apparatus. The organization is configured in a paramilitary hierarchy typical of most fire departments and is divided into three divisions: Administration, Life Safety, and Emergency Operations. The town is also home to the University of North Carolina, and both are undergoing a significant period of growth and change. Located in the metropolitan area known as the Triangle, so named for the cities of Raleigh, Durham, and Chapel Hill, the department participates in multiple mutual aid and regional efforts. Despite being one of the smaller career departments in the metro area, Chapel Hill often exceeds its neighbor departments in terms of services delivered to our customers. The organization has long struggled with meeting service demands and its own high standards with what can only be described as grossly inadequate staffing when compared to the

8 Analysis of firefighter 8 number of initiatives that the department is involved. Only in the last two years has staffing been added to the operations division baseline, which has made some improvement in personnel safety and response capability. During the same time period, the department was finally able to add one staff position, a full-time Training and Safety officer. The addition of the Training and Safety Chief in October, 2003 was a milestone for the organization because previously there had not been any one individual responsible for implementing training and safety programs for the department. Instead, the tasks associated with the position were split up as additional duties among various staff members, each with his or her own responsibilities and agendas. Consequently, neither safety nor training received the priority commiserate with the importance of either, given the impact of both on the organization. However, the training and safety programs are still in developmental stages, due in part to personnel changes and the re-emergence of academy training. Safety, in particular, is not a fully functional program, but holds the promise to be able to address many of the issues raised in this research. Another prevalent issue is the safety climate in the organization. As with any fire department, Chapel Hill posses its own unique culture in addition to the aspects of fire service culture that are nearly universal. The organizational stance on safety is evident in the mission statement of the department: The mission of the Chapel Hill Fire Department is to protect lives, property and the community environment from the destructive effects of fire, disaster or other life hazards through public education, incident prevention and emergency response services. Our Priorities are: Safety, Service and Morale. (Chapel Hill Fire Department [CHFD], 2004, p. 1)

9 Analysis of firefighter 9 Since its inception, the Fire Chief has ensured all members participate in the annual Safety Stand Down that was initially sponsored by the International Association of Fire Chiefs (IAFC) and Fire Chief Magazine. This represents a positive trend that continues to develop new ideas and challenge old ways of doing business. Despite the organizational posture and the commitment of the leadership to safe practices, there are still areas for improvement in the department. Among these are mitigating the impact of incident stressors and hazards through more proactive incident scene rehabilitation and better respiratory protection policy and practices. According to a report by the United States Fire Administration (USFA) and the National Fire Data Center (2004), stress and overexertion continues to be the leading cause of firefighter fatalities. Additionally, younger firefighters are more subject to smoke inhalation injuries and older firefighters are prone to sprains and strains; injuries directly related to overexertion (United States Fire Administration / National Fire Data Center). This applied research project is directly related to the USFA Operational Objectives. The third USFA objective is to reduce the loss of life from fire of firefighters; this project is directly related to firefighter health and safety. The fifth USFA operational objective is to respond appropriately in a timely manner to emerging issues. Firefighter health and safety and particularly, incident scene rehabilitation, are emerging issues in the fire service today. This study is also directly related to the course material in the Executive Analysis of Fire Service Operations in Emergency Management as this research looks at an important consideration in emergency response operations.

10 Analysis of firefighter 10 Literature Review There is a fire service axiom that says: take care of yourself first, take care of your team second, and take care of the people at the incident third, because if you do not take care of yourself, you cannot take care of anything else. This is the premise behind incident scene rehabilitation or rehab. Much emphasis is placed on proper rehab in the modern training environment because of the physically demanding work of firefighting. Instructors keep an eye on students to ensure they are not pushing too hard nor getting enough rest. At emergency scenes, crew chiefs, safety officers and incident commanders are responsible for ensuring the welfare of responders. Rehabilitation is essential on emergency responses and in training to ensure safe and effective fire operations. Tired firefighters are more injury prone and caring for injured firefighters diverts limited resources away from mitigating the incident. (National Fire Protection Association / International Association of Fire Chiefs [NFPA/IAFC], 2004, ) According to one study, the majority of firefighter injuries in the 2002 study period occurred on the fireground and the largest percentage of those injuries were strains, sprains, and muscle pain directly related to overexertion (TriData Corporation [TriData], 2004). While the overall trend in firefighter injuries fell 20 percent over the previous 10 year period (TriData), the number of structure fires only fell 13 percent in the seven years prior to 2002 (Federal Emergency Management Agency [FEMA], 2006). Although, the injury trend is getting better, the TriData (2004) study included several recommendations to improve firefighter injuries related to this study. Among the recommendations were to research ways to instill safety awareness and change the behavior of firefighters because, the degree to which firefighters behave without regard to their safety, and to standard procedures, affects that safety (TriData, 2004, p. 52).

11 Analysis of firefighter 11 Improving training was another recommendation because improved training reduces risk through increasing experience levels, and that is critical to safety-related fireground decisions. The study also advocated the use of various technologies to improve the situational awareness of incident commanders that will provide them better data and lead to safer operations. Finally, improving firefighter fitness was a suggested solution that relates to this study. (TriData) In the Fundamentals of Firefighter Skills, respiratory protection is listed as one of the most critical elements of PPE. When protecting your lungs, good is not enough is the sage advice found on respiratory protection (NFPA/IAFC, 2004, p. 804). A recent theory involving respiratory protection suggests that the hidden danger lurking on the fireground is cyanide poisoning. Cyanide is a by-product of burning wool, silk, leather, and most plastics, and continues to be produced as long as the combustible product is off-gassing (Lee, 2007). According to the Centers for Disease Control, the most likely route for cyanide is through inhalation and in the blood stream, cyanide prevents cells from using oxygen which leads to cell death (Centers for Disease Control [CDC], 2004). Because cyanide interrupts cellular respiration, the symptoms of cyanide poisoning can mimic other conditions, such as exhaustion, carbon monoxide poisoning, or even a heart attack (Lee). The problem is that cyanide poisoning is difficult to diagnose and the symptoms are often hard to differentiate. Fortunately, the solution is simple: if post-fire fuels are off-gassing, firefighters must remain on SCBA while performing overhaul (Lee). In a presentation to the Chapel Hill Fire Academy, Dr. Preston Rich, Chief of Trauma and Critical Care at the University of North Carolina Hospital, discussed the increased risk of heart attack for firefighters, specifically relating information from the recent study that revealed the abnormally high number of firefighter heart attack deaths that occurred during fire

12 Analysis of firefighter 12 suppression. Dr. Rich relayed information from the study showing that the odds of dying of a heart attack while performing fire suppression were between 10 and 100 times greater than would be statistically predictable. However, the overall risk of a fatal heart attack in firefighters is only 90 percent of the general population. Dr. Rich postulates that a primary cause of the dramatic increase in firefighting coronary death is from the perfect storm of cellular oxygen starvation that is a result of the additional and unique risks that firefighters face on the fireground. That perfect storm is brought on by inhalation exposure to carbon monoxide and cyanide. (Rich, 2007) In reviewing departmental SOPs, a weakness against the inhalation hazards posed by carbon monoxide and cyanide quickly emerges. SOP stipulates Protective Clothing Requirement for firefighters in various types of duty. Under the category overhaul and salvage, the following items are listed: boots, pants, gloves and helmets. SCBA until thoroughly ventilated. (CHFD, 1990, p. 1). The problem lies in the definition of thoroughly ventilated. The common practice for many in the fire service is to use the Occupational Safety and Health Administration (OSHA) permissible exposure limit (PEL) for carbon monoxide to determine if it is safe to remove SCBA. As illustrated by Lee (2007) and Rich (2007), this practice may be leading to a more hazardous exposure than is assumed and can include exposure to cyanide gas, which is not monitored the same as carbon monoxide and is more difficult to detect through blood analysis. In his article, Lee cites a National Institute of Standards and Technology (NIST) study that found that nearly all of the 100 deaths from the tragic Station nightclub fire in Rhode Island were caused by cyanide poisoning resulting from the burning plastics, used to enhance acoustics, on the walls.

13 Analysis of firefighter 13 In 2002, the SOP on SCBA performance and operation was updated to address current practices and policies. SOP states that it is not acceptable to remove SCBA during overhaul when the smoke clears residual harmful vapors may be present (CHFD, 2002, p. 5). It goes on to say that it is acceptable to remove SCBA when approved by command, operations, safety; when the atmosphere has been determined with testing and monitoring; and when the unit prevents escape from a dangerous condition (CHFD, 2002). Unfortunately, the update does not address all of the issues emerging concerning respiratory protection. According to the NFPA recommended practice on rehabilitation, standard operating procedures (SOPs) should be developed that include the following elements: medical evaluation and treatment, food and fluid replenishment, and crew rotation and relief. Additionally, the Emergency Medical Service (EMS) protocols should be developed in collaboration with the EMS medical director, the fire department physician, and the fire chief. NFPA 1584 also recommends that all members are trained to recognize the symptoms or heat and cold stress. Finally, SOPs should ensure that rehab operations are put in place whenever an incident escalates beyond the normal limits of physical or mental endurance. (National Fire Protection Association [NFPA], 2003, chap. 4) NFPA 1584 also stipulates that proper hydration and nutrition are essential prior to an incident. Daily hydration should include six to eight ounces of water every six hours in addition to fluid intake at meals. Furthermore, in pre-incident and training situations, firefighters should include an additional sixteen ounces of fluids within two hours prior. If the incident or training is projected to last longer than an hour, then sports drinks are preferred for pre-hydration. Proper nutrition should consist of smaller, more frequent meals that are comprised mostly of carbohydrates with smaller portions fat and protein. Food and beverages to avoid consist of:

14 Analysis of firefighter 14 caffeinated and high-sugar/fructose drinks, high fat and/or high protein foods, any alcohol within eight hours of duty, and finally, excessive fluid intake. (NFPA, 2003, chap. 4) There are numerous site considerations that the incident commander (IC) should include. First, ICs must ensure that rehab is set up in area that is capable of conducting rehab operations and is also sheltered from any weather extremes. In the event of hot weather, the area should be shaded or equipped with tents, fans, and misters, or air conditioning if inside a facility. Firefighters should also have the ability to sit and remove gear. For extremes of cold and wet, the area or facility should be dry and provide warmth and dry clothing. In large or geographically separated incidents, more than one rehab area may be necessary. (NFPA, 2003) Other site considerations include either keeping the rehab area far enough away or separated from the incident or training, so that personnel can remove their personal protective equipment (PPE) and also be shielded from the noise and stress of the event. The area should also be protected from exhaust fumes from vehicles as well as any products from the incident. Prior to entering the designated rehab area, firefighters should have the ability to remove and leave their PPE and self-contained breathing apparatus (SCBA). Medical personnel or the medical sector should have easy access to the rehab area. Finally, the area should be close and accessible enough that firefighters can quickly return to the incident (NFPA, 2003). EMS at a minimum of Basic Life Support (BLS) level should be provided for firefighters and EMS personnel should be included within the tactical level of the incident management systems (IMS). Advanced Life Support (ALS) level care is preferred when available. EMS personnel should question firefighters arriving at rehab to determine illness, injury, and exertion. Questions and observations should be used to reveal symptoms of dehydration, heat or cold stress, exhaustion, irregular heart rhythms, as well as mental or emotional stress and exhaustion.

15 Analysis of firefighter 15 The Rating of Perceived Exertion (RPE) scale should be used to determine the level of physical output. Upon entering the rehab area, the following criteria from each firefighter should be evaluated: 1-10 on the RPE scale, blood pressure, temperature, and heart rate. Local EMS protocols and department SOPs should always be utilized in the triage and treatment of firefighters. Firefighters meeting or exceeding any triage parameter should be evaluated after twenty minutes. If, after rest, the firefighter is still within an unacceptable range in any one parameter, the firefighter should be taken for medical treatment. (NFPA, 2003) Assignment to and out of rehab is a function of the IMS and members must be tracked through a personnel accountability system. Upon entering rehab, firefighters should have the resources to add or remove clothing in order to regain body temperature, eat food to replace the calories expended in the operation, and drink water or sports drinks to return the body s fluid and electrolyte balance. The fluid goal during a 20-minute rehab period is ounces, in addition to the recommended 2-4 ounces every 20 minutes taken in during the incident. A recommended practice is keeping water available on the truck and near bottle changing stations so that firefighters can re-hydrate while their SCBA cylinder is serviced. (NFPA, 2003) A key feature found in the NFPA recommended practice is the work-rest cycle. The work-rest cycle establishes the following guidelines for personnel engaged in various types of work: Up to one 30-minute SCBA cylinder or 20 minutes of intense work without SCBA to at least 10 minutes of self-rehabilitation (rest with hydration) as a company or crew. The company officer or crew leader should ensure that all members in the company or crew seem fit to return to duty. Up to two 30-minute SCBA cylinders or one 45-minute or 60- minute SCBA cylinder when encapsulating chemical protective clothing is worn or 40

16 Analysis of firefighter 16 minutes of work without SCBA to at least 20 minutes of rest (with hydration) in a rehabilitation area. (NFPA, 2003, chap. 6) NFPA goes on to say that following the formal establishment of rehab, no one should be allowed to return to duty until after resting and re-hydrating for a minimum of 10 minutes and being medically evaluated and cleared by EMS personnel. Also, firefighters should not be in an operational role at a scene for 12 or more hours without a multi-hour break away from the scene. (NFPA, 2003) If one or more crew members are determined to be unfit for duty, the other members of the crew may remain on duty and be reassigned with certain considerations due the decreased number. However, if a member or members of the crew are seriously injured or killed, the entire crew should be relieved of duty immediately. The department should then implement critical incident stress management protocols to assist the crew members. (NFPA, 2003) There are additional considerations during and after the incident. Documentation during the incident is critical. The time entering and leaving rehab should be recorded for all personnel. Any medical evaluation done should be documented on a rehab evaluation report. If any medical treatment is performed, the required EMS forms as well as injury reports and workers compensation forms must be accomplished. Following the incident, firefighters should look for signs and symptoms of dehydration and report any incident related illness or injury that is discovered after leaving the scene. Also, firefighters should follow the same nutritional guidelines as pre-incident and avoid high-fat foods, caffeine, foods with excessive calories, and carbonated beverages. (NFPA, 2003) An additional rehab tool and technique not addressed by NFPA 1584 involves the concept of active cooling. Research conducted by Defense Research and Development Canada

17 Analysis of firefighter 17 (DRDC) demonstrated a remarkable improvement in recovery times using the technique. The research compared active cooling, comprised of forearm immersion, the use of a mister for cooling, and passive cooling, which was the control. The active cooling revealed a dramatic differential over the other cooling methods. As a result of the research, manufacturers are now producing specialized rehab chairs that allow firefighters to immerse their forearms in water for active cooling in the rehab sector. (Selkirk, McLellan, & Wong, 2004) In addition to describing the elements of the NFPA recommended standard, the literature review has highlighted the injury problem as it relates to rehab, identified other issues and trends regarding rehab and respiratory protection. The two department policies that relate to respiratory protection have also been identified and the relevant sections outlined. The review has clearly revealed problems facing the department as well as potential solutions. Procedures Descriptive research was the primary method for analysis of the problems with firefighter rehab and respiratory protection. The process originally evolved after seeing two presentations: one on firefighter rehab, and another on the firefighter heart attack risk. The decision was then made to investigate what impact the information might have on the Chapel Hill Fire Department to improve processes related to firefighter rehab and respiratory protection. The literature review consisted of information developed out of web searches and the information gathered or retained following the presentation. Web searches with the keywords firefighter rehab and firefighter respiratory protection yielded results, as did the resources available through the USFA web site. The NFPA web site was used to access NFPA Finally, books from the author s library and organization s reference materials were used to round out the literature review.

18 Analysis of firefighter 18 Two questionnaires were developed to gather data from internal and external sources. An internal survey was used to determine the level of understanding, the common practices, and the attitudes towards firefighter rehab and respiratory protection, and the external questionnaire was used to gauge the department against a variety of organizations throughout the state. The internal questionnaire was distributed to operations personnel at the level of engine company officer and below. Firefighters hired within the last year and life safety division personnel were excluded. For the internal sample, the population of the group was 54 at the time the survey was distributed. A sample of 51 was needed to ensure a 95 percent confidence level and 53 surveys were returned. The survey, included in Appendix A, contained 9 questions that were designed to illicit responses regarding comprehension of policies (questions 2, 3, 6, 8), management involvement (question 1), attitudes regarding rehab (questions 4-5, 9), and current practices (question 7). The external questionnaire was distributed to conference attendees at the North Carolina instructor s conference. The primary audience is training officers, but some respondents were company level officers and at least one chief officer of the department. The sample of 86 required a response of 82 for 95 percent compliance. The number of attendees and the rate of the return both fell short of projections. The questionnaire, included in Appendix B, contained eight questions designed to gather data on the respondents knowledge and understanding of their organization s policies (questions 1, 5), the practices of their department (questions 2-4, 6), and the make-up and jurisdictional demographic of their organization (question 7, 8). Finally, the NFPA 1584 recommended practice was used as a comparison tool to identify areas for improvement. The proposals in NFPA 1584 were organized through the literature review and examined in terms of full compliance, partial compliance, and non-compliant.

19 Analysis of firefighter 19 Limitations The major limitation was the insufficient number of questionnaires returned for the external survey. Another mechanism should have been used to access a better sample. Also, the internal questionnaire could have been better constructed to gather more data regarding the effect of cultural attitudes rehab and respiratory protection, and should have been followed by a short test to determine how accurate their responses really were. Definitions Rating of Perceived Exertion (RPE) Scale: The original chart for RPE was created by Dr. Gunnar Borg, and is often referred to as the Borg scale. This scale started at 6 and ended at 20. Borg originally created this scale to correspond to heart rates, so that a 6 would be equal to a heart rate of 60 beats per minute and, most individuals would rate between 12 and 16 during maximum exertion. A new chart has replaced the Borg scale that ranges from 1 10, with 10 being hardest. Most individuals rate between 4 and 7 at maximum exertion on the new RPE scale, and that correlates with 60 percent to 85 percent of maximum heart rate. (NFPA, 2003) Results The literature review analysis of current research and reporting in the areas of fireground rehab and respiratory protection yielded significant results. Although the trends cited in the TriData study and affirmed through USFA structure fire statistics seem to point in positive direction, the information revealed by Dr. Rich and Chief Lee casts a pall of doubt over the trend toward decreasing injuries. However, armed with the knowledge of the silent killers lurking on

20 Analysis of firefighter 20 the fireground, departments can easily mitigate the hazards. The concept of active cooling was also revealed through the literature review. The current situation in the department was done through the analysis of policies in the literature review and through the internal questionnaire. The policy review yielded two results and both contained only limited information on respiratory protection. There was no policy found on rehabilitation, although it is practiced on almost all scenes and follows many of the NFPA 1584 recommendations. The results of the internal questionnaire are included in Table 1. Table 1 Responses to Internal Questionnaire Question: My supervisor stresses the importance of rehab on fireground scenes I fully understand rehab SOPs and protocols I am allowed to work as long as I want on the fireground without being sent for rehab 4. I have been criticized for going to or spending too much time in rehab or I have felt pressure to work past my limits 5. I have been critical of others for going to or spending too much time in rehab 6. I fully understand respiratory protection policies and protocols related to fireground operations 7. I have performed overhaul without an SCBA while there were products of combustion (off-gassing or smoke), to which I was exposed 8. It is OK to work in smoky atmospheres without SCBA as long as the air has been monitored and the CO levels are within acceptable limits 9. The only time medical monitoring is necessary is when someone has physiological symptoms that need to be examined

21 Analysis of firefighter 21 For the first question, my supervisor stresses the importance of rehab on fireground scenes, the majority at 43 percent, agreed, with the next highest percentage, 24.5, rated as neutral. The overwhelming majority of over 54 percent felt they fully understood rehab SOPs and protocols. A little over 11 percent disagreed or strongly disagreed with question 2. A clear majority of over 77 percent either disagreed or strongly disagreed that they had been criticized for spending too much time in rehab, while a smaller majority of 43 percent either disagree or strongly disagreed that they had been critical of others for spending too much time in rehab. Over 88 percent responded that they either agreed or strongly agreed that they fully understood respiratory protection policies and protocols. Almost half the respondents strongly disagreed or disagreed in regards to performing overhaul without an SCBA, and only 36 percent either agreed or strongly agreed. More than 64 percent disagreed or strongly disagreed that CO levels alone was an acceptable monitoring standard, with 28 percent agreeing or strongly agreeing that it was OK to work without SCBA in a CO monitored, but smoky atmosphere. The vast majority disagreed with the statement that only symptomatic personnel require medical evaluation. In the external survey, the desired goal was to identify what other organizations are doing in terms of firefighter rehab and respiratory protection. The results are included in Table 2. Table 2 Responses to External Questionnaire 1. Does your department have an SOP / SOG that governs fireground rehabilitation? Yes 16 No 11 Not Sure 1

22 Analysis of firefighter Is it standard procedure in your department to establish a formal rehab sector? Yes 18 No 8 Not Sure 2 3. Does your department utilize specialized rehab equipment, such as mister fans and tents, rehab / cool down chairs, rehab trucks or trailers? Yes 19: 8 mister fans, 5 tents, 3 active cooling chairs, 6 trucks or Trailers, and 3 fans No 9 4. Does your department mandate medical monitoring of firefighters at structure fires when entering and leaving rehab? Yes 10 No but EMS is available if needed 13 No EMS only responds if called 5 5. Does your department have a specific respiratory protection policy? Yes 24 No 3 Not Sure 0 6. What method does your department use to clear an atmosphere to allow firefighters to work without an SCBA? Monitor atmosphere for safe Carbon Monoxide level 8 Use positive pressure ventilation to clear structure 3 No policy Judgment call of the Incident Commander 8 Not allowed Policy mandates wear of SCBA in any hazardous atmosphere 5 Other: monitor and use positive pressure 3 7. What is the composition of your department? All Paid 9 All Volunteer 3 Combination 14

23 Analysis of firefighter What population level does your jurisdiction serve? Less than 10, ,000 50, , Over 100,000 4 Over 57 percent of the respondents reported their organization did have an SOP for fireground rehab and over 64 percent had a procedure to establish a formal rehab sector. Almost 68 percent used some type of specialized equipment to support rehab. A majority of departments, 46 percent, did not require medical monitoring, but did have EMS available. Nearly 86 percent said they had a respiratory protection policy. Clearing the atmosphere was split at 25 percent each for monitor for carbon monoxide and no policy. The next highest response was mandated SCBA wear with almost 18 percent. Over half the respondents represented combination departments and the majority of departments served populations less than 50,000. The final procedure involved analyzing the current practices of the department as compared to the NFPA 1584 standard and those results are displayed in Table 3. Table 3 Comparison of CHFD practices to the NFPA 1584 recommended practice Criteria: F = full compliance, P = partial, N = non-compliant F P N Standard Operating Procedures (SOPs) should be developed that include the following elements: medical evaluation and treatment, food and fluid replenishment, and crew rotation and relief. Emergency Medical Service (EMS) protocols should be developed in collaboration with the EMS medical director, the fire department physician, and the fire chief. All members are trained to recognize the symptoms or heat and cold stress.

24 Analysis of firefighter 24 SOPs should ensure that rehab operations are put in place whenever an incident escalates beyond the normal limits of physical or mental endurance. Personnel are trained in proper hydration and nutrition ICs must ensure that rehab is set up in area that is capable of conducting rehab operations and is also sheltered from any weather extremes In the event of hot weather, the area should be shaded or equipped with tents, fans, and misters, or air conditioning if inside a facility. Firefighters should also have the ability to sit and remove gear For extremes of cold and wet, the area or facility should be dry and provide warmth and dry clothing. EMS at a minimum of Basic Life Support (BLS) level should be provided for firefighters and EMS personnel should be included within the tactical level of the incident management systems EMS personnel should question firefighters arriving at rehab to determine illness, injury, and exertion. Upon entering the rehab area, the following criteria from each firefighter should be evaluated: 1-10 on the RPE scale, blood pressure, temperature, and heart rate. Local EMS protocols and department SOPs should always be utilized in the triage and treatment of firefighters. Firefighters meeting or exceeding any triage parameter should be evaluated after twenty minutes. If, after rest, the firefighter is still within an unacceptable range in any one parameter, the firefighter should be taken for medical treatment. (NFPA, 2003) Assignment to and out of rehab is a function of the IMS and members must be tracked through a personnel accountability system Upon entering rehab, firefighters should have the resources to add or remove clothing in order to regain body temperature, eat food to replace the calories expended in the operation, and drink water or sports drinks to return the body s fluid and electrolyte balance Work-rest cycles are established for personnel engaged in various types of work. Following the formal establishment of rehab, no one should be allowed to return to duty until after resting and re-hydrating for a minimum of 10 minutes and being medically evaluated and cleared by EMS personnel Firefighters should not be in an operational role at a scene for 12 or more hours without a multi-hour break away from the scene. If a member or members of the crew are seriously injured or killed, the entire crew is relieved of duty immediately. The department then implements critical incident stress management protocols

25 Analysis of firefighter 25 The time entering and leaving rehab should be recorded for all personnel. Medical evaluation done should be documented on a rehab evaluation report. If any medical treatment is performed, the required EMS forms as well as injury reports and workers compensation forms must be accomplished. Discussion The importance of understanding the underlying cause and the significant hazards of exposure to carbon monoxide and cyanide cannot be overstated. That is one of the single most important elements that resulted from this study. Especially since cyanide is such a common by product in fires due to the plastics and other materials found in the modern built environment (Lee, 2007). Equally troubling is the high potential for lethality and the short half-life in the body that makes it so difficult to diagnose and treat, especially since it mimics other symptoms so well (Lee). The encouraging news is the advent of experimental therapies that can be given post exposure that chemically combines with the cyanide to form a harmless B vitamin (Rich, 2007). Additionally, armed with the knowledge that the silent killers are lurking on the fireground, departments can easily mitigate the hazard by ensuring firefighters only remove their SCBA when there in zero off-gassing of post-fire fuels. This should become policy and practice in every department in America. The review of the department policies was not surprising. SOP is in need of an update and SOP does not establish an unequivocal benchmark for when it is safe to remove SCBA (CHFD, 2002). Having served in each of the identified command roles, command, operations, and safety, the author can attest that it is standard practice to allow firefighters to enter post-fire buildings when there is off-gassing of fuels taking place, so long as the carbon monoxide benchmark is met. Having been one of the firefighters, the desire to get out

26 Analysis of firefighter 26 of the SCBA is normally much stronger than the perceived harm, and therein lies the problem: the hazards present in today s fire are more hazardous than ever, but the perception is that a little smoke will not hurt you. In order to ensure the health and safety of our personnel, we must provide the necessary education to change attitudes and behaviors. Clearly, there exists a need for a comprehensive respiratory protection policy where all the required information can be accessed by everyone. The responses to the questionnaires in regards to policies and practices are also somewhat bewildering. The vast majority of personnel responded that they understood rehab SOPs and protocols, yet there is no SOP that covers rehab. A positive note from the internal survey was the recognition among a sizable portion that it was not OK to work in smoky atmospheres, and that medical monitoring is not just for the symptomatic. Another positive was that only a small group felt that their supervisor did not stress the importance of rehab, and a majority also has neither criticized others nor been criticized for going to rehab. There were few surprises in the external survey. The results of the medical monitoring and atmosphere clearing questions were somewhat troubling, but the majority did have an SOP for rehab as well as a respiratory protection policy. A large majority employ specialized equipment to support rehab. Another key element of the study was the information on active cooling. The forearm immersion study conducted by the DRDC was nothing less than astounding (Selkirk et al., 2004). The use of the active cooling concept needs to be widely communicated and others in the marketplace need to develop new equipment and tools utilizing the concept. The use of the NFPA 1584 standard as a process benchmark served to identify areas for improvement in the departments rehab program. Not surprising, there were many areas were full

27 Analysis of firefighter 27 or partial compliance were already present. The identification of avenues for process improvement is a good first step towards change. Recommendations The first recommendation is to complete an overhaul of SOP and In addition to or in place of, there needs to be a comprehensive respiratory protection SOP that provides all the information needed for a successful program and includes it all in one place. Additionally, a new SOP governing rehab needs to be developed. The new rehab SOP should follow the guidelines established in NFPA 1584 as closely as possible. All personnel need training on the new and revised policies to ensure there are no assumptions of what the SOPs and policies are. The information regarding the carbon monoxide and cyanide poisoning needs to be communicated to each member and followed up with recurring training to ensure everyone understands the significant threat that those hazards posses. Finally, in order to take advantage of the phenomenal concept of active cooling, the department should implement it as soon as possible. Investigate the purchase of rehab chairs and/or adapt equipment for use in active cooling. The better a firefighter recovers, the more work can be accomplished and the incident of injury reduced. Investing in equipment that helps firefighters rehab more effectively and reduces the potential for exhaustion and injury is definitely an acquisition worth pursuing.

28 Analysis of firefighter 28 References Centers for Disease Control (2004, January 27). Facts about cyanide. Retrieved April 14, 2007, from Chapel Hill Fire Department (1990). Standard Operating Procedure No In D. L. Jones (Ed.), Chapel Hill Fire Department: Standard Operating Procedures (pp. 1-2). Chapel Hill, NC: Author. Chapel Hill Fire Department (2002). SOP In D. L. Jones (Ed.), Chapel Hill Fire Department: Standard Operating Procedures (pp. 1-7). Chapel Hill, NC: Author. Chapel Hill Fire Department (2004). Rules, regulations and policies of the Chapel Hill Fire Department. Chapel Hill, NC: Author. Federal Emergency Management Agency (2006, December 28). U.S. Structure Fire Loss: Retrieved April 5, 2007, from all_structures.shtm Lee, M. (2007, April 11). Cyanide poisoning poses hidden threat. Firerehab.com, 3, pp Retrieved April 14, 2007, from National Fire Protection Association (2003). Recommended practice on the rehabilitation of members operating at incident scenes operations and training exercises (2003 ed.). Quincy, MA: Author. National Fire Protection Association / International Association of Fire Chiefs (2004). Fundamentals of firefighter skills (1st ed.). Sudbury, MA: Jones and Bartlett. Rich, P. B. (2007, March 26). The heart, hemoglobin, and the firefighter. Paper presented at the Chapel Hill Fire Academy, Chapel Hill, NC.

29 Analysis of firefighter 29 Selkirk, G. A., McLellan, T. M., & Wong, J. (2004, August). Active versus passive cooling during work in warm envrionments while wearing firefighter protective clothing. Retrieved April 17, 2007, from TriData Corporation (2004). The economic consequences of firefighter injuries and their prevention. Gaithersburg, MD: National Institute of Standards and Technology. United States Fire Administration / National Fire Data Center (2004). Fire in the United States: (13th ed.). Emmitsburg, MD: Author.

30 Analysis of firefighter 30 Appendix A CHFD Rehab Questionnaire Please evaluate the following questions in terms of your personal opinion and perspective. All responses are anonymous and confidential. All responses should be given within the context of your position at the CHAPEL HILL FIRE DEPARTMENT ONLY. Each item is rated in terms of how strongly you agree or disagree with each statement on a five point scale: 1 = Strongly Disagree, 2 = Disagree, 3 = Neutral, 4 = Agree, 5 = Strongly Agree. Only rate a question neutral if you have no opinion or no information on which to base an answer. Place an in the block that most represents your point of view. Strongly Disagree Neutral Agree Strongly Disagree Agree Question: My supervisor stresses the importance of rehab on fireground scenes 2. I fully understand rehab SOPs and protocols 3. I am allowed to work as long as I want on the fireground without being sent for rehab 4. I have been criticized for going to or spending too much time in rehab or I have felt pressure to work past my limits 5. I have been critical of others for going to or spending too much time in rehab 6. I fully understand respiratory protection policies and protocols related to fireground operations 7. I have performed overhaul without an SCBA while there were products of combustion (off-gassing or smoke), to which I was exposed 8. It is OK to work in smoky atmospheres without SCBA as long as the air has been monitored and the CO levels are within acceptable limits 9. The only time medical monitoring is necessary is when someone has physiological symptoms that need to be examined

31 Analysis of firefighter 31 Appendix B Fireground Rehab and Respiratory Protection Questionnaire This is a research project survey to determine how organizations are managing firefighter rehabilitation and respiratory protection on the fireground. 9. Does your department have an SOP / SOG that governs fireground rehabilitation? Yes No Not Sure 10. Is it standard procedure in your department to establish a formal rehab sector? Yes No Not Sure 11. Does your department utilize specialized rehab equipment, such as mister fans and tents, rehab / cool down chairs, rehab trucks or trailers? Yes Please specify: No 12. Does your department mandate medical monitoring of firefighters at structure fires when entering and leaving rehab? Yes No but EMS is available if needed No EMS only responds if called 13. Does your department have a specific respiratory protection policy? Yes No Not Sure

32 Analysis of firefighter What method does your department use to clear an atmosphere to allow firefighters to work without an SCBA? Monitor atmosphere for safe Carbon Monoxide level Use positive pressure ventilation to clear structure No policy Judgment call of the Incident Commander Not allowed Policy mandates wear of SCBA in any hazardous atmosphere Other: 15. What is the composition of your department? All Paid All Volunteer Combination 16. What population level does your jurisdiction serve? Less than 10,000 10,000 50,000 50, Over 100, Please list your organization. All information collected will remain confidential and this information is only being collected to avoid duplication. Thank You!