Running head: DEVELOPING AN EMERGENCY INCIDENT FIREFIGHTER

Transcription

1 Developing an Emergency 1 Running head: DEVELOPING AN EMERGENCY INCIDENT FIREFIGHTER Developing an Emergency Incident Firefighter Rehabilitation Procedure for the Middletown, Connecticut Fire Department John Woron Middletown Fire Department Middletown, Connecticut

2 Developing an Emergency 2 Certification Statement I hereby certify that this paper constitutes my own product, that where language of others is set forth, quotation marks so indicate, and that appropriate credit is given where I have used the language, ideas, expressions, or writings of another. Signed:

3 Developing an Emergency 3 Abstract Firefighting is a strenuous and arduous profession. In the discharge of their duties, firefighters are routinely exposed to emotional, physical, physiological, and psychological stressors. Emergency incident firefighter rehabilitation programs are designed to mitigate or alleviate the effects of the fore mentioned stressors. Several studies have shown that proper firefighter rehabilitation during the active phases of emergency incident operations reduce both injuries and or death caused by thermal, mechanical or psychological insult on the body. As fore mentioned, although several studies have shown the positive benefits of a properly implemented emergency incident rehabilitation program, currently the Middletown Fire Department does not utilize a formal program. Through action research, the purpose was to investigate best practices used by area fire departments and develop a Standard Operating Procedure to address emergency incident firefighter rehabilitation in the Middletown Fire Department. The research answered the following questions: a) How are area fire departments conducting emergency incident firefighter rehabilitation? b) What standards and recommendations exist for emergency incident firefighter rehabilitation? c) What discrepancies currently exist in the method the Middletown Fire Department utilizes to conduct emergency incident firefighter rehabilitation? d) How can the existing emergency incident rehabilitation procedures utilized by the Middletown Fire Department be incorporated into a comprehensive Standard Operating Procedure? Utilizing a comprehensive literature review, internal and external questionnaires, and peer interviews, the research concluded that not only was there a need for a comprehensive emergency firefighter incident rehabilitation Standard Operating Procedure, but also a change in the department s culture concerning rehabilitation. A draft Standard Operating Procedure was developed and presented to the Fire Chief for consideration for approval.

4 Developing an Emergency 4 Table of Contents Certification Statement 2 Abstract 3 Table of Contents.4 Introduction..5 Background and Significance..6 Literature Review.9 Procedures..19 Results 21 Discussion and Implications..28 Recommendations..37 References..39 Appendix A 41 Appendix B 45 Appendix C 47 Appendix D 48 Appendix E 53 Appendix F 55 Appendix G 62 Appendix H 63

5 Developing an Emergency 5 Introduction Firefighting is a strenuous and demanding profession that often times leads to injuries due to environmental stressors and over exertion. Firefighters are required to operate in combative conditions while wearing several additional pounds of protective clothing and equipment. Increased emotional, physical, and psychological stress coupled with increased exertion levels can quickly lead to over-exertion related medical emergencies or injuries. Advancements in protective firefighting clothing have become a double edged sword to the fire service. While this state of the art protective clothing provides better protection, it also has a tendency to trap a firefighter s body heat and sweat which becomes a cumulative physiological stressor. The fire service is steeped in tradition. For years firefighters have accepted injury and even death as an inherent part of their job, even a badge of courage. Fire departments largest fixed cost is its personnel. Beyond the empathetic and compassion aspects of firefighter injuries lies the financial impact to a department and municipality as a result of firefighter injuries and deaths. In 2010, 85 firefighters died in the line of duty, 61% of these deaths were attributed to stress and overexertion related activities (United States Fire Administration, 2010). The National Fire Protection Association identified 32,205 firefighter injuries on the fire ground during the 2009 calendar year with 2,650 or 8.4% of the total injuries being attributed to stress and overexertion. The problem is that the Middletown Fire Department does not currently possess a Standard Operating Procedure addressing emergency incident firefighter rehabilitation. Currently firefighter rehabilitation at emergency scenes is accomplished in a very inconsistent manner. The purpose of this research study is to investigate best practices used by area fire departments and develop a draft emergency incident firefighter rehabilitation operating procedure.

6 Developing an Emergency 6 This research project will utilize action research to assist in answering the following questions: a) How are local fire departments conducting emergency incident firefighter rehabilitation? b) What standards and recommendations exist for emergency incident firefighter rehabilitation? c) What discrepancies currently exist in the method the Middletown Fire Department utilizes to conduct emergency incident firefighter rehabilitation? d) How can the existing emergency incident rehabilitation procedures utilized by the Middletown Fire Department be incorporated into a comprehensive Standard Operating procedure? Background and Significance The Middletown Fire Department provides a diversified all hazards response to a city of 60,000 residents and visitors each day. The City of Middletown is centrally located in the State of Connecticut, is bordered to the east by the Connecticut River and is transected by two Interstate Highway Systems. The City of Middletown is comprised of 42 square miles and is diversified to include urban, suburban and rural areas. Middletown is located in the Hartford- Springfield Metropolitan Region which includes a population of 1.9 million people. The Middletown Fire Department (MFD) staffs four shifts of fourteen personnel per shift. The MFD is a fully career fire department. All members are certified Emergency Medical Technicians and are contractually required to be trained to the NFPA 1001 Firefighter II level. The MFD provides service from two fire stations. Services include fire, rescue, emergency medical services, fire prevention, education, technical rescue, dive rescue, and marine operations. Emergency responses are handled by one Battalion Chief, three Engine Companies,

7 Developing an Emergency 7 one Truck Company, and one Assistant Chief/Safety Officer. The Middletown Fire Department (MFD) runs close to 5,000 emergency calls each, approximately 60% which are medical based in nature. The City of Middletown enjoys a distinct four season climate. Winter temperatures average 25 degrees Fahrenheit with extreme low temperatures below zero at times, while summer temperatures average in the mid 80 degree Fahrenheit range with typically 10 or more days above 90 degrees. Average precipitation is 55 inches where winters typically average around seventy inches of snowfall. Weather extremes can create year round firefighter rehabilitation challenges for MFD personnel operating at incidents that are labor intensive. These include but are not limited to; structural fires, motor vehicle extrications, technical rescue incidents, hazardous materials incidents, long duration EMS incidents, and long term deployments. At the present time the Middletown Fire Department does not possess a formal emergency incident firefighter rehabilitation Standard Operating Procedure (SOP). Without a formal SOP in place, firefighter rehabilitation is completed at the discretion of the Incident Commander or immediate supervisor. Because there is no SOP in place, rehabilitation is never performed in a consistent manner from shift to shift. In the warmer months rehabilitation takes the form of firefighters taking a break, removing their protective clothing, and re-hydrating with water. In the colder months rehabilitation consists of getting cold, wet, or tired firefighters out of the cold and into a warm environment. Although the Middletown Fire Department possesses a hazardous materials decontamination trailer which can be utilized as a warming or cooling vehicle, it is not a front line manned apparatus and must be special called. In

8 Developing an Emergency 8 most instances on scene engine and truck company apparatus are utilized as the vehicles to warm or cool the firefighters during rehabilitation. Not possessing an adequate and consistent rehabilitation SOP is potentially putting Middletown Fire Department personnel at risk of injury or even death from stress or overexertion. At many emergency incidents, firefighter rehabilitation becomes an after thought. Because of pre-established cultural norms, firefighters tend to look at rehabilitation as a weakness, thus they attempt to avoid rehabilitation whenever possible. Without an SOP to utilize as a benchmark and a policy to enforce, many Shift Commanders and Company Officers will look the other way and not activate or enforce rehabilitation for the personnel resources assigned to them. Firefighters do not want to take needed work breaks, thus they can overexert themselves which can jeopardize their health and safety. As fore mentioned, the (United States Fire Administration) reported that 61% of the 2010 Firefighter Line Of Duty Deaths were attributed to stress and overexertion. Bledsoe (2008) states: Rehabilitation should be an integral part of the IMS for both the fire ground and training exercises. Rehabilitation should commence anytime emergency or training operations pose the risk of department members exceeding a safe level of mental or physical endurance. (p. 3) While the safety culture in the fire service can be slow to change, there are several agencies and organizations which have championed firefighter safety. One such group is the National Fire Academy s (NFA) Executive Fire Officer Program (EFOP). The Executive Development Course identifies three primary curriculum themes; leadership, research, and change. Translated into a safety message, true fire service leaders champion research and positive change to ensure

9 Developing an Emergency 9 firefighter health and safety is always the highest priority for their organizations. The United States Fire Administration (USFA) is another strong proponent of firefighter health and safety. In a 2008 report to Congress, the USFA identifies one of its key objectives is to significantly reduce the nation s loss of life from fire, while also achieving a reduction in property loss and non-fatal injury due to fire (p. 1). This reduction in the loss of life from fire and injuries includes the fire service. With over 50% of line of duty deaths and over 2,600 injuries annually contributed to stress and overexertion, possessing a comprehensive emergency incident firefighter rehabilitation procedure is imperative. Literature Review A literature review was conducted to research current emergency firefighter rehabilitation programs and rehabilitation program recommendations. The information gathered in this literature review was used to assist the author in preparing a draft Standard Operating Procedure (SOP) for emergency incident firefighter rehabilitation in the Middletown Fire Department (MFD). The idea to create this new SOP to address emergency incident firefighter rehabilitation was presented to MFD Fire Chief Ouellette; the selling point was current documentation of several agencies linking overexertion and stress on the fire ground with an increased risk of injury or even death. Knowing that any fire department s greatest asset is its personnel, the chief agreed to allow the author to research and create a draft SOP. The greatest benefit of a new rehabilitation SOP would be a consistent model to follow for each of the four platoons of the MFD. Firefighting can be compared to the scene from the 1994 movie Forrest Gump. While waiting for a bus, Forrest quotes (IMDb, 1994) how his momma always said, life was like a box of chocolates, you never know what you re gonna get (p. 3). Each and every day, firefighters

10 Developing an Emergency 10 are required to respond to a myriad of emergency calls. Emergency incidents have no bounds; they take place day or night, holidays, week days and weekends. Firefighter stressors can come in the form of physical, physiological, environmental or a combination of each. The United States Fire Administration (USFA) publication Emergency Incident Rehabilitation (2008) speaks to these issues: Unlike many jobs, firefighters cannot pick the time or conditions these jobs must be carried out. When you combine the inherent stresses of handling emergency incidents with the environmental dangers of extreme heat and humidity or extreme cold, you create conditions that can have an adverse impact on safety or health of the individual emergency responder. Members who are not provided adequate rest and rehydration during emergency operations or training exercises are at increased risk for illness or injury, and may jeopardize the safety of others on the incident scene. (p. 3) Why do firefighters resist being sent to emergency incident rehabilitation? The fire service is a tradition driven fraternity, many times you hear firefighters quote the fire service, 200 years of tradition unimpeded by progress. Many in the fire service live by the macho creed that injuries and even death are collateral risk of being a firefighter. Dickinson and Wieder (2004) refer to this phenomenon as a badge of courage that is worn with pride. While this might have been an acceptable practice and attitude at one time, the safety culture of the fire service finally seems to be shifting away from this type of behavior. Many fire service organizations including the United States Fire Administration (USFA), National Fire Protection Association (NFPA), International Association of Fire Chiefs (IAFC), and International Association of Firefighters (IAFF) have produced research studies and supporting documentation championing the benefits of emergency incident firefighter rehabilitation.

11 Developing an Emergency 11 In the foreword section of the Bledsoe (2008) Rehabilitation and Medical Monitoring Standard, Gary Ludwig points out that annually approximately 50% of firefighter deaths continue to be attributed to heart attack and strokes. Line of Duty Death (LODD) research has begun to show a correlation between heavy exertion, stress, fatigue and smoke inhalation and cardiac based LODD s and injuries. Whether career or volunteer, many fire departments operate with limited power and staffing levels. This translates into fire departments having to juggle sending firefighters to rehab while having enough manpower available to continue to handle the given emergency. Many times these limited manpower situations force Incident Commanders to push their personnel to extremes, thus exposing firefighters to possible overexertion or stress related emergencies. Wolf (2007) writes: NORMal leaders subject their two or three person companies to more physical punishment and greater risk of injury because of a lack of sufficient staffing to perform the many tasks required on the fireground. Fire fighters on understaffed departments go through three or four air bottles before the fire is knocked down because insufficient staffing prevents rotating crews through rehab or distributing the workload among more engine companies. (p. 1) Many different professions require their personnel to properly prepare themselves for exertion based activities. Professional sports teams are a good example. These teams assign trainers, doctors, and other wellness based personnel to ensure their athletes are properly stretched, hydrated, receive proper caloric intake and are mentally and physically ready for the ensuing event. Many fire departments have realized the benefits associated with health and safety programs and practices directed at ensuring on duty personnel are fit for duty at any given time.

12 Developing an Emergency 12 Bledsoe (2008) summarizes health risks can be reduced through sufficient hydration, diet, limited outdoor physical exercise on hot days, acclimatization, and monitoring of weather conditions. This will help department members understand the dangers associated with working in varying climatic conditions (p. 6). One of the most important aspects of a quality rehabilitation procedure is knowing when to establish it. The Incident Commander must walk the fine line between waiting too long and running the risk of overexerting personnel or removing line personnel and sending them to rehab and creating a manpower shortage. Many fire departments that utilize an emergency incident rehabilitation program front load emergency incidents with adequate levels of manpower. This is achieved through extra stand-by companies or through the use of automatic or mutual aid. Another important initial decision is where to locate the rehabilitation sector. This area needs to be close enough to the emergency incident to facilitate the needs for on scene resources that need to be utilized but far enough away from the emergency incident to ensure that emergency personnel are not attempting to leave rehab to re-enter the hot zone to work again. Once the decision to formally establish emergency incident rehabilitation is made, a strict accountability system must be implemented. Dickinson and Wieder (2004) explain Responders staffing rehab must understand how their department s accountability system operates and must make sure that all personnel in rehab strictly adhere to accountability procedures. (p. 16) One of the most efficient systems to track personnel in and out of rehab is with the use of an accountability document or form. Although most individual departmental accountability forms differ, certain generic information should be standard. This would include; name, organization represented, rank, crew or individual assignment, time in, time out, numbers of self-contained

13 Developing an Emergency 13 breathing cylinders used, time of initial medical evaluation, heating or cooling interventions, hydration or nourishment, medical complaints, medical interventions, and any recommended hospital transport. Lindsey (2009) suggests that when being sent to rehab that crews remain intact both entering and leaving. This ensures that individuals do not get separated from their assigned work group. Although many emergency incident firefighter rehabilitation models exist, most are tailored to each individual organization. With that being said, there still remains specific benchmarks that should be met regardless of the template used. These include; accountability, medical monitoring, relief from climatic conditions, active and/or passive warming or cooling, rest and recovery, rehydration, caloric and electrolyte replacement, initial critical incident stress debriefing, EMS treatment or transport, and release or reassignment. Medical monitoring is one of the gray areas of emergency incident firefighter rehabilitation. Predominately there are two methods for medical monitoring. It can be done by EMS trained department personnel or EMS personnel from outside the organization. Most firefighters when asked about medical monitoring prefer to have members from their own organizations performing this assignment. The first and most important step in medical monitoring is documentation. Bledsoe (2008) clearly identifies the delineation between medical monitoring and emergency medical care documentation. When a firefighter enters rehab and undergoes medical monitoring, this information is maintained as part of the incident record in the department s data collection system. If a firefighter receives emergency medical care, this information must be kept by the entity providing the care and a copy put in the individuals medical file.

14 Developing an Emergency 14 Medical monitoring must include an initial assessment of the firefighter s vital signs beginning with heart rate. It appears that the consensus threshold is 100 beats per minute at the twenty minute rehab mark. If the firefighter s heart rate has not dropped to under 100 beats per minute after 20 minutes of rest, then the firefighter should not be released from rehab and should undergo further medical evaluation. While many studies recommend body core temperature readings, this becomes very impractical during rehab. Oral and tympanic methods of measurement are the only practical options, but can be anywhere from one to three degrees cooler than the core body temperature. For this reason, many organizations do not utilize temperature monitoring during rehab. Respiratory rate is another suggested vital sign that should be monitored in rehab. While a normal adult respiratory rate is 12 to 20 breaths per minute, firefighters entering rehab will most likely have respiratory rates above 20 breaths per minute. After adequate rest and rehab these respiratory rates should return to normal levels prior to the firefighter being released from rehab. Many fire departments check their members pulse oximetry. Normal oxygen saturation runs between 95% and 100%. Members who fall under 95% oxygen saturation should be checked for hypoxemia, and may require oxygen therapy to restore their oxygen levels to normal. While being considered relatively new technology, many fire departments are beginning to also check personnel for carbon monoxide saturation and cyanide exposures. Both blood gases have been linked to sudden cardiac events in stressed and overexerted firefighters. The last vital sign that most departments check during medical monitoring is blood pressure. Blood pressure measurement is one of the most controversial rehab monitoring medical checks. Bledsoe (2008) states: Blood pressure measurement has a significant potential for error, especially in the noisy

15 Developing an Emergency 15 and tumultuous prehospital environment. Blood pressure cuffs, like other medical devices applied repeatedly to multiple, often sweaty and grimy people, are implicated in spread of antibiotic-resistant bacteria between individuals. Members of ethnic and racial groups respond very differently to physiological stress, sometimes with dramatic increases in blood pressure blood pressure can be affected by cardiac rhythm, physical conditioning, pain, temperature, age, sex and a variety of internal and external stimuli. (p. 34) It is for these reasons that many fire departments are no longer measuring blood pressures. For those who continue to monitor blood pressure, individuals with systolic readings above 160 and diastolic readings above 100 after 20 minutes are not released from rehab and are referred for continued medical monitoring. Most firefighter rehabilitation models recommend vital signs being checked every 10 minutes. When performing emergency incident firefighter rehabilitation, it is important to assess how personnel will be sheltered or removed from climatic conditions. These conditions can occur in the form of heat, humidity, cold, rain, snow, and ice to name a few. Facilities, vehicles or other areas that firefighters will be removed to becomes dependent upon the availability of these resources and the duration of the emergency. USFA Emergency Incident Rehabilitation (2008) states The use of fixed facilities is especially helpful on long-term incidents and in wet or otherwise extreme climatic conditions. Buildings with large, open spaces immediately adjacent to entrance/exit doors make the best rehab areas. (p. 96) Many times these types of structures provide the benefit of climatic controlled areas, running water, restroom facilities, and kitchen facilities. When fixed facilities are not an option, most fire departments will utilize fire apparatus or vehicles as an avenue to remove their personnel from adverse climatic conditions. Examples of

16 Developing an Emergency 16 apparatus are; fire pumpers, aerial apparatus, heavy rescue apparatus, ambulances, or other ancillary fire department vehicles. One option that seems popular is to utilize buses. A bus works well for several reasons, several firefighters can be housed in a single bus, the interiors are usually rugged enough to handle dirty or wet protective clothing, and an open aisle way makes medical monitoring easier for EMS personnel assigned that task. USFA Emergency Incident Rehabilitation (2008) points out Most of these buses are equipped with heating and air conditioning systems that allow the interior climate to offset adverse exterior weather conditions and allow firefighters to doff their equipment for maximum rest and recovery (p. 101) Many fire departments have carried this idea forward and utilize converted busses as their organizations rehab vehicle. Active/passive heating and cooling relates to the methods used to heat or cool firefighters in rehabilitation. Passive heating or cooling is defined as allowing the firefighter to reheat or cool on their own with no intervention. This can be as simple as bringing firefighters into the rehab area and having them doff their gear to begin to cool off or enter a warm environment to supplement rewarming. Active heating and/or cooling requires intervention to assist the firefighters achieve the desired results. Smith and Haigh (2006) describe active cooling as implying external means of lowering core body temperature and includes cold towels, hand and forearm immersion, misting fans and tents, and ice vests. The most effective are cold towels and forearm immersion. (p.3) Active heating can be achieved by removing firefighters from their wet gear, applying warm blankets, and providing warm foods or beverages. Both active heating and/or cooling may take longer to achieve, thus requiring the firefighter to remain in rehab for a longer period of time.

17 Developing an Emergency 17 Rest and recovery periods are dynamic to the given emergency. Most rehabilitation programs recommend rest and recovery times to be driven by SCBA cylinder use or periods of intense work. Bledsoe (2008) recommends: Personnel entering rehab for the first time should rest for at least 10 minutes-longer when practical. A member should not return to operations if he or she does not feel adequately rested. Personnel should rest for a minimum of 20 minutes following use of a second 30- minute SCBA cylinder, a single 45 minute SCBA cylinder, a single 60-minute SCBA cylinder, or 40 minutes of intense work without an SCBA. (p. 16) Hydration, electrolyte, and caloric replacement becomes imperative during firefighter rehabilitation. While caloric replacement may be tied to longer term emergency incidents, basic hydration and electrolyte replacement takes place during all emergency firefighter rehabilitation periods. The USFA Emergency Incident Rehabilitation (2008) report discusses how the human body can lose as much as a liter of sweat per hour when being subject to extreme exertion related activities. Bledsoe (2008) takes this theory further by discussing how firefighter gear interferes with the body s heat exchange by trapping moisture between their skin and the inner most level of protective clothing, this causes an even greater fluid loss Firefighters can easily lose 32 ounces of sweat in less than 20 minutes of strenuous firefighting activities. In addition, sweating will continue even after a firefighter stops working and enters rehabilitation. (p. 26) Smith and Haigh (2006) recommend that plain water be the choice of fluid replacement during firefighter rehabilitation. Tracking how many bottles of water each firefighter consumes affords a simple method of tracking consumption. For longer work periods, electrolyte replacement needs to be considered. This is usually accomplished with sports drinks. When used as a replacement fluid during rehabilitation, sports drinks should not be diluted. Dilution of

18 Developing an Emergency 18 sports drinks causes them to lose their osmolarity which in return causes them to lose their absorption qualities. This can lead to nausea or vomiting which will accelerate dehydration. Caffeinated and carbonated drinks should also be avoided, as they have a tendency to accelerate fluid loss in the firefighter. Most studies agree that caloric replacement should be considered for long duration incidents or extreme work periods of over an hour. Bledsoe (2008) suggests that firefighters in rehabilitation requiring caloric intake consume between 30 and 60 grams/hour of carbohydrates. Smith and Haigh (2006) point out that foods used for caloric replacement should be low in fat and appropriate for the activity. Foods like pizza, donuts, and fast food should be avoided. To reduce the chance of contamination, water or waterless hand cleaner and towels should be available to anyone required to eat during rehab. Firefighter well being and mental health should also be assessed during emergency incident rehabilitation. Personnel should be closely observed for any contraindicated behaviors. Bledsoe (2008) suggests: If one or more members of a crew or company are seriously injured or killed during an incident, all members of the crew or company should be removed from emergency responsibilities at the incident as soon as possible. Again, services of competent, licensed mental health personnel should be made available to members of the department. (p. 38) As firefighters have spent the appropriate amount of time in rehabilitation, they must receive a final medical monitoring check. At this point three options are available for personnel in rehabilitation. They can be eligible for release and reassignment, a need for more time in rehabilitation, or medical transport to a hospital due to medical contraindications. All of the emergency firefighter rehabilitation models researched concurs that a sufficient amount of

19 Developing an Emergency 19 transport ambulances should be available on scene. If a firefighter needs to transported to the hospital, all medical information generated during rehabilitation and at the hospital must be included in the member s personal medical file. Whether released from rehab or sent to the hospital, member accountability must be thoroughly maintained throughout the rehabilitation process. At the conclusion of the emergency incident, all information generated during rehab should be retained and cross referenced to the incident documentation. Through several firefighter health and safety initiatives, the fire service has proactively tackled the issue of emergency incident firefighter rehabilitation. Researching materials for this literature review, the author found a wealth of firefighter rehabilitation procedures, reports, and recommendations. It is the charge of the fire service to utilize these resources to research, develop and implement emergency incident firefighter rehabilitations programs for their own individual organizations. Procedures Research for this project was conducted utilizing action research and an extensive literature review. The goal of this action based research and literature review was to seek, review and collect data to assist in producing a draft Standard Operating Procedure (SOP) for emergency incident firefighter rehabilitation for the Middletown Fire Department. Two feedback surveys were prepared; one survey was distributed to nineteen fire officers within the Middletown Fire Department (MFD). The goal of this internal survey was to determine what parameters each officer utilizes when making the decision to provide emergency firefighter rehabilitation even though the department presently operates without a formal SOP.

20 Developing an Emergency 20 The second survey was designed to obtain information from twelve other fire departments and the Connecticut State Fire Academy (CFA) as to how they provide emergency firefighter rehabilitation for their organizations. The literature review looked at several articles found both on the Internet and fire department trade journals. Three specific documents were extremely helpful in providing relevant rehabilitation information, these include; Emergency Incident Rehabilitation by Dickinson and Wieder (2004), Bledsoe, A Guide for Best Practices Rehabilitation and Medical Monitoring (2008) and United State Fire Administrations Emergency Incident Rehabilitation (2008). The three fore mentioned publications are specifically designed to address and make recommendations for the implementation of emergency incident firefighter rehabilitation. The survey that was developed for dissemination within the MFD was hand delivered to each officer by the author. Each member given a survey was briefed on the background of this Executive Fire Officer Research Paper and how the information obtained from the survey would be used to help construct a new emergency firefighter rehabilitation program for the MFD. Although the survey was distributed to nineteen fire officers, only eleven of these officers typically have the authority to initiate emergency rehabilitation. The other eight officers were allowed to participate in the survey because during extreme emergencies, they could have the potential to cover as an Acting Shift Commander or Incident Commander. The author received nineteen surveys back which created a 100% participation rate. Because the eight junior Fire Lieutenants had not yet worked in the capacity of Incident Commander or Shift Commander at emergencies requiring emergency firefighter rehabilitation, they did not participate in the survey. A copy of this internal survey is shown in Appendix B of this paper. A total of seven questions were asked, Appendix E lists the complete results of the survey.

21 Developing an Emergency 21 A second survey was developed for local area fire departments and the Connecticut State Fire Academy (CFA). This survey was distributed to twelve fire departments and the CFA. A cover letter (Appendix C) was sent with each survey along with a follow-up telephone call from the author. All thirteen surveys were returned providing 100% compliance. The survey (Appendix A) asked eighteen questions. The author chose these thirteen agencies based on being either like size fire departments or organizations that provide similar emergency services as the Middletown Fire Department. The complete results of this survey are included in (Appendix D). The two research surveys worked well as 100% compliance was reached and valuable information was obtained both internally and externally to be utilized in the formation of a draft Standard Operating Procedure on emergency incident firefighter rehabilitation for the Middletown Fire Department. One interesting component of the external survey indicated that the majority of the organizations polled had very similar rehabilitation programs. This indicated that when these individual organizations designed or modified their programs, they consulted many of the other organizations the author used for this survey and shared their information. Results The first survey reviewed by the author was the internal survey of officers in the Middletown Fire Department. Question 1 asked As a potential MFD Incident Commander, how often do you utilize a formal rehabilitation operation? The majority of those surveyed responded that they sometimes initiated rehab; only two respondents answered rarely. Question 2 asked What criteria do you utilize to determine the need for a formal firefighter rehabilitation operation? The candidates were given four choices; all eleven respondents checked each of the possibilities. These included the type of incident, atmospheric conditions, air consumption, and request of MFD personnel. Questions 3 inquired Who do you assign to supervise the

22 Developing an Emergency 22 Rehabilitation Sector? The candidates were given three choices and could also fill in any other information. All eleven candidates agreed upon Middlesex Hospital Paramedics and MFD Personnel as their choices. Question 4 asked What parameters do you utilize to see that firefighter rehabilitation is accomplished? The candidates were given five choices and could write in any other information. All eleven candidates agreed upon the five given choices. These included; Specific rest periods, food/fluid replacement, removal of protective clothing, medical monitoring/evaluation, and air consumption. Question 5 asked Do you utilize a formal accountability system for personnel in rehabilitation? All eleven candidates answered yes, indicating that formal accountability is always practiced during rehabilitation. Question 6 requested the candidate to answer What parameters are used to clear firefighters from rehabilitation back to service? Five choices were given and the candidate could also write in any additional information. All eleven respondents agreed that normal vital signs and specific rest periods were used as criteria. Two respondents based the decision with the Incident Commander and two other respondents felt the decision was that of the Rehabilitation Sector Commander. Question 7 asked How are MFD personnel s rehabilitation activities documented? The candidates were given four choices and also given an area to fill in additional information. All eleven candidates agreed that the NFIRS report and EMS reports were the avenue to document rehabilitation for each member of the MFD. The eleven members of the Middletown Fire Department who participated in the survey hold the following ranks; Fire Chief, Deputy Fire Chief, Assistant Fire Chief, (4) Battalion Chiefs, and (4) Senior Fire Lieutenants. The results were compiled and can be referenced in (Appendix D).

23 Developing an Emergency 23 The second survey prepared was designated for distribution to twelve local area fire departments and the Connecticut Fire Academy. Questions were designed to describe how these local agencies conduct emergency incident firefighter rehabilitation. Question 1 asked Does your organization utilize a formal firefighter rehabilitation program at emergency incidents? Eleven of the organizations surveyed utilized a formal rehab program; the two organizations that stated no utilized what they considered to be informal programs. Question 2 asked Does your organization utilize an emergency incident rehabilitation Standard Operating Procedure? As the answers dictated with question 1, the same eleven fire departments utilized a formal Standard Operating Procedure, while the two other fire departments did not. Question 3 asked What standards and criteria were used to develop your organizations Standard Operating Procedure? All eleven departments that indicated they utilized a formal Standard Operating Procedure used NFPA 1500 Standard on Fire Department Occupational Safety and Health Program (2007), NFPA 1584 Standard on the Rehabilitation Process for Members During Emergency Operations and Training Exercises (2008), NFPA 1582 Comprehensive Occupational Medical Program for Fire Departments (2007), and NFPA 1583 Health-Related Fitness Programs for Fire Department Members (2008) as the base criteria for building their procedures. Question 4 inquired Does your organization follow the recommendations of NFPA 1584 (2008) Firefighter Rehabilitation and Medical Monitoring? Although all thirteen organizations polled stated they followed NFPA 1584 for medical monitoring of their personnel, only eleven agencies had a policy for this standard in their rehabilitation procedures. Question 5 asked What type of training dictates utilizing emergency firefighter rehabilitation? All twelve fire departments polled stated structural fires, hazardous materials emergencies, long duration events

24 Developing an Emergency 24 and training events meeting criteria were the basis for requiring rehabilitation. The Connecticut Fire Academy utilized rehabilitation for training and long duration events. Question 6 asked Does your organization employ a rehabilitation vehicle? Eight of the thirteen agencies polled stated they utilized a specific rehabilitation vehicle. Question 7 asked If your organization employs a rehabilitation vehicle, who delivers the vehicle to an emergency scene? Of the eight agencies that possess vehicles, seven of the fire departments respond the rehab vehicle with on duty personnel. The CFA hires medically trained instructors to transport and operate their rehabilitation vehicle. Question 8 asked Who staffs your Rehabilitation Sector? Of the twelve fire departments who responded, eleven fire departments utilized a mix of department personnel and a private ambulance company as the transport agency. One fire department entirely utilized a private ambulance service for the staffing and the CFA utilized instructional staff and a private ambulance company for transport. Question 9 asked What equipment is carried on your organization s rehabilitation vehicle? Most departments answered in a generic fashion. All departments carried EMS equipment, water, sports drinks, energy bars, towels, blankets, folding chairs, misting fans, accountability equipment, tarps, portable heaters, disposable clothing, pop-up tents, coolers, and different lighting equipment. Question 10 asked How does your organization determine when a firefighter must go to rehabilitation? The departments polled were given six choices and also had the option of writing in additional information. The results for this question varied. All twelve fire departments and the CFA indicated the type of incident, number of SCBA bottles used, environmental factors, and time spent in the hazardous environment were utilized. A limited number of departments indicated that rehabilitation was determined by the Incident Commander or Company Officer.

25 Developing an Emergency 25 Question 11 asked Are firefighters that are sent to rehabilitation checked in and are utilizing an accountability system? All twelve fire departments and the CFA answered yes to this question. Question 12 inquired For informational purposes, how do you document a firefighter s visit to rehabilitation? The organizations polled were given four choices and had the option to write in any additional information. All twelve fire departments utilized the NFIRS report and a rehabilitation worksheet. If a member were required to be transported for medical treatment, all twelve fire departments utilized an EMS run form. The CFA used a rehabilitation worksheet for each student or instructor; they also mirrored the fire departments use of an EMS run form for any medical treatment provided. Question 13 inquired Which of the following factors does your rehabilitation policy employ? The respondents were given six choices and also had the ability to write in additional information. All thirteen agencies utilized fluid replacement, food replacement, medical monitoring, specific rest periods, and cooling or heating. While not utilized at every rehabilitation incident, all thirteen agencies indicated that Critical Incident Stress Debriefing was an option if needed. Question 14 asked What type of medical monitoring is performed in the rehabilitation sector? The respondents were given six choices and also had the ability to write in any additional information. All thirteen agencies checked blood pressure, pulse, respirations, and oxygen saturation. A limited group utilized temperature and carbon monoxide readings as part of their medical monitoring. Question 15 asked Which of the following practices does your rehabilitation policy employ? The organizations surveyed were given 10 choices and also had the ability to write in any additional information. All thirteen agencies polled utilized; ancillary vehicles for cooling/heating, misting fans, wet towels, ice packs, cool beverages, blankets, and

26 Developing an Emergency 26 hot beverages. Cooling chairs, cooling vests, and change of clothes were utilized by a mixture of the organizations polled. Question 16 inquired What parameters are used to clear firefighters from rehabilitation back to service? The organizations polled were given five choices and had the ability to write in additional information. All thirteen agencies polled utilized; normal vital signs, specific rest periods, and the Rehabilitation Sector Commanders decision. Utilizing the Incident Commander or Company Officer drew a mixed response. Question 17 asked for department information for the individual who was completing the survey. Information requested was; name of person completing the survey, rank, department, choices of career/volunteer/combination departments, number of personnel in the organization, and approximate emergency call volume. Question eighteen requested the respondent indicate the population served by their organization. Each organization polled were given seven choices of different population ranges. The fire department serving the largest population was the Bridgeport Fire Department at 144,000 residents and the smallest fire department was the South Fire District serving 50,000 residents. The results of this research paper are designed to answer the original four research questions. The first research question was How are area Fire Departments conducting Emergency Incident Firefighter Rehabilitation? This information was identified through a survey (Appendix A), quantitative results were furnished by twelve local fire departments that match similar demographics of the Middletown Fire Department (MFD). This survey also obtained rehabilitation information from the Connecticut State Fire Academy, an agency that the MFD is required contractually to send each new member to for recruit fire school training. The second research question asked What standards and recommendations exist for emergency incident firefighter rehabilitation? This information was obtained through the

27 Developing an Emergency 27 literature review. Several pertinent National Fire Protection Association (NFPA) Standards were utilized and referenced through this review. The information obtained from the fore mentioned NFPA Standards was utilized for the formation of the draft Standard Operating Procedure (SOP) for emergency incident firefighter rehabilitation in the MFD. Because the MFD utilizes many NFPA Standards as guides, this information was a good fit to build the rehabilitation SOP around. The literature review also provided relevant information from fire industry experts as well as private sector leaders in the field of exertion based field rehabilitation. The third research question asked What discrepancies currently exist in the methods the Middletown Fire Department utilizes to conduct emergency incident firefighter rehabilitation? This information was obtained through the use of an internal MFD survey. Seven questions were formulated for this survey, with the intent of identifying current discrepancies in the use of emergency incident firefighter rehabilitation within the MFD. The research obtained in this survey provided extremely useful information that identified rehabilitation inconsistencies. Not only from shift to shift, but also from officer to officer. Once these rehabilitation inconsistencies were identified, it was easier to ensure that they were addressed in the draft emergency incident firefighter rehabilitation SOP. The fourth research question asked How can the existing emergency incident firefighter rehabilitation procedures utilized by the Middletown Fire Department be incorporated into a comprehensive Standard Operating Procedure? A comprehensive draft emergency incident firefighter rehabilitation Standard Operating Procedure (SOP) was developed utilizing information obtained from the; internal MFD survey, external emergency incident firefighter rehabilitation survey, and literature review. By identifying existing deficiencies, examining current best practices, examining existing programs from local fire departments and agencies,

28 Developing an Emergency 28 and incorporating current industry based rehabilitation recommendations; the author was able to formulate the draft SOP (Appendix F). In the end, these four research questions supported the hypothesis that the MFD had existing discrepancies in the methods they used to perform emergency incident firefighter rehabilitation. The entire literature review and research surveys provided the information needed to develop a draft emergency incident firefighter rehabilitation SOP for the MFD. Discussion and Implications Studies have shown that firefighting is an inherently dangerous occupation, either as a career or volunteer. Long term data collection has also shown that each year approximately 50% of firefighter line of duty deaths (LODD) can be attributed to heart attacks and/or strokes. In the forward of Bledsoe, A Guide for Best Practices in Rehabilitation and Medical Monitoring, Deputy Chief Gary Ludwig discusses the correlation of how many of the LODD stroke and cardiac emergencies happen during or immediately after events requiring heavy exertion. Over the past twenty-five years, the fire service has made a concentrated effort to improve firefighter health and safety issues. The United States Fire Administrations (USFA) Emergency Incident Rehabilitation Document (2008) addresses this issue: Perhaps no event in the history of the fire service brought these safety issues to the forefront more than the release of the first edition of the National Fire Protection Association (NFPA) 1500, Standard on Fire Department Occupational Safety and Health Program in This document recognized many of the issues that were injuring and killing firefighters and provided standard methods for correcting them. (pg. 1) While NFPA 1500 paved the way for firefighter health and safety, new standards like NFPA 1584, Standard on the Rehabilitation Process for Members during Emergency Operations and

29 Developing an Emergency 29 Training Exercises (2008) have established a benchmark for emergency incident firefighter rehabilitation. When the NFPA 1584 committee met in 2006, they decided to change the existing 2003 standard from a recommended practice to the 2008 edition which is a standard. Bledsoe states: Rehabilitation should be an integral part of the IMS for both the fire ground and training exercises. Rehabilitation should commence anytime emergency or training operations pose the risk of department members exceeding a safe level of mental or physical endurance. (pg. 3) Results from the Rehabilitation Practices of the Middletown Fire Department Survey confirmed that the Incident Commanders of the Middletown Fire Department at times practice emergency incident firefighter rehabilitation; it also pointed out that this rehabilitation is not conducted on a consistent basis. Even though firefighter health and safety has gained greater acceptance in the fire service, emergency firefighter rehabilitation continues to have a negative stigma attached to it. In a (2007) article for FireRehab.com, Dr. David Janslow discusses this stigma: Brotherhood denotes the firefighting family that we all know and love, but too often this family atmosphere condones the group mentality that health promotion is for sissies and encourages unnecessary risk and a living on the edge philosophy. All of us are guilty of falling into this description at some point or another. (pg. 2) Many of the senior fire officers within the Middletown Fire Department continue to exhibit the fore mentioned behaviors. The data obtained from the internal MFD survey confirmed the need for an emergency incident firefighter rehabilitation Standard Operating Procedure (SOP). By establishing an SOP, command officers would be required to follow an established standard

30 Developing an Emergency 30 which translates into consistent application of firefighter rehabilitation. An SOP would also allow for a mechanism to help change the attitude towards rehabilitation. In his article, Dr. Janslow also discussed the need for an attitudinal shift and a paradigm shift towards medical monitoring and rehabilitation practices for the fire service. The internal MFD survey (Appendix B) also determined that MFD Incident Commanders were relying on; types of incidents, atmospheric conditions, air consumption, and request of MFD personnel to initiate emergency incident firefighter rehabilitation. These results also coincided with the results of the external survey (Appendix A), each of the thirteen organizations survey indicated that; incident type, number of SCBA bottles used, environmental factors, and time in the hazardous environment were the benchmarks that were utilized to facilitate the need for emergency incident firefighter rehabilitation. Both the literature review and internal/external surveys revealed the need for emergency firefighter rehabilitation. The one common thread achieved throughout this research project was the lack of consensus for when emergency incident firefighter rehabilitation should be initiated. USFA Emergency Incident Rehabilitation (2008) addresses this specific issue The truth of the matter is that determining when to establish rehab operations at an incident remains more of an art than it is a science. (pg. 73) It goes on to say that many fire departments utilize benchmarks in their rehabilitation SOP s, the problem with benchmarks are they need to be flexible and fluid when dealing with the ever changing conditions encountered on the fire ground. NFPA 1584 Rehabilitation and Medical Monitoring (2008) goes as far as saying Rehabilitation should commence anytime emergency or training operations pose the risk of department members exceeding a safe level of mental or physical endurance (p. 3).

31 Developing an Emergency 31 Much of the literature review focused on reduction in firefighter injuries and deaths through proper rehabilitation practices. The 2009 NFPA U.S. Firefighter Injury Report identified 32,205 firefighter injuries on the fire ground, 2650 or 8.4% of these injuries were attributed to overexertion or stress. In 2010, 85 firefighters lost their lives in line of duty deaths. 61% of the deaths were attributed to stress or overexertion related activities. The most important resource of any fire department is its personnel. When a fire department suffers firefighter injuries or even worse, a line of duty death, this can have a detrimental effect on the organization. Not only is there pain and suffering for the injured firefighters, crew and families, but this also creates a financial impact to the organization. In a 2007 article for Fire Engineering Magazine, Paul Gerardi states: A study conducted by the National Institute of Standards and Technology and released in May 2005, which measured the economic impact of firefighter injuries, reported that about 80,000 U.S. firefighters are injured annually. The economic burden to the nation for addressing and preventing firefighter injuries is 2.7 billion to 8.7 billion per year according to the report. (pg.1) Many of these fire ground injuries are linked to overexertion and fatigue. Bledsoe (2008) discusses how research and experience have taught the fire service how firefighter safety is tied to an organized rehab program and medical monitoring at emergency incidents and training events. In many instances during intense firefighting activities, firefighters get pushed beyond the thresholds of normal exertion and stress. These conditions can be present without the firefighter being aware that they are in any danger or the firefighter purposely not reporting a problem to continue working with their crew or group. This data only reinforces the need for emergency incident firefighter rehabilitation.

32 Developing an Emergency 32 Of the thirteen organizations surveyed, each one shared five common rehabilitation practices. These included; fluid replacement, food replacement, medical monitoring, specific rest periods, and cooling/heating techniques. Critical Incident Stress Debriefing was universally shared by each organization when the emergency incident warranted. All three major emergency incident firefighter rehabilitation documents utilized in the literature review supported these findings. Fluid replacement is an essential component of firefighter rehabilitation. Dickinson and Wieder (2004) discusses the importance of fluid replacement and hydration It is now recognized that replenishment of fluids is not simply a way of making firefighters feel better but is, in fact, a crucial component of maintaining overall well-being (pg.114). During strenuous firefighting activities firefighters can lose as much as 32 ounces of sweat in just 20 minutes. Smith and Haigh (2006) suggest that fluid replacement is the single most important component of firefighter rehabilitation. Because 60% of a person s total body mass is water, water replenishment is a vital function during rehabilitation. They also recommend ounces of water at every SCBA bottle change. Two ounce bottles of water during rehabilitation, another ounce bottle of water post incident and if the incident duration exceeds one hour, the water should be a 50/50 mix of a sport drink. At a minimum, most rehabilitation standards suggest that fluid replacement equal the estimated amount of sweat loss. Another common component of emergency incident firefighter rehabilitation is food/caloric replacement. Bledsoe (2008) points out, that during both heat and cold stress, the body consumes tremendous amounts of calories. In order for the body to continue to perform, these depleted calories must be replenished. As important as it is to replace the depleted calories, the choice of caloric replacement is just as important. Research has shown that old food staples such as pizza

33 Developing an Emergency 33 or doughnuts can actually cause more harm than good during a rehabilitation event. Smith and Haigh (2006) suggest Calorie replacement should come from foods high in carbohydrates and proteins that are low in fat (pg. 6). They recommend foods that are easy on the digestive track such as; peanut butter and jelly sandwiches, soups, apples, bananas, pears, energy bars, or trail mix. Many civic or emergency response groups that help by providing food during rehabilitation activities need to be informed of these suggestions so they can provide the proper food groups. Another key component to caloric intake is having hand and face washing facilities available. This is important to ensure the firefighter in rehabilitation does not cross contaminate their food or fluid intake. Medical monitoring is another key component of emergency incident firefighter rehabilitation. When a firefighter enters rehabilitation there are two separate but distinct medical components, medical monitoring and emergency medical treatment. Most rehabilitation programs recommend the measurement of a firefighter s medical vital signs upon arrival into the rehabilitation sector. Bledsoe (2008) recommends; temperature, pulse, respirations, blood pressure, pulse oximetry, carbon monoxide, and hydrogen cyanide if possible. Presently most rehabilitation standards and individual fire department rehabilitation SOP s cover a wide array of vital sign benchmarks. There does not seem to be a fire service consensus on what should be checked and what medical thresholds should be established. Bledsoe (2008) skirts the vital sign issue by stating the measurement of vital signs is the most reliable methods of evaluating a firefighter s medical condition in rehab. The vital sign readings need to be interpreted in the context of the general appearance of the firefighter and any ongoing health issues. This same standard is quick to note that many fire departments do not take vital signs during rehabilitation because there are presently no established studies using vital

34 Developing an Emergency 34 signs to tie firefighter medical treatment or time limits needed to hold a firefighter in rehabilitation. In a 2008 article for Fire Engineering Magazine, Mike McEvoy discusses the inconsistencies of vital sign measurement during rehabilitation: Vital sign measurement is not required. We know very little about normal vital signs in rehab and even less about what measurements have any value in the rehab process. What vital sign measurement provides is a certain level of objective assessment that can help a fire department physician set parameters for when a member needs immediate emergency medical treatment, requires more close medical monitoring in the rehab area, and when he can be released from rehab. Medical authorities developing protocols that incorporate vital-sign parameters need to be cautious to interpret measured vital signs within the context of the individual s overall condition and appearance at the time of assessment. (pg. 3) It is important to ensure that there are an adequate amount of EMS transport vehicles on scene and immediately available to transport anyone requiring medical treatment. Whenever possible these vehicles should be staffed by Advanced Life Support (ALS) personnel. Once a firefighter has entered rehab and has been officially accounted for, two types of documentation need to be established. The first is a medical monitoring form (Appendix H) which will track the firefighter s progression through rehab. This information will eventually be filed with the NFIRS incident report. If medical transport and treatment is required, a separate form must be maintained and filed in the individual s department medical file. There are many different versions of these tracking forms, most are custom designed to work within the procedures of the authority having jurisdiction.

35 Developing an Emergency 35 Firefighter well being and safety is not only physical based monitoring; it also includes monitoring and treatment for psychological stressors. Dickinson and Wieder (2004) point out Many organizations have implemented procedures and provided personnel an avenue to deal with critical incident stress both at the emergency scene and in follow-up care long after the incident has been formally terminated (pg.14). USFA Emergency Incident Rehabilitation (2008) reminds us that certain firefighting duties and actions can create a heavy burden on the psychological well being of the firefighter. Many times the firefighter is subjected to serious injuries or death of civilians and/or firefighters. These psychological stressors must be closely monitored during rehabilitation and if warranted, individuals or entire crews taken out of service for Critical Incident Stress Debriefing (CISD). Experienced Command Staff and EMS providers need to keep a vigilant watch for any signs of critical incident stressors. Even though no official definitive vital sign protocols exist for rehabilitation, the majority of fire departments continue to monitor vitals signs during the firefighter rehabilitation process. Most standards only give a group of recommended vital signs to check. The author feels strongly that this component needed to be included in the Middletown Fire Department Emergency Incident Firefighter Rehabilitation SOP. Closely tied to medical monitoring is the establishment of specific rest periods during emergency incident rehabilitation. All thirteen organizations polled in the external survey indicated that the specific amount of SCBA bottles consumed during emergency operations were a benchmark for specific rest periods during rehabilitation. Bledsoe (2008) Rehabilitation and Medical Monitoring states: Personnel entering rehab for the first time should rest for at least 10 minutes-longer when practical. A member should not return to operations if he or she does not feel

36 Developing an Emergency 36 adequately rested. Personnel should rest a minimum of 20 minutes following the use of a second 30-minute SCBA cylinder, a single 45-minute cylinder, a single 60- minute SCBA cylinder, or 40 minutes of intense work without an SCBA. (pg. 16) Although the Middletown Fire Department does not presently utilize a formal emergency incident firefighter rehabilitation procedure, they do follow the fore mentioned rest period recommendations. The benchmark time recommendations from NFPA 1584 were the consensus standards of the thirteen organizations surveyed. The final consensus component identified in the external survey was active and passive heating/cooling of firefighters assigned to rehabilitation. It appears that most of the focus in the literature review material and established rehabilitation guidelines and procedures concentrated more on active cooling than heating. Because the human body generates heat during physical activity, the negatives effects of environmental induced stressors seems to be greater in a heat generated environment. Most fire departments, including those surveyed do an adequate job passively heating and cooling their personnel during emergency incident firefighter rehabilitation. Many studies have concluded that active cooling is the most efficient method to quickly remove heat from the over stressed firefighter in rehab. At times the Middletown Fire Department has utilized cold towels and misting fans during rehabilitation, but seems to be operating below the curve of the 13 organizations surveyed. McEvoy (2008) states: The most effective are cold towels and forearm immersion. Firefighters in two cooling studies found cold towels the most refreshing and effective active cooling measure. Compared to forearm immersion, cold towels require less space and setup time and cost considerably less. (pg. 3)

37 Developing an Emergency 37 In a 2004 article for Fire Engineering Magazine, Ross, McBride, and Tracy stressed that the human physiology depends on keeping the core body temperature regulated as close to 98.6F as possible. Rises in the core body temperature above 102F is dangerous and can lead to heat stress. Body core temperature rise to 105F can cause sudden death on the fire ground. The opposite effect is true for cold emergencies. Rapid drops in body core temperature can not only cause physical limitations but body core temperatures as low as 85F can cause sudden cardiac arrest. There is no doubt that emergency incident firefighter rehabilitation is a requirement for today s fire service. Working firefighters beyond their capabilities is no longer an accepted practice. NFPA 1500 established the original baseline for emergency incident firefighter rehabilitation and since then several other standards and recommendations have been developed. While the Middletown Fire Department utilizes emergency incident firefighter rehabilitation at times, they do not perform it in a consistent manner and ultimately this behavior puts their personnel at risk for injury or even death. An acceptable solution to mitigate this deficiency is to develop a comprehensive emergency incident firefighter rehabilitation Standard Operating Procedure (SOP). Once written: adopt it, implement it, train the organization in its use, and mandate a 100% compliance rate in its use. Recommendations For the past twenty-five years, the fire service has shown the need for emergency incident firefighter rehabilitation through several NFPA Standards and fire industry based studies and recommendations. This research paper employed a comprehensive literature review and survey based action research. The results proved that while at times the Middletown Fire Department practices emergency incident firefighter rehabilitation, this inconsistency is an unsafe and an unacceptable practice. Based on the best practices of NFPA 1584, literature review, and data

38 Developing an Emergency 38 collected by survey, a draft emergency incident firefighter rehabilitation SOP was developed and forwarded to the Fire Chief of the MFD for review. This draft SOP is located in Appendix F. If implemented, this SOP will require an initial capital expenditure for equipment, a training implementation plan from the MFD Training Division, and a time table to perform a department review of the standards effectiveness. If adopted by the MFD, this SOP will require an annual review to ensure the most up to date practices and equipment are being utilized for firefighter rehabilitation. Researching this topic revealed a plethora of material and information. An organization developing SOP s must be careful to not accept all practices as boilerplate and utilize resources to customize a procedure which best meets their organizations needs and goals. The bottom line to any quality rehabilitation program is protecting the department s greatest resource, their personnel.

39 Developing an Emergency 39 References Bledsoe, B. E. (2008). Rehabilitation and medical monitoring a guide for best practices an Introduction to nfpa Midlothian, TX: Cielo Azul Publications. Dickinson, E.T. & Weider, M.A. (2004). Emergency incident rehabilitation (2 nd ed.). Upper Saddle River, NJ: Prentice Hall. Gerardi, P.R. (2007). Fitness and training are keys to safety. Fire Engineering, 160(6). Retrieved from http// Haigh, C. & Smith, D.L. (2006). Implementing effective on-scene rehabilitation. Fire Engineering, 159(4), Internet Movie Database (1994). Forrest gump. Retrieved 6/7/11 from: Title/tt /quotes Janslow, D. (2007). Firefighter rehabilitation: more harm than good? FireRehab.com, (5). Retrieved 6/7/11 from: http// Rehabilitation-More-Harm-Than-Good? Lindsey, J. (2009). Rehab accountability, release and documentation. FireRehab.com, (9). Retrieved 6/7/11 from: http// Rehab-Accountability-Release-And-Documentation McEvoy, M. (2008). The elephant on the fireground: secrets of nfpa 1584-compliant rehab. Fire Engineering, 161(8). Retrieved from display.articles.fire-engineering.volume-161/issue_8/the_elephant_on_the_fireground Secrets_of_NFPA_1584_Compliant_Rehab Engineering, 159 (4),

40 Developing an Emergency 40 National Fire Protection Association. (2008) NFPA 1584, Standard on the rehabilitation process For members during emergency operations and training exercises, 2008 edition. Quincy, MA: National Fire Protection Association. National Fire Protection Association. (2009). U.S. firefighter injuries Quincy, MA: Author. Ross, D., McBride, P.J., & Tracey, G.A. (2004, May). Rehabilitation: standards, traps, and tools. Fire Engineering, 157(5). Retrieved from Display/207037/articles/fire-engineering/volume-157/issue_5/Features/Rehabilitation_ Standards_Traps_and_Tools United States Fire Administration. (2010) fatality summary statistics. Emmittsburg, MD: Author. United States Fire Administration. (2008, February). Emergency incident rehabilitation. Emmittsburg, MD: Author. United States Fire Administration. (2008). CRS report for congress. Emmittsburg, MD: Author. Wolf, D. (2007, June). Why be a normal leader? Firehouse, 32(6). Retrieved from Firehouse.com/topic/leadership-and-command/why-be-normal-leader

41 Developing an Emergency 41 Appendix A Firefighter Incident Rehabilitation Survey 1. Does your organization utilize a formal firefighter rehabilitation program at emergency incidents? Yes No 2. Does your organization utilize an emergency incident rehabilitation Standard Operating Procedure? Yes No 3. What standards and criteria were used to develop your organizations Standard Operating Procedure? 4. Does your organization follow the recommendations of NPFA 1584 (2008) Rehabilitation and Medical Monitoring? Yes In Part No N/A 5. What type of emergency dictates utilizing emergency firefighter rehabilitation? 6. Does your organization employ a rehabilitation vehicle? Yes No 7. If your organization employs a rehabilitation vehicle, who delivers the vehicle to an emergency scene? 8. Who staffs your rehabilitation sector? Fire Department Personnel Commercial Ambulance/Paramedic Service Mutual Aid Personnel Other 9. What equipment is carried on your organizations rehabilitation vehicle?

42 Developing an Emergency How does your organization determine when a firefighter must go to rehabilitation? (Please check all that apply) Type of incident Number of SCBA bottles used Request of the Incident Commander Request of the Company Officer Environmental factors Time spent in the hazardous environment Other 11. Are firefighters that are sent to rehabilitation checked in and are utilizing an accountability system? Yes No 12. For informational purposes, how do you document a firefighter s visit to rehabilitation? NFIRS Rehabilitation Worksheet EMS Run Form No documentation Other 13. Which of the following factors does your rehabilitation policy employ? Fluid replacement Food replacement Medical monitoring

43 Developing an Emergency 43 Specific rest periods Cooling/Heating Critical Incident Stress Debriefing Other 14. What type of medical monitoring is performed in the rehabilitation sector? Blood Pressure Pulse Temperature Respirations Oxygen Saturation Carbon Monoxide Other 15. Which of the following practices does your rehabilitation policy employ? Ancillary vehicles used for cooling/heating Cooling chairs Cooling vests Misting fans Wet towels Ice Packs Cool beverages Blankets Change of clothes Hot beverages Other 16. What parameters are used to clear firefighters from rehabilitation back to service? Normal vital signs Specific rest periods Incident Commanders decision Company Officer s decision Rehabilitation Sector Commander s decision Other 17. Department Information Name of person completing the survey Rank Department Career Fire Department Combination Fire Department Volunteer Fire Department Number of personnel in your organization

44 Developing an Emergency 44 Approximate emergency call volume 18. Population served by your organization Less than 4,999 5,000 24,999 25,000 49,999 50,000 99, , , , , , ,999

45 Developing an Emergency 45 Appendix B Rehabilitation Practices of the Middletown Fire Department 1. As a potential MFD Incident Commander, how often do you utilize a formal firefighter rehabilitation operation? Always Sometimes Rarely Never 2. What criteria do you utilize to determine the need for a formal firefighter rehabilitation operation? (Please check all that apply) Type of incident Atmospheric conditions Air consumption Request of MFD personnel 3. Who do you assign to supervise the Rehabilitation Sector? MFD personnel Mutual aid personnel Middlesex Memorial Hospital Paramedics Other 4. What parameters do you utilize to see that firefighter rehabilitation is accomplished? (Please check all that apply) Specific rest period Food/fluid replacement Removal of protective clothing Medical monitoring/evaluation Air consumption Other 5. Do you utilize a formal accountability system for personnel in rehabilitation? Yes No

46 Developing an Emergency What parameters are used to clear firefighters from rehabilitation back to service? Normal vital signs Specific rest periods Incident Commanders decision Company Officer s decision Rehabilitation Sector Commander s decision Other 7. How are MFD personnel s rehabilitation activities documented? NFIRS report EMS report Private agency report Mutual aid company report Other

47 Developing an Emergency 47 Appendix C JAY WORON ASSISTANT CHIEF MIDDLETOWN FIRE DEPARTMENT TRAINING/SAFETY DIVISIONS 533 MAIN STREET MIDDLETOWN, CT Fire Service Professional: My name is Jay Woron; I currently serve as the Assistant Chief of the Middletown Fire Department. I am presently enrolled in the National Fire Academy Executive Fire Officer Program. To meet the requirements of this program, I am researching firefighter rehabilitation procedures utilized during emergency scene operations. I am requesting your assistance to complete a brief survey describing how your organization facilitates emergency firefighter rehabilitation. I have enclosed the survey and a prepaid return mailing envelope for your convenience. I would ask that this survey be completed by the individual in your organization that is responsible to oversee this program. I would like to take this opportunity to thank you and your organization for sharing their emergency firefighter rehabilitation information. The goal of this research project is to develop an emergency firefighter rehabilitation Standard Operating Procedure for the Middletown Fire Department. Once completed, if you would like a copy of the new policy please indicate this information on your survey. Thank You

48 Developing an Emergency 48 Appendix D Results of Firefighter Incident Rehabilitation Survey 1. Does your organization utilize a formal firefighter rehabilitation program at emergency incidents? Responses Percentage Yes 11 85% No 2 15% 2. Does your organization utilize an emergency incident rehabilitation Standard Operating Procedure? Responses Percentage Yes 11 85% No 2 15% 3. What standards and criteria were used to develop your organizations Standard Operating Procedure? Responses Percentage Yes 11 85% No 2 15% All 11 respondents used: NFPA 1500 Standard on Fire Department Occupational Safety and Health Program NFPA 1582 Comprehensive Occupational Medical Program for Fire Departments NFPA 1583 Health-Related Fitness Programs for Fire Department Members NFPA 1584 Standard on the Rehabilitation Process for Members During Emergency Operations and Training Exercises 4. Does your organization follow the recommendations of NFPA 1584 (2008) Rehabilitation and Medical Monitoring? Responses Percentage Yes % 5. What type of emergency dictates utilizing emergency firefighter rehabilitation? 12 Fire Departments responded: Structural Fires

49 Developing an Emergency 49 Hazardous Materials Events Long Duration Events Training Events Connecticut Fire Academy responded: Training Events Long Duration Events 6. Does your organization employ a rehabilitation vehicle? Responses Percentage Yes 8 62% No 5 38% 7. If your organization employs a rehabilitation vehicle, who delivers the vehicle to an emergency scene? The seven fire departments that responded used on duty personnel. The Connecticut Fire Academy hires an EMS trained instructor to drive the vehicle. 8. Who staffs your rehabilitation sector? Eleven Fire Departments utilize a mix of in-house personnel and private ambulance. One Fire Department strictly used a private ambulance company. The Connecticut Fire Academy utilized in-house personnel and a private ambulance. 9. What equipment is carried on your organizations rehabilitation vehicle? All thirteen respondents are a very generic list of equipment, some examples were: EMS equipment, water, sports drinks, energy bars, towels blankets, folding chairs, Misting fans, accountability equipment, tarps, portable heaters, disposable clothing, pop-up tents, coolers and lighting equipment. 10. How does your organization determine when a firefighter must go to rehabilitation? All thirteen respondents used: Type of Incident

50 Developing an Emergency 50 Number of SCBA bottles used Environmental factors Time spent in a hazardous environment Three Fire Departments used at the request of the Incident Commander Two Fire Departments used at the request of the Company Officer 11. Are firefighters that are sent to rehabilitation checked in and are utilizing an accountability system? Responses Percentage Yes % 12. For Informational purposes, how do you document a firefighter s visit to rehabilitation? All twelve fire departments used: NFIRS Reports Rehabilitation Worksheets EMS Run Forms The Connecticut Fire Academy used: Rehabilitation Worksheets EMS Run Forms 13. Which of the following factors does your rehabilitation policy employ? All thirteen respondents utilized: Fluid replacement Food replacement Medical monitoring Specific rest periods Cooling/Heating Critical Incident Stress Management (as needed) 14. What type of medical monitoring is performed in the rehabilitation sector? All thirteen respondents checked: Blood Pressure Pulse Respirations

51 Developing an Emergency 51 Pulse Oximetry Seven organizations checked: Temperature Carbon Monoxide 15. Which of the following practices does your rehabilitation policy employ? All thirteen respondents utilized: Ancillary vehicles for heating/cooling Misting Fans Wet Towels Ice packs Cool beverages Blankets Hot beverages Eight respondents utilized cooling chairs and cooling vests Two respondents carried a change of clothes 16. What parameters are used to clear firefighters from rehabilitation back to service? All thirteen respondents utilized: Normal vital signs Specific rest periods Rehabilitation Sector Commanders decision Three respondents utilized the Incident Commander Two respondents utilized the Company Officer 17. Department Information Each respondent filled in the appropriate information 18. Population served by you organization: Bridgeport Fire Department 144,000 East Hartford Fire Department ,000 Greenwich Fire Department ,000 Hartford Fire Department.. 124,000 Manchester Fire Department.. 58,000

52 Developing an Emergency 52 Milford Fire Department. 53,000 New Haven Fire Department 129,000 Norwalk Fire Department. 63,000 South Fire District 50,000 West Hartford Fire Department.. 63,000 West Haven Fire Department. 52,000 West Shore Fire Department.. 52,000 Connecticut Fire Academy N/A

53 Developing an Emergency 53 Appendix E Results of Rehabilitation Practices of the Middletown Fire Department Survey 1. As a potential MFD Incident Commander, how often do you utilize a formal firefighter rehabilitation operation? Responses Percentage Sometimes 9 82% Rarely 2 18% 2. What criteria do you utilize to determine the need for a formal firefighter rehabilitation operation? (Please check all that apply) Responses Percentage Type of incident % Atmospheric conditions % Air Consumption % Request of MFD personnel % 3. Who do you assign to supervise the Rehabilitation Sector? Responses Percentage MFD Personnel % Mutual Aid Personnel 0 0% Middlesex Hospital Paramedics % Other 0 0% 4. What parameters do you utilize to see that firefighter rehabilitation is accomplished? Responses Percentage Specific rest period % Food/fluid replacement % Removal of protective clothing % Medical Monitoring/evaluation % Air Consumption % Other 0 0% 5. Do you utilize a formal accountability system for personnel in rehabilitation? Responses Percentage

54 Developing an Emergency 54 Yes % 6. What parameters are used to clear firefighters from rehabilitation back to service? Responses Percentage Normal vital signs % Specific rest period % Incident Commanders decision 2 18% Company Officer s decision 0 0% Rehabilitation Sec. Commander s decision 2 18% Other 0 0% 7. How are MFD personnel s rehabilitation activities documented? Responses Percentage NFIRS report % EMS report % Private agency report 0 0% Mutual Aid Company report 0 0% Other 0 0%

55 Developing an Emergency 55 Appendix F STANDARD OPERATING POLICY MIDDLETOWN FIRE DEPARTMENT SUBJECT: EMERGENCY INCIDENT FIREFIGHTER REHABILITATION Issue Date: AUGUST 1, 2011 Date Effective: TBD Date Updated: S.O.P. Page 1 of 5 Written by: Assistant Chief Jay Woron Dept. Head Approval: PURPOSE: The purpose of this standard operating procedure is to provide a formal framework for the establishment of an emergency incident firefighter rehabilitation program. This rehabilitation program will ensure that both the mental and physical needs of the members of the Middletown Fire Department and mutual aid companies are met during emergency operations, training events, and extended operational work periods. SCOPE: This standard operating procedure (SOP) shall be followed by all personnel responding to emergency incidents, training evolutions, or extended operational work periods within the Middletown Fire Department. This SOP identifies when the implementation of a formal emergency incident firefighter rehabilitation sector is required. All personnel assigned to manage this rehabilitation sector shall follow the framework set forth by this policy. POLICY: I. General a. Rehabilitation shall commence whenever emergency operations or training activities pose the risk of Middletown Fire Department or mutual aid members exceed safe levels of physical or mental endurance. b. Emergency incident firefighter rehabilitation is established at the discretion of the incident commander, rehabilitation shall include, but not be limited to: 1. Rehabilitation Command/control 2. Rehabilitation site 3. Accountability 4. Hydration 5. Rest and recovery

56 Developing an Emergency Medical monitoring 7. Climatic relief 8. Active heating/cooling (*if needed) 9. Caloric replacement (*if needed) 10. Medical treatment (*if needed) 11. Critical incident stress management (*if needed) 12. Release 13. Rehabilitation equipment list II. Rehabilitation Command/Control a. Incident Command (IC) shall be responsible for: 1. Evaluate conditions requiring formal rehabilitation during emergency incidents, training evolutions, or extended operational work periods. 2. Whenever possible, assign a member of the Middletown Fire Department (MFD) to serve as rehabilitation sector commander. An R-5 paramedic from either Middlesex Hospital or Hunters Ambulance Service shall be assigned as the rehabilitation medical sector supervisor. A member of the MFD or a mutual aid company shall be assigned to coordinate accountability check-in, tracking, and release. 3. The IC shall determine which company or individual personnel shall be designated to rehabilitation. This decision shall be based upon: 1. Climatic conditions 2. Incident duration 3. Type of incident 4. Number of SCBA bottles used 5. Workload or stress of personnel operating 6. At recommendation of MFD safety officer 7. At recommendation of MFD company officer 8. At recommendation of mutual aid officer 9. Physical or mental state of personnel 4. Maintain contact with rehabilitation sector command for status or progress updates. III. Rehabilitation Site A. The physical location of the rehabilitation site shall be located close enough to the incident scene to be convenient for personnel rotating through rehabilitation, but far enough away as to not jeopardize personal safety. B. Whenever possible, climate controlled facilities shall be utilized. Other options are City of Middletown Area Transit (MAT) buses, MFD apparatus. C. The rehabilitation site shall be large enough to provide rehabilitation facilities for the total amount of manpower operating at the emergency.

57 Developing an Emergency 57 D. The rehabilitation site should provide a specific location for personnel to remove and store their personal protective equipment and exchange expended SCBA bottles. IV. Accountability A. Strict rehabilitation sector accountability shall be maintained at all times. Each firefighter entering the rehabilitation sector shall be logged on the MFD master Rehabilitation Personnel Roster. Each firefighter shall be logged out of rehabilitation or if being sent for medical evaluation or treatment. V. Hydration A. All personnel operating at any MFD incident shall be required to drink 12 ounces of water during any SCBA bottle change-out. Each MFD apparatus carries drinking water and cups. B. Once in rehabilitation, firefighters shall rehydrate at the following rate: 1. 2 bottles (12-16 ounces) during rehabilitation 2. Another 1-2 bottles during post incident 3. if the firefighter has been working longer than one hour, a 50/50 mix of sports drink should be added to the water consumed. After one hour, one bottle (12-16 ounces) should be consumed. 4. Carbonated and caffeinated fluids should be avoided. VI. Rest and Recovery A. Firefighters in rehabilitation shall be required to take specific rest and recovery periods. These recovery periods shall adhere the following: minute "self-rehab" after one 30-minute SCBA operational period, or 20 minutes after intense work minute rest period after 30-minute SCBA operational period minute rest period after one 60-minute SCBA cylinder minute rest period after operating within an encapsulating hazmat suit. 5. Specific rest period after operating at the discretion of the rehabilitation sector commander or EMS supervisor. VII. Medical Monitoring A. As each firefighter enters rehabilitation and has checked in with accountability, they shall be issued a MFD medical monitoring card. This medical monitoring card shall record the following information:

58 Developing an Emergency Name 2. Date 3. Assignment 4. Age 5. Time-in 6. Initial blood pressure 7. Initial pulse 8. Initial respirations 9. Initial temperature 10. Initial pulse oximetry B. During the initial vital sign monitoring, the following threshold benchmarks shall be utilized: 1. Blood pressure-7160 systolic,<100 systolic,>90 diastolic 2. Pulse - > Temperature - >99.5 F 4. Pulse oximetry - <90% C. Any member meeting any threshold vital sign reading will be assigned to medical evaluation and rehabilitation. Members remaining under the threshold limits will remain in rehabilitation only. D. Those firefighters requiring medical evaluation/rehabilitation will have their vital signs taken every 10 minutes and recorded. If after three readings or 30 minutes they have not changed below threshold values, the firefighter may be eligible to be transported to a medical facility for treatment or evaluation. E. Those firefighters who are in rehabilitation only or whose threshold limits have returned to acceptable levels will be returned to the fireground after meeting the proper rest period. F. Firefighters returning to duty on the fireground shall leave their medical monitoring cards with the accountability officer. These forms shall be filed with the incident NFIRS report. Members requiring medical transport and evaluation shall have their medical monitoring card accompany them to the medical facility. This information will be filed in their personal medical file. G. Any personnel leaving rehabilitation shall be signed out on the Master Accountability Roster. VIII. Climatic Relief A. In cold weather rehabilitation situations, personnel shall be removed from the elements and located in a warm environment; these include but are not limited to: 1. Environmentally controlled buildings

59 Developing an Emergency City of Middletown area transit (MAT) buses 3. MFD apparatus 4. Remove wet or cold PPE B. Utilize passive warming 1. Blankets 2. Hot beverages 3. Hot foods 4. Clothes change 5. Blower style heaters C. In hot weather rehabilitation scenarios, personnel shall remove their PPE, begin their hydration procedure and whenever possible, be located in an airconditioned environment including but not limited to: 1. Environmentally controlled buildings 2. City of Middletown area transit buses (MAT) 3. MFD apparatus D. Utilize passive cooling 1. Cold towels 2. Cold water for hydration 3. Remove PPE IX. Active Heating/Cooling A. Active heating shall be utilized whenever passive heating measures are not adequate, including but not limited to: 1. Heat packs 2. Warming blankets 3. Administration of warm IV's B. Active cooling shall be utilized whenever passive cooling measures are not adequate, including but not limited to: 1. Wet towels applied to the head and neck 2. Forearm immersion chairs 3. Misting fans 4. Cold vests C. Active heating and cooling will only be utilized when passive measures are ineffective. X. Calorie Replacement A. When deciding if calorie replacement is needed, the following benchmarks will be considered: 1. Duration of the event

60 Developing an Emergency Amount of exertion 3. Time since last meal 4. General condition of the individual B. Calorie replacement should come from foods high in protein and carbohydrates but low in fats. These include the following but are not limited to: 1. Chicken soup 2. Bean soup 3. Split pea soup 4. Apples 5. Bananas 6. Pears 7. Yogurt 8. Trail mix 9. Peanut butter and jelly sandwiches 10. Chicken sandwich 11. Turkey sandwich 12. High protein energy bars C. Prior to any firefighter partaking in calorie replacement, they shall wash their hands and face to avoid contamination of food or beverages. This can be accomplished by: 1. Soap, water, paper towels 2. Waterless soap, paper towels 3. Purell XI. Critical Incident Stress Management A. Occasionally, emergency incidents can produce high levels of stress, either physical or emotional. These incidents may include but not be limited to: 1. multiple-casualty incidents 2. Severe trauma 3. Terrorist events 4. Long-term hostage events 5. Incidents with serious injuries or fatalities to civilians or firefighters. B. At the discretion of the IC, rehab sector commander or rehabilitation EMS supervisor, individuals or entire companies may be taken off line and assigned to critical incident stress debriefing. C. In cases where individuals or companies are taken off line, the critical incident stress debriefing shall take place at a location other than the emergency scene. XII. Release

61 Developing an Emergency 61 A. Once personnel are cleared by the EMS sector supervisor, they shall check out with their accountability control point. Each member will ensure their medical monitoring card is left with the accountability officer. Once released, the firefighter or company shall report back to incident staging, check in with accountability, and receive a new assignment. XIII. Rehabilitation Equipment List A. The following rehabilitation equipment shall be carried on Rescue 1: 1 misting fan 48 towels 1 box of cold packs 24 wool blankets 2 cases of water (16 ounces) 2 cases of Gatorade (16 ounces) 1 case sports energy bars 1 O2 set-up 1 medical jump bag 1 AED 1 pulse oximeter 2 thermometers 2 stethoscopes 2 blood pressure cuffs (each size) 2 folding tables 12 collapsible chairs 6 immersion chairs 1 hand washing kit 6 12'x`12' tarps 1 accountability kit 1 medical form kit 1 12'x12' pop-up tent 24 Tyvek suits 1 box EMS forms 2 ice chest/coolers

62 Developing an Emergency 62 Appendix G MIDDLETOWN FIRE DEPARTMENT REHABILITATION ACCOUNTABILITY FORM Incident Location Date Rehab Sector Command Accountability Officer EMS Sector Supervisor DEPT UNIT ASSGN. CREW SIZE TIME IN TIME OUT OTHER INFO

63 Developing an Emergency 63 Appendix H MIDDLETOWN FIRE DEPARTMENT MEDICAL MONITORING FORM Name Age Date Assgn. ENTRY VITAL SIGNS TIME IN B/P PULSE RESPIRATIONS TEMP. Systolic <100 >160 Diastolic >90 >100 Pulse OX <90% >95.5F REHAB ONLY MEDICAL EVAL. & REHAB TIME B/P VITAL SIGNS TO BE READ EVERY 10 MINUTES Threshold >160 Systolic <100 Systolic >90 Diastolic PULSE >100 RESP. TEMP. >99.5 PULSE/OX <90% READ BY RETURN TO DUTY CSID MEDICAL TRANSPORT EMS REHAB OFFICER RELEASE TIME DISPOSITION