REDUCING FIRE GROUND INJURIES DUE TO HEAT STRESS. Leading Community Risk Reduction

Reducing Fire Ground Injuries 1 REDUCING FIRE GROUND INJURIES DUE TO HEAT STRESS Leading Community Risk Reduction Reducing Fire Ground Injuries Due to Heat Stress at Hanover Park Fire Department Craig A. Haigh Hanover Park Fire Department, Hanover Park, Illinois November 2006

Appendix B Not Included. Please visit the Learning Resource Center on the Web at http://www.lrc.dhs.gov/ to learn how to obtain this report in its entirety through Interlibrary Loan.

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

Reducing Fire Ground Injuries 3 Abstract The problem was the number of illnesses/injuries experienced by Hanover Park Fire Department which are attributable to heat stress. The purpose of this research was to investigate heat stress and assess methods to reduce its impact. Descriptive research was conducted using literature reviews and surveys to find: 1. Types of injuries/illnesses firefighters are incurring at structure fires or live fire trainings 2. Physical and physiological strains associated with heat stress 3. Methods that can be implemented to prepare firefighters for the physical demands of heat stress 4. Rehab programs other fire departments are using The results of the information gathered created recommendations for training, health screening/wellness programs, and standardized rehab policies.

Reducing Fire Ground Injuries 4 CONTENTS Abstract...3 List of Tables...5 Table of Figures...6 Introduction...7 Background and Significance...9 Literature Review...11 Procedures...23 Results...25 Discussion...33 Recommendations...35 References...37 Appendix A--REHABILITATION POLICY...39 Appendix B--FDIC REHABILITATION CLASS...48

Reducing Fire Ground Injuries 5 List of Tables Table 1 Number of Fires...9 Table 2--Wet Bulb Globe Temperature Index...16 Table 3--Injuries to Hanover Park Firefighters...25 Table 4--First-Aid Reports for Hanover Park Firefighters...26

Reducing Fire Ground Injuries 6 Table of Figures Figure 1 Possible Causes of Heart Attacks in Firefighters...14 Figure 2 Core Body Temperatures...19

Reducing Fire Ground Injuries 7 Introduction Firefighting by its very nature exposes firefighters to heat extremes and the products of combustion in the course of a day s work. Firefighters undergo a combination of physical and physiologic strains resulting from heavy muscular activity, working under conditions of emotional strain, hot and hostile work environments and heavy protective equipment. (Denise L. Smith & Craig A. Haigh, 2006) This protective equipment is designed to reduce the potential injuries caused by exposure to this environment. However, the protection garnered by these garments, including breathing apparatus, is offset by the great potential to produce high body core temperatures due to the reduced ability for the body to naturally eliminate internal heat via sweating and exhalation of heated respiratory gases. Protective equipment creates a microclimate inside the firefighters gear and next to their skin, thereby rapidly reaching a humidity of nearly 100 percent. This microclimate, coupled with temperatures inside a burning structure routinely reaching in excess of 800 F, quickly generates a variety of health problems including dehydration, cardiovascular strain and thermal strain. (Denise L. Smith & Craig A. Haigh, 2006) Hanover Park Fire Department has experienced a number of firefighter illnesses and injuries while operating on the fireground which can be attributed to the heat stress and strain associated with fire ground operations. The purpose of this research paper is to analyze heat stress and assess methods to reduce the number of illnesses and injuries caused by heat stress to Hanover Park Firefighters. This will be accomplished by focusing on methods to better prepare the firefighter to physically operate within heated environments. Research also focuses on the identification of best practices for managing the impact of heat stress on firefighters working an incident, including on-scene rehabilitation programs.

Reducing Fire Ground Injuries 8 Descriptive research methods are used to answer the following questions: 1. What types of injuries/illnesses have Hanover Park Firefighters incurred following a working structure fire or live fire training? 2. What are the physical and physiological strains associated with heat stress caused by fireground operations? 3. How can we better prepare firefighters for the physical demands of heat stress caused by fireground operations? 4. What rehab programs are other fire departments using?

Reducing Fire Ground Injuries 9 Background and Significance The Hanover Park Fire Department is a municipal organization providing emergency services to the Village of Hanover Park and the Hanover Park Fire Protection District (formerly known as the Ontarioville Fire Protection District). Prior to 2000, the organization was governed by a fire protection district board and levied property tax for provision of services; however, in July 2000, the district was absorbed by the Village of Hanover Park whereby all assets including personnel were transferred to municipal control. The Village is located in the western suburbs of the Chicago metro area with the department serving a population base of 40,000 residents. The department is an active participant with both MABAS (Mutual Aid Box Alarm System) Divisions II and XII and responds to more than 2,600 emergency calls annually. Due to MABAS agreements for auto aid response, it is important to note that the population base served by Hanover Park companies on a first alarm basis exceeds 120,000 people. A five-year average shows Hanover Park companies responding to 73 working fires annually (this includes auto and mutual aid response). Table 1 Number of Fires Year Number of Fires 2000 76 2001 64 2002 51 2003 87 2004 81 2005 72

Reducing Fire Ground Injuries 10 During this same time period, fifty (50) firefighters filed accident reports for injuries or illnesses that occurred while operating at the scene of an emergency incident, during training, and for medical exposures. These accident s generated 22,649 hours of work comp sick leave due to the injury. In the 78-year history of Hanover Park Fire Department, only one line-of-duty cardiac event resulted in a myocardial infarction. The firefighter was left with limited cardiac output necessitating his retirement with a full disability pension. This event in 1998 led fire administration to increase the available physical fitness equipment but failed to develop a comprehensive health and wellness program. Hanover Park Fire Department has been blessed to have never experienced a line-of-duty death. Information obtained through research for this project will help educate firefighters on the physical and physiological demands of firefighting and help determine appropriate methods for reducing fire ground illnesses and injuries caused by heat stress, including best practices for the development of on-scene rehabilitation and medical monitoring protocols. This research relates to the USFA goal of reducing the loss of life from fire to firefighters. It also links to the Leading Community Risk Reduction class through its assessment and identification of a problem and then taking action to correct this problem through education and engineered practices.

Reducing Fire Ground Injuries 11 Literature Review The review of literature for this project focused on the findings of research conducted on heat stress and the associated physical and physiologic response of the human body. Fire Service trade journal articles were reviewed as well as published materials from exercise and sports medicine scientists, immunologists and psychologists, and researchers from the United States Military, the British Royal Navy, the Zimbabwe Army, and the Singapore Armed Forces. In general, very little information currently exists specifically related to the effects of heat stress in firefighters. Much is known about the physical and physiological effects of exercise in heated environments, but little focus has been applied to fire suppression activities while working in thermal-resistant protective equipment. Much of the existing scientifically-based material comes from the University of Illinois Fire Service Institute where Denise L. Smith, PhD, has been conducting on-going studies since the early 1990s. Additionally, the City of Chicago commissioned a study in 1991 through the University of Wisconsin Milwaukee looking specifically at the relationship between heart rate and oxygen consumption to determine the energy expenditure requirements of physically demanding tasks. During the Falklands War, the British Royal Navy investigated the effectiveness of hand and forearm immersion in water as a technique for reducing heat stress in shipboard firefighters, and the Workplace Safety and Insurance Board of Ontario conducted a study on the heat stress of wearing firefighting protective clothing. These studies, coupled with research from exercise physiologists, can assist us in understanding the detrimental effects of exercise in heated environments by painting a clearer picture of the body s response.

Reducing Fire Ground Injuries 12 Loring Rowell, Chairman of the University of Washington Department of Physiology/Biophysics writes: Probably the greatest stress ever imposed on the human cardiovascular system is the combination of exercise and hyperthermia. Together these stresses can present lifethreatening challenges, especially in highly motivated athletes who drive themselves to extremes in hot environments. (Rowell, 1986) Although Dr. Rowell is speaking of highly motivated endurance athletes, his quote could just as easily apply to firefighters. Ross, McBride, and Tracy (Ross, 2004) report that heat stress occurs when the body s internal core temperature rises above its normal level. It is a result of internal, metabolic heat buildup (from wearing bunker gear) and external stress from environmental factors while wearing personal protective equipment. Heat stress can be induced by any number of factors but most commonly high ambient air temperatures; high humidity; physically demanding work; and the type, style, and breathability of protective equipment. A firefighter s fitness level, body composition and psychological disposition are all contributing factors as well. Studies conducted at the University of Illinois Fire Service Institute discuss the relationship between heat stress and stroke volume. Firefighters working in protective equipment inside heated environments force their cardiovascular and body systems to compete for blood flow. The metabolically active muscle groups require oxygen carried by the blood to support the heavy muscular work, while the skin works to shunt blood away from the core for cooling in order to maintain the thermoregulatory system of the body. The vital organs of the brain and heart also require blood flow in order to sustain consciousness and vegetative functions. These cardiovascular demands are exacerbated by the tremendous fluid loss caused

Reducing Fire Ground Injuries 13 from profuse sweating and vasodilatation. The studies indicate that the hearts stroke volume (the amount of blood pumped with each beat of the heart) is substantially decreased during firefighting which is most likely caused from a combination of decreased venous return (caused by pooling of blood in the working muscles of the extremities) and profuse sweating which reduces the blood s plasma level. In addition to the reduced plasma level, Fibrinogen, a factor in blood clotting, is increased during firefighting. This increase elevates the risk of the body developing a clot within the circulatory system. Although this study does not show a definitive link to fireground cardiac incidents, it does identify potential areas of concern. (Smith, 2001) According to reports from the United States Fire Administration and National Fire Protection Association approximately 45 percent of line-of-duty deaths occur annually from heart attacks. (Fahy, 2004) (United States Fire, 2002) Dr. Denise Smith stated in an interview with the author that although most of these deaths can be related to long-term disease progression; it is likely however that the stress associated with firefighting can and does serve as the trigger for many cardiac related events. (Denise L. Smith, personal communication, February 8, 2006)

Reducing Fire Ground Injuries 14 Figure 1 Possible Causes of Heart Attacks in Firefighters Simplified Schematic of Possible Causes of Heart Attack in Firefighters Profuse Sweating Increased Body Temperature Activation of Sympathetic Nervous System Decreased Plasma Levels Altered Electrolytes Increased Blood Viscosity Changes in Heart Rate & Blood Pressure Circulatory Shock Arrhythmias Clot Formation Plaque Disruption Heart Attack The Chicago Fire Department commissioned a study in 1991 looking at oxygen consumption during fire suppression. Ten male firefighters were tested to determine their oxygen consumption and heart rates while performing simulated fire suppression drills. The men were initially tested on a treadmill to determine rate and consumption, and then moved to the simulated suppression activity where a marked reduction in oxygen consumption was noted compared to the elevated heart rate. The findings indicated that the heart rate energy expenditure as compared to oxygen consumption is not straightforward and hard to predict in fire suppression settings. Based on the findings of this study, researchers believe that firefighters develop over time a higher relative intensity work threshold (acclimation) compared to non-firefighters as it relates to required fire suppression tactics. In essence, the experienced firefighter figures out

Reducing Fire Ground Injuries 15 how to accomplish the required tasks with the least amount of physical exertion required. This is believed to be a learned muscle memory practice used to minimize the physical difficulty of the job and the associated heat stress. (Sothmann, 1991) Bodil Nielsen of the University of Copenhagen, Denmark agrees that repeated exposures to hot environments leads to acclimation and the delayed onset of fatigue. He goes on to say that the physical signs of heat stress continue to be present, yet somewhat slowed and reduced. The subjects do not feel as fatigued because the mind is tricked into believing that these conditions are routine. (Nielsen, 1994) Dr. Robert Glatz, Retired Medical Director of the King (NC) Fire Department presented the following as part of a firefighter safety and survival course at the 1998 Stokes County Fire School. (Glatz, 1998) Glatz recommended that firefighters engage in a regular physical training regiment since frequent exercise increases water and blood plasma levels by 10%-12%. Muscles cells contain 75% water while fat cells contain 25% water. In addition fat insulates the body there-by eliminating the body s ability to cool. Continued aerobic physical training will increase the efficiency and effectiveness of the body s cooling systems, reduce body fat, allow the firefighter to carry more water, sweat less, achieve greater cooling, and lose less salt thereby allowing faster re-hydration & recovery. He also suggested a carbohydrate-rich diet since carbohydrates give us the energy to work and sweat. A 60% carbohydrate rich diet (fruits, vegetables, breads, cereals, grains, rice and pastas) will increase the firefighter s ability to store energy and water. Finally, he recommends acclimation to working in heat. He suggests that if you are required to work in turnout gear, you need to train in turnout gear. This issue of acclimation has been readily studied as it relates to athletes competing in heated environments, workers who are subject to extreme temperatures (both heat and cold), and

Reducing Fire Ground Injuries 16 most notably, with soldiers who are required to perform within the most extreme of conditions. The Singapore Armed Forces Soldier Performance Centre, through repeated study of soldiers working in hot environments, concluded that acclimation can be produced in terms of core body temperature and sweat loss. Heart rate acclimation necessitates cardiovascular training, but when coupled with training in a heated environment, the soldiers perform better and longer with less detrimental effects due to heat stress. (Lin, 1997) The United States Military agrees; however, heat stress studies ongoing since 1950 have established that acclimation, cardiovascular fitness and hydration only go so far in the prevention of the effects of detrimental heat stress. Studies have demonstrated that heat illness rates are reduced by restricting the physical activity and dress of soldiers when the wet bulb globe temperature index (WBGT) exceeds 80 F. The military defines the WBGT as a weighted temperature index that takes into account air temperature, air movement, humidity and radiant heat exchange. This index was originally developed to predict sweat rates thereby predicting soldier heat stress. (Kark, 1996) For the last several decades military command policy has established a standard manner in which non-combat physical activity has been modified based on the WBGT. Table 2--Wet Bulb Globe Temperature Index WBGT Levels Physical Activity Modification 80-84.9 F Green Flag Exercise continues with caution 85-87.9 F Yellow Flag Strenuous exercise suspended for first phase recruits 88-89.9 F Red Flag Strenuous exercise suspended for all recruits 90 F Black Flag Suspension of all out door physical activity

Reducing Fire Ground Injuries 17 This modification has significantly reduced heat stress injuries. (Kark, 1996) However, during combat situations, usage of the WBGT system is not practical and systems of rehabilitation and fluid replacement become a necessity. Couple this with the need for chemical protective equipment as exhibited in the first Gulf War, and the heat stress issues faced by the military begins to approach the fire service situation. In these situations, the military has instituted protocol for cooling with ice water in the field as well as rehydration. If transport for medical care is required, treatment with rapid IV fluids is initiated including close monitoring of vital signs and continued cooling while being transported to a medical care facility or field hospital. The Zimbabwe Army Health/Environmental Medicine Unit in cooperation with the Department of Anatomy and Physiology at the University of Dundee, United Kingdom, conducted research on the benefits of consuming water alone or a dextrose with electrolytes drink. Results showed the critical need for continued fluid replacement during periods of exercise/work in hot conditions and better achievement of whole body water and electrolyte balance when electrolyte-containing drinks are ingested. Test subjects also reported a delay in the feeling of fatigue with the utilization of electrolyte containing drinks. (Mudambo, 1997) The NFPA 1584 (Recommended Practice on the Rehabilitation of Members Operating at the Incident Scene and Training Exercises 2003 Edition) standard recommends that firefighters consume a 50/50 mix of water and an electrolyte-containing sports drink 1 hour into the incident and additional electrolyte-containing drinks after every 2-3 bottles of water throughout the life of the incident. (NFPA 1584., 2003) Sports drinks work well to replace lost electrolytes, but care must by taken to ensure that their concentrations and osmolarity is less than 350 mosm/liter. Beverages with too high an osmolarity may actually draw fluids out of the cells in an effort to

Reducing Fire Ground Injuries 18 make it less concentrated, hence the NFPA recommendation of mixing the drinks 50/50 with water. (Verfuss, 2004) Typically, once a firefighter departs from a heated environment, their protective clothing is removed and the body is allowed to cool through evaporation. (Ross, 2004) However, the British Royal Navy conducted testing during the Falklands War with firefighters wearing protective equipment while exposed to heated environments; then hand and forearm immersion was used to lower core body temperatures. By immersing the hands in water between 50 F and 86 F, a significant lowering of core temperature was noted within 10 minutes. (Ross, 2004) The Royal Navy continued their research on hand and forearm immersion with much success during the Persian Gulf operations where soldiers wearing chemical protective clothing were cooled using hand immersion to prevent heat stress injuries. (House, 1997) The DefenCe Research and Development Canada (DRDC) Study evaluated similar data to the Chicago study and the Royal Navy study in an attempt to determine work limits for firefighters wearing protective clothing, to establish hydration strategies and to evaluate cooling strategies including passive cooling, misting fans and forearm immersion. Using this information, the group hoped to develop standards for how long a firefighter could and should work as well as measurable standards indicating when they are ready for release from rehab and available for another strenuous assignment. Suspecting that body core temperature and heart rate would be good indicators of overall physical condition, these two factors were evaluated. It was discovered that heart rate is not a useful method to assess recovery during rehab since heart rate rapidly returns to near normal levels, making the firefighter feel much better, yet core body temperatures still remained high. In fact, without active cooling methods (forearm immersion or misting fans), core temperatures continued to rise over a 30-minute rest period even with a

Reducing Fire Ground Injuries 19 marked decrease in heart rate. (McLellan, September 2003) This finding is consistent with Dr. Smith s research at the Illinois Fire Service Institute where she discovered that core temperatures continue to rise even after firefighters have been removed from the heated environment, protective clothing removed and placed in an air conditioned ambulance in a semi-fowlers position on an ambulance cot. (Smith, 2006) Figure 2 Core Body Temperatures 39 Core Body Temperatures after 10 Minute Recovery 38.5 38 37.5 Trectal 37 36.5 36 P re Trial 1 Trial 2 Trial 3 10 min rec Also in agreement, Dr. Smith suggests pushing fluids during the periods of rest (changing an SCBA cylinder, waiting for a new job assignment, etc.) and within the rehab sectors. (Smith, 2006) The DefenCe Research indicates a 20 percent performance improvement following fluid replacement as compared to no fluid intake while resting or in rehab. (McLellan, September 2003) It was also conclusively identified that rehab times are different for all firefighters based on individual age, sex, physical condition, psychological health, body make-up, environmental conditions, and the given emergency situation. Therefore, it is impossible to establish a set rest period encompassing all firefighters in every situation. Based on this, rehab sectors must include rehydration, cooling and medical monitoring. (Denise L. Smith, personal communication, February 8, 2006)

Reducing Fire Ground Injuries 20 In addition to the loss of circulating volume due to dehydration causing a decreased stroke volume and increased viscosity of the blood, the elevated core temperatures decrease the body s ability to process information and make rational decisions. A study conducted by the Human Sciences Laboratory, Transvaal and Orange Free State Chamber of Mines in Johannesburg, South Africa, looked at heat reactions of male and female Caucasians working in heated environments. Subjects were tested using a stair machine at a rate of 12 steps per minute to ensure a standardized continuous work rate of 1,560 ft lb/min. The tests were conducted in a climatic controlled tent at 95-96 F for 4-hours per day over an 11-day period. Male test subjects were dressed in shorts and female subjects in bikini type clothing. Subject s core temperatures were measured using rectal probes and the testing was stopped when rectal temperatures exceeded 104 F or when the subject became giddy or exhibited signs of exhaustion or distress due to headache or abdominal pain. Researchers discovered that heart rates and rectal temperatures rose to very high levels much more rapidly in the females and that they produced considerably less sweat in the first hour of the tests than their male counterparts. However, the sweat rates became much closer in the second and subsequent hours. Important is that both sexes were psychologically affected showing signs of marked aggression and irritability and loss of their usual social inhibitions. One man had hysterical manifestations and several of the females broke down and wept. Most subjects complained of epigastric/precordial pain, tingling of the extremities, difficulty in breathing, swallowing, throbbing headaches and giddiness. (Wundham, 1964) Additional research on cognitive function within heated conditions (104 F) shows that simple reaction time and accuracy significantly deteriorates as the core temperature increases. (Razmjou & Kjellberg, 1992) A study conducted by the Department of Psychological Sciences/Center for Human Sciences, Defense Research Agency in Farnborough, Hampshire,

Reducing Fire Ground Injuries 21 UK determined that the neural conduction velocity decreases as the temperature rises causing a marked reduction in memory and accuracy of assigned tasks. (Frim, 1994) In addition to cognitive function disorders, the body responds chemically to heat stress in a variety of negative ways. Blood tests of firefighters participating in live fire evolutions as part of the Illinois Fire Service Institute s ongoing study indicates the body experiences several negative effects. Platelet levels increase as does Fibrinogen, and when coupled with reduced plasma levels, the risk of blood clots increase. Especially telling is the fact that Antithrombin III, a protein that helps prevent and regulate blood clotting, is also elevated post evolution. Sodium levels decrease due to the massive dehydration and glucose levels often reduce to levels seen in clinical hypoglycemia. This hypoglycemic or near hypoglycemic state may also contribute to the reduced cognitive function, but this has not yet been specifically studied. Cortisol, a hormone produced by the adrenal gland important for function of the immune system, glucose regulation, vascular tone and bone metabolism and is secreted during periods of stress is also elevated. Cortisol levels post evolution routinely are elevated 100% above pre-activity levels. Additionally a decrease in the bodies immune cells are seen including an increase in leukocyte or white blood cell levels. (Smith, 2006) In order to mitigate or minimize the detrimental affects of heat stress an effective rehabilitation sector is a required fireground tactic. Fire departments need to develop policies that include rest, hydration, active cooling and fueling for operating personnel. (Ross, 2004) Additionally, policies need to be established for medical monitoring including standing medical orders to assist medial personnel assigned to the rehab sector determine the conditions of firefighters. These medical assessments as well as the time in/time out, the amount of fluid

Reducing Fire Ground Injuries 22 ingested, types of cooling procedures used as well as nourishment needs to all be tracked. It is recommended that this documentation be maintained as part of the department s permanent records regarding the incident. (Denise L. Smith & Craig A. Haigh, 2006) In summary, the reviewed literature clearly identifies the physical and physiological impact of heat on the human body. This information paints a convincing picture of the negative influences of heat stress and the need to aggressively mitigate its effects. Additionally, this review clarified how little information currently exists that specifically studies the impact on the human body of firefighting. Continued scientific based research is needed in order to fully understand the impact of heat stress on firefighters.

Reducing Fire Ground Injuries 23 Procedures The procedures used to derive this applied research project focused on: (1) whether common strains, sprains and falls are related to heat stress events, (2) are Hanover Park firefighters sustaining injuries from heat stress? To answer these questions a comprehensive review of all fire department injury reports, resulting from structure fires or live fire training, was conducted dating back to July of 2000. This date was selected based on the availability and completeness of records following the merger of the fire protection district and the municipality. The total number of accidents was calculated, and then broken down into 15 categories. The physical and physiological strains associated with heat stress were identified through the literature review: 1. Core body temperate 2. Hydration levels 3. Blood pressure and pulse rate 4. Rate of perceived exertion 5. Level of consciousness Next, I analyzed current conditions and practices to identify ways to better prepare firefighters for the physical demands of fireground operations. 1. What is our current physical fitness program? 2. Do we have established dietary suggestions to promote good nutrition? 3. Are we utilizing the most appropriate kind of protective equipment to minimize heat stress? If so, is it in good repair? 4. What is the current health status of each employee?

Reducing Fire Ground Injuries 24 Finally, I evaluated rehabilitation practices. Did a current rehab policy exist within our department? If so, did it include: 1. Rehydration 2. Body cooling and protection from climate 3. Medical monitoring 4. Rest and recovery period 5. Member accountability How strongly do the firefighters in general embrace the rehab program? Do they believe rehab is needed--that it subsequently reduces line of duty injuries? Meetings were held with each Hanover Park shift to discuss rehab and the beliefs and attitudes of the firefighters. Firefighters were asked the following questions: 1. Do you believe that rehab is an important part of incident management? 2. If so, at what alarm level should a formal rehab sector be established? 3. What components are needed as part of a rehab sector? 4. Does the heat stress associated with firefighting lead to heart attacks? An Illinois Fire Service Institute Library ListServe Survey was conducted as well as a NFA TRADE Survey asking information regarding fire departments rehab practices including copies of their standard operating guidelines. They were also asked to provide insight into stumbling blocks that prohibited the effective use of rehab sectors. Sixteen departments representing thirteen states responded.

Reducing Fire Ground Injuries 25 Results The answers to the research questions were compiled based on a review of departmental injury records, a survey of departmental personnel, a comprehensive literature review and a University of Illinois Fire Service Institute Library ListServe Survey and NFA TRADE Survey. 1. What type of injuries/illnesses have Hanover Park Firefighters incurred following a working structure fire or live fire training? Since 2000, fifty Hanover Park firefighters have filed accident reports related to injuries/illnesses that occurred while operating on the fire ground or during training including medical exposures: Table 3--Injuries to Hanover Park Firefighters # of Injuries Type of Injury 4 Heat Exhaustion 8 Back Strains 2 Neck Injury/Muscle Strains 4 Shoulder Strains 3 Knee Strains 4 Ankle Sprain 2 Burns 6 Lacerations/Contusions/Punctures 1 Wrist Injury 1 Hydraulic Fluid in Eyes 1 Respiratory Injury 14 Medical Exposures

Reducing Fire Ground Injuries 26 Additionally, thirty (30) first-aid reports were submitted and are listed by category: Table 4--First-Aid Reports for Hanover Park Firefighters # of Injuries Type of Injury 1 Debris in the eye 13 Lacerations/Contusions/Punctures 16 Strains/Sprains 2. What are the physical and physiological strains associated with heat stress caused by fireground operations? Physical and Physiological changes are compiled below. All information comes from the literature review and shown below for comparison purposes: a. Hearts stroke volume b. Venous return due to fluid loss from sweating and vasodilatation. c. Fibrinogen (clotting factor) d. Platelets (component in the blood that generates clots) e. Plasma (fluid component of blood) f. Antithrombin III (protein that helps regulate clotting) g. Glucose levels h. Cortisol levels (hormone for that assists with the immune system, glucose regulation, vascular tone and bone metabolism) i. Immune cells j. Ability to process information and make rational decisions

Reducing Fire Ground Injuries 27 k. Reaction time and accuracy of decision making 3. How can we better prepare firefighters for the physical demands of heat stress caused by fireground operations? a. What is our current physical fitness program? i. Currently no formal physical fitness program exists at Hanover Park Fire Department. ii. Effective September 2006 the Village of Hanover Park has begun contracting with Alexian Brothers Medical Center for a long term health screening and individually developed wellness plan for all fire department personnel who choose to participate in the program. Participation was encouraged but was not mandated due too prohibition by current collective bargaining contracts. Twenty-five of the department s full time members voluntarily completed the initial health screening and are in the process of having wellness programs developed. The department has also recently updated the available physical fitness equipment and workout facilities to encourage participation in cardiovascular, strength and flexibility training. b. Do we have established dietary suggestions to promote good nutrition? i. The department does not have such a program. c. Are we utilizing the most appropriate kind of protective equipment to minimize heat stress? If so, is it in good repair? i. The department uses protective equipment meeting the most current NFPA standards.

Reducing Fire Ground Injuries 28 ii. This equipment is evaluated on a semi annual basis by the department s quartermaster to ensure that the gear is in good repair, that the moisture barriers are working effectively and the fit and sizing of the gear is still appropriate for the wearer. d. What is the current health status of each employee? i. No department sponsored medical evaluation is conducted due to prohibition by collective bargaining contracts with IAFF Local 3452 and SEIU Local 73. 4. What rehab programs are other fire departments using? a. Hanover Park utilized a rehab policy that revolved around calling for The Salvation Army once the alarm was elevated to the 2-11 status. It included no established standards for rehydration, body cooling and protection from the climate, medical monitoring, rest and recovery, or member accountability. b. In meetings with Hanover Park firefighters they were questioned about their personal feelings toward rehab: c. Do you believe that rehab is an important part of incident management? i. Firefighters generally responded that rehab is important for delayed incidents but that nothing further than rehydration is needed for the typical building fire. d. If so, at what alarm level should a formal rehab sector be established? i. Some indicated rehab should be established at the MABAS Box Alarm level while the majority said not until a 2-11 alarm is called. e. What components are needed as part of a rehab sector?

Reducing Fire Ground Injuries 29 i. All firefighters felt rehydration was needed but few felt that nourishment, an area for rest and recovery, relief from climatic conditions, body cooling or medical monitoring was needed except for extreme circumstances. f. Does the heat stress associated with firefighting lead to heart attacks? i. Most felt that heart attacks could be triggered by excessive work in firefighters who are in poor cardiovascular health but that dehydration and heat stress play a minimal role in the overall myocardial infarction process. g. An Illinois Fire Service Institute Library ListServe Survey was conducted as well as a NFA TRADE Survey asking for information regarding fire departments rehab practices. Respondents were also asked to provide insight into any stumbling blocks that prohibited the effective use of rehab sectors. i. Sixteen (16) departments responded to this request painting a varying picture of rehab services throughout the country. Several departments provided copies of their rehab policies while others shared their department s position on rehab. 1. The Barberton Ohio Fire Department responded that rehab consists of the break you get when you have the empty air bottle removed from your pack and a full one put in its place. (Michael. Benson, personal communication, March 17, 2006) 2. Yarmouth Fire Department (MA) routinely calls for a mutual aid ambulance to respond and provide medical evaluations. The local

Reducing Fire Ground Injuries 30 Red Cross who is also called at the same time is responsible for fluid replacement and nourishment. 3. EMS Supervisor Rick Todd however admits that the ambulance crew sometimes gets used for fire suppression activities and therefore is not available to complete their pre-assigned duties. He suggests that poor decision making and utilization by the incident commanders are the key reasons why their rehab practice has limited success. (Rick. Todd, personal communication, March 17, 2006) 4. The Colorado Springs Fire Department relies on the county firefighter s association to respond with one of two available rehab units. These units are staffed by volunteers who are paged immediately upon the report of a working fire. Units have the capability to provide fluids, food, misting fans, chairs, sheltering tents as well as lighting. Each department annually contributes funds to maintain this service. (Jim. Rackl, personal communication, March 17, 2006) 5. The Merced City Fire Department (CA) equips their chief s cars with rehab supplies to provide rehydration and shade. On working fires a safety officer is automatically dispatched and is responsible in part to establish a rehab sector including misting fans when required. The Red Cross also responds to provide nourishment

Reducing Fire Ground Injuries 31 when requested. (Steve. Raney, personal communication, March 3, 2006) 6. Marshfield Wisconsin Fire Department carries bottled water and fruit bars on their apparatus and has agreements with local merchants to supply food when the department calls. They also assign an ambulance to the rehab area to monitor blood pressures and pulses however they have no formal operating policy which allows those firefighters who wish to avoid rehab the ability to go until they drop. (Ed. Erickson, personal communication, March 3, 2006) 7. The Cool Springs Volunteer Fire Department (NC) relies on their County EMS to provide both rehydration and medical monitoring. They establish rehab in close proximity to their staging area so that as personnel are sent to rehab, an equal number of personnel can be sent to replace them. (David. Cline, personal communication, March 6, 2006) 8. The Lawrence Township Fire Department located in metro Indianapolis starts a rapid intervention team and their ladies auxiliary to the scene as soon as a working fire is confirmed. The auxiliary responds with a converted ambulance and is rapidly becoming a mainstay for rehab services within the area. (Chuck. Benslay, personal communication, March 3, 2006)

Reducing Fire Ground Injuries 32 9. Captain Jeffery Birt of the Louisville Fire Department and Assistant EMS Chief John Dick of the Minneapolis Fire Department both commented that their departments have rehab policies within their standard operating procedures but that they are utilized on a hit or miss basis and that they are not readily supported by fire department personnel. (Jeffery. Birt, personal communication, March 6, 2006) (John F. Dick, personal communication, March 15, 2006) 10. The Lincoln Nebraska Fire Department utilizes a unique concept of having their fleet maintenance shop staff and respond with a haz mat decon trailer that is equipped with rehab equipment and supplies. This unit responds on all major incidents along with the Red Cross and a group of chaplains who assist with food and drink as well as shelter for the occupants. (Kim. McKay, personal communication, March 3, 2006)

Reducing Fire Ground Injuries 33 Discussion Two common threads are evident in the information presented within this applied research project. The first is that heat stress in general has a negative impact on the human body and when coupled with fire suppression activities the effects are compounded. As evidenced by Dr. Smith s research, although firefighting probably does not alone cause a firefighter to have a heart attack, there is a strong link between heat stress and a trigger event that can produce cardiac related problems including a myocardial infarction. The second thread is that a misconception still exists amongst the fire service regarding the need for rehab and its physical and physiological impact on the human body. Fire Departments would not dream of sending personnel into a working structure fire without protective equipment due to the inherent dangers associated with that environment. However many see little need to minimize the dangers associated with heat stress. It is this researcher s opinion that this is due primarily to the lack of available information regarding the dangers of heat stress coupled with the limited amount of fire service specific research. When applying these to the Hanover Park Fire Department it becomes evident that we are a microcosm of the fire service in general. Although a rehab policy exists that is based on the guidelines of NFPA 1584, we have no comprehensive system to minimize the detrimental effects of heat stress. In reality, any rehab policy adopted by Hanover Park Fire Department that does not include training for the neighboring departments within our MABAS (Mutual Aid Box Alarm System) Division will not be fully implemented at an emergency incident. Currently, and for the foreseeable future, Hanover Park will respond with all on-duty personnel to any confirmed fire within the village. Current response standards call for all eleven personnel to respond staffing two engines, a tower ladder, and ALS ambulance and the shift

Reducing Fire Ground Injuries 34 Battalion Chief. This response is supplemented by automatic aid equipment consisting of a third engine, a second truck, a second ALS ambulance, a Heavy Rescue Squad, the on-call Hanover Park administrative chief and a chief officer from the closest neighboring community. Arriving companies from both inside and outside the village have pre-assigned duties with rehab falling to the second responding ALS ambulance. It is this system that requires any rehab policy adopted by the department to be fully understood by the auto aid ambulance in order for it to be implemented effectively. Currently, no system exists to provide this training to the seven possible neighboring departments who will be requested to provide this service. It is also evident based on the meetings with department personnel that the majority of the members do not fully understand the physical and physiological strain associated with fire suppression and the intense need for rehab even at the relatively minor incidents. Department members also seem to lack a clear understanding of how to minimize the effects of heat stress prior to response to the emergency incident through physical training and nutrition.

Reducing Fire Ground Injuries 35 Recommendations The following recommendations are made: 1. Update existing rehab policy and accountability system. (see Appendix A) 2. Utilizing as a template the course developed by this researcher and Dr. Denise Smith for presentation at FDIC and Fire Rescue International, conduct training with all department personnel on the physical and physiological strain of firefighting. This course can easily be adapted to become department specific and will provide a good baseline for department members. Included as part of this training, review the existing rehab policy and accountability system to ensure understanding by all department personnel. (see Appendix B) 3. Encourage department members to participate in the Alexian Brothers Medical Center health screening and wellness program. As part of the contract with the Village, Alexian Brother will develop individual wellness plans for all personnel participating in the program including providing personal trainers. 4. Work through labor management meetings with the IAFF and SEIU to develop a system of required medical exams based on the firefighter s age. 5. Request of the MABAS Divisions II and XII presidents to be placed on their meeting agendas to discuss Hanover Park s rehab policy and the need to train personnel who will respond as part of our auto aid agreements. Offer to conduct these trainings at the seven departments who will most commonly serve as our rehab medical unit. 6. Since departments within Divisions II and XII operate using similar response protocols Hanover Park will volunteer to chair a committee to develop a standardized rehab policy for use by all member departments.

Reducing Fire Ground Injuries 36 7. Since no Standing Medical Orders currently exist for medical evaluation of firefighters in rehab, work with The Greater Elgin Mobile Intensive Care System to develop protocol for use by EMS personnel assigned to the medical monitoring section of rehab. 8. Develop a system of tracking the rehab accountability sheets for long term study to ensure success in reducing illness and injuries from heat stress.

Reducing Fire Ground Injuries 37 References Denise L. Smith & Craig A. Haigh. (2006, April). Implementing Effective On-Scene Rehabilitation. Fire Engineering. Fahy, R. (2004). Sudden Cardiac Death. National Fire Protection Association, July/August, 44-47. Frim, J. (1994). British Crown. In Sixth International Conference on Environmental Ergonomics Montebello, Canada: British Crown. Glatz, Robert. (1998). Firefighter Safety & Survival. In Stokes County Fire School NC. House, J. R. (1997). Prevention of Heat Strain by Immersing the Hands and Forearms in Water. Royal Naval Medical Service, 83.1, 26-30. Kark. (1996). Exertional Heat Illness in Marine Corps Recruit Training. Aviation, Space and Environmental Medicine, 67(4), 354-359. Lin, Chin Leong. (1997). The Effects of Prolonged Passive Heat Exposure and Basic Military Training on Thermoregulatory and Cardiovascular Responses in Recruits from a Tropical Country. Military Medicine, 162(9:623), 623-627. McLellan, Tom. (September 2003). Current fire Fighter Occupational Medicine Issues, Approaches for Fire Fighter Rehabilitation. In IAFF John P. Redmond Foundation Health and Safety Seminar San Francisco. Mudambo, K. S. M. T. (1997). Dehydration in soldiers during walking/running exercise in the heat and the effects of fluid ingestion during and after exercise. European Journal of Applied Physiology, 76, 517-524.

Reducing Fire Ground Injuries 38 NFPA 1584. Recommended Practice on Rehabilitation of Members Operating at the Incident Scene and Training Exercises. (2003). NFPA. Nielsen, Bodil. (1994). Heat Stress and Acclimation. Ergonomics, 37(1), 49-58. Razmjou, Shahram., & Kjellberg, Anders. (1992). Sustained Attention and Serial Responding in Heat: Mental Effort in the Control of Performance. Aviation, Space, and Environmental Medicine, July, 594-600. Ross, David. (2004, May). Rehabilitation: Standards, Traps, and Tools. Fire Engineering, 2004, 2. Retrieved May 26, 2006, from Fire Engineering Web site: http:// pennwell.printthis.clickability.com/pt/cpt?action=cpt&title=fire+engineering+-+re Rowell, Loring. (1986). Human Circulation: Regulation During Physical Stress. London: Oxford Press. Smith, D. L. (2001). Effects of Live Fire Training on Recruits. Fire Engineering, September. Smith, D. L. (2006). Rehab -- What's Been Missing? Implementing Effective On-Scene Rehabilitation. In Fire Department Instructors Conference Indianapolis, IN. Sothmann, M. (1991). Oxygen consumption during fire suppression: error of heart rate estimation. Ergonomics, 34(12), 1469-1474. United States Fire Administration. (2002). Firefighter Fatality Retrospective Study (FA220). Washington, DC: Author. Verfuss, Erik. (2004). Can adequate rehab prevent firefighter deaths? Fire Engineering, December. Wundham, C. H. (1964). Heat reactions of male and female Caucasians. Ergonomics, 357-364.

Reducing Fire Ground Injuries 39 Appendix A REHABILITATION POLICY Purpose To ensure that the physical and mental condition of employees operating at the scene of an emergency, training exercise, or other fire department activity does not deteriorate to a level that affects the safety or well-being of each employee or that jeopardizes the safety and integrity of the operation. Scope This guideline shall apply to all activities of the fire department, including, but not limited to, fire ground operations, EMS operations, training exercises and drills where strenuous mental and physical activities or exposure to heat or cold exist. 1. Responsibilities 1.1 Incident Commander - The Incident Commander (IC) shall have the responsibility and authority to implement and monitor all provisions of this operational guideline. The Incident Commander shall consider circumstances of each incident and make adequate provisions early in the incident for the rest and rehabilitation for all members operating at the incident. These provisions shall include: medical evaluation, treatment and monitoring; food and fluid replenishment; physical and mental rest; relief from extreme climatic conditions; relief from other extreme environmental factors caused by the incident. The rehabilitation shall include provisions for Emergency Medical Services (EMS) at the Advanced Life Support (ALS) level. 1.2 Sector/Company Officers - All Sector/Company Officers (CO) shall maintain an awareness of each member operating within his/her span of control and ensure adequate steps are taken to provide for each member s health and safety. The Incident Command System (ICS) shall be utilized to request relief and/or reassignment of working crews. 1.3 Line Personnel - Each member is responsible for his/her preparedness prior to an incident, including sufficient rest prior to reporting for duty, pre-hydration during hot days, proper dress during cold days and ensuring that protective clothing and equipment is present and in good working order. During any emergency incident or training activity, all members shall advise their supervisor when they believe that their level of fatigue or exposure to heat or cold is approaching a level that could affect themselves, their crew, or the operation in which they are involved. Members shall remain aware of the health and safety of other members of their working crew. 2. Establishment of Rehabilitation Sector/Division/Group 2.1 Responsibility - The Incident Commander shall establish a Rehabilitation Sector or Division when conditions indicate that rest and rehabilitation is needed for personnel

Reducing Fire Ground Injuries 40 working at an incident scene or training exercise. The IC shall designate a certified Paramedic as Rehab Officer and place him/her in charge of the Rehab Sector. The Rehab Officer shall then act within the ICS and report to the Logistics Officer. If no Logistics Officer is designated, the Rehab Officer shall report to the IC. 2.2 The Incident Commander shall establish a Rehab Sector during: 2.2.1 Any General Alarm for a working structure fire where crews will perform structural firefighting. 2.2.2 Any Hazardous Materials Incident or hands-on training exercise using Level A or B suits. 2.2.3 Any emergency incident that results in a MABAS Box Alarm or higher. 2.2.4 Any prolonged extrication or rescue. 2.2.5 Any incident that has lasted or is expected to last 2 hours or more in duration. 2.2.6 Any incident that is expected to last 1 hour or more during extreme climatic conditions. 2.2.7 Any training exercise where prolonged physical exertion or testing will be performed. 2.2.8 Any incident that is large in size, labor intensive and that may rapidly deplete the energy and strength of personnel. 2.3 The Incident Commander may establish a Rehab Sector during any other fire department activities at his/her discretion; climatic and environmental factors need not be the sole criteria or justification for establishing a Rehabilitation Sector/Division. 2.3.1 Location 2.3.1.1 The Incident Commander will normally designate the location for the Rehabilitation Sector. If a specific location has not been designated, the Rehab Officer shall select an appropriate location based on the site characteristics listed below. 2.3.1.2 Multiple Rehab Sectors may be necessary if the incident is large or divided. In the event there are more than one Rehab Sectors, they shall be designated Rehab 1 and Rehab 2, etc. Each Rehab Sector will have its own Rehab Officer who shall report to the Logistics Officer. Each Rehab Officer shall be a certified Paramedic. 2.3.2 Site Characteristics 2.3.2.1 It shall be in a location that will provide physical rest by allowing the personnel to recuperate from the demands and hazards of the emergency operation or training evolution. 2.3.2.2 It shall be far enough away from the scene that personnel may safely remove their turnout gear and SCBA and be afforded mental rest from the stress and pressure of the emergency operation or training evolution.

Reducing Fire Ground Injuries 41 2.3.2.3 It shall provide suitable protection from the prevailing environmental conditions. During hot weather, it should be in a cool, shaded area. During cold weather, it should be in a warm, dry area. 2.3.2.4 It shall enable personnel to be free of exhaust fumes from apparatus, vehicles, or equipment (including those used in the Rehab Sector). 2.3.2.5 It shall be large enough to accommodate several crews, based upon the incident size. 2.3.2.6 It shall be easily accessible by EMS vehicles. 2.2.3.7 It shall allow prompt re-entry to the incident. 2.3.3 Site Designations 2.3.3.1 Squad 370 or other on-scene vehicles designed for this purpose. 2.3.3.2 Ambulance(s) not available for transporting patients 2.3.3.3 School buses, Pace buses or Metra train cars. 2.3.3.4 Nearby buildings, stores or other structures. 2.3.3.5 If in a high-rise, several floors (3 min.) below the incident. 2.3.3.6 An open area where tarps, fans, heaters, etc can be set up. 2.3.4 Resources 3. General Operational Principles 3.1 Establishment 2.3.4.1 Medical Equipment The Rehab Officer shall maintain at least one Advanced Life Support Ambulance for every 15 people undergoing rehabilitation in the Rehab Sector. 2.3.4.2 Medical Personnel - The Rehab Officer shall maintain a staffing in the Rehab Sector of one certified Paramedic for every 10 people undergoing rehabilitation in the Rehab Sector. 2.3.4.3 Fluids/Food - The Rehab Officer shall provide, or have provided sufficient potable water, oral electrolyte solution, ice and food as may be necessary. The Salvation Army Mobile Canteen should be notified early into an incident to allow for travel time. 2.3.4.4 Other Equipment The Rehab Officer shall secure from the Logistics Officer any other needed items such as, tarps, lights, fans, blankets, towels, traffic cones, fire-line tape, etc. 3.1.1 Climatic or environmental conditions that indicate the need to establish a Rehab Sector are a heat stress index above 90 degrees Fahrenheit or wind-chill index below 10 degrees Fahrenheit.

Reducing Fire Ground Injuries 42 3.2 Hydration 3.2.1 During heat stress, each personnel should replace at least one quart of water per hour. The re-hydration solution should be a 50/50 mixture of water and a commercially prepared beverage such as Gatorade. Carbonated beverages, coffee, tea or alcoholic beverages should be avoided. 3.3 Nourishment 3.4 Rest 3.3.1 If food is required or provided, it shall be soups, broths, fruits (bananas, apples, oranges) or other easily digested foods. Fast food sandwiches, fatty or salty foods should be avoided. 3.4.1 Rest shall be provided after the two bottle rule or 45 minutes, which ever comes first. 3.4.2 Personnel should re-hydrate at least 8 ounces during SCBA bottle change. 3.4.3 Rest shall be no less than 10 minutes and may exceed 30 minutes as determined by the Rehab Officer. 3.4.4 Personnel requiring more than one hour of rest should be released from duty and transported to a medical facility. 3.4.5 Personnel released by the Rehab Officer shall report to the Staging Area. 3.5 Medical Evaluation 3.5.1 The Rehab Sector shall be staffed with a Personnel/Paramedic ratio of no less than 10:1. 3.5.2 Rehab Sector medical evaluation shall consist of a minimum of a) visual exam, b) blood pressure, c) pulse, d) oral temperature. 3.5.3 All treatment shall be consistent with policy and procedures set forth by the Grater Elgin Area Emergency Medical System. 3.5.4 Any member who exhibits a body temperature of > 100.6F, a consistent pulse rate of > 110bpm shall not be permitted to wear full protective clothing, including SCBA and shall require addition rehabilitation. 3.5.5 Any member(s) who receive any treatment(s) other than fluid, food, and/or rest shall be treated and documented as an injury to personnel. As an example, ice for sprains or strains shall be considered injuries rather than rehabilitation. 3.5.6 All Rehab Sector evaluations shall be documented on Form# XXX and shall become a permanent record attached to the incident report.

Reducing Fire Ground Injuries 43 4. Accountability 3.5.7 All injury reports shall remain part of the employee s protected medical file and treated as other confidential medical records. 3.5.8 Any/all Rehab Sector reports involving Mutual or Auto Aid personnel shall be made available to their respective departments. 4.1 Personnel assigned to the Rehab Sector/Division shall enter and exit the Rehabilitation Area as a crew. The crew designation, number of crew personnel, and the times of entry/exit shall be documented by the Rehab Officer, or his/her designee on Form# XXX 4.2 Crews shall not leave the Rehabilitation Area unless authorized to do so by the Rehab Officer. 5. HEAT STRESS INDEX Relative Humidity T 10% 20% 30% 40% 50% 60% 70% 80% 90% E 104 98 104 110 120 132 M 102 97 101 108 117 125 P 100 95 99 105 110 120 132 E 98 93 97 101 106 110 125 R 96 91 95 98 104 108 120 128 A 94 89 93 95 100 105 111 122 T 92 87 90 92 96 100 106 115 122 U 90 85 88 90 92 96 100 106 114 122 R 88 82 86 87 89 93 95 100 106 115 E 86 80 84 85 87 90 92 96 100 109 84 78 81 83 85 86 89 91 95 99 F 82 77 79 80 81 84 86 89 91 95 80 75 77 78 79 81 83 85 86 89 78 72 75 77 78 79 80 81 83 85 76 70 72 75 76 77 77 77 78 79 74 68 70 73 74 75 75 75 76 77 Note: Add 10F when protective clothing is worn and add 10F when in direct sunlight. Humidity Index F Danger Injury or Threat Category Below 60 F None Little or no danger under normal circumstances 80 90 F Caution Fatigue possible if exposure is prolonged and there is physical activity 90 105 F Extreme Caution Heat cramps and heat exhaustion possible if exposure is prolonged and there is physical activity 105 130 F Danger Heat cramps or exhaustion likely, heat stroke

Reducing Fire Ground Injuries 44 Above 130 F Extreme Danger possible if exposure is prolonged and there is physical activity Heat Stroke Imminent!!

Reducing Fire Ground Injuries 45 WIND CHILL INDEX Temperature Degrees Fahrenheit 45 40 35 30 25 20 15 10 5 0-5 -10-15 W 5 43 37 32 27 22 16 11 6 0-5 -10-15 -21 I 10 34 28 22 16 10 3-3 -9-15 -22-27 -34-40 N 15 29 23 16 9 2-5 -11-18 -25-31 -38-45 -51 D 20 26 19 12 4-3 -10-17 -24-31 -39-46 -53-60 S 25 23 16 8 1-7 -15-22 -29-36 -44-51 -59-66 P 30 21 13 6-2 -10-18 -25-33 -41-49 -56-64 -71 E 35 20 12 4-4 -12-20 -27-35 -43-52 -58-67 -75 E 40 19 11 3-5 -13-21 -29-37 -45-53 -60-69 -76 D 45 18 10 2-6 -14-22 -30-38 -46-54 -62-70 -78 Wind Chill Danger Temperature o F A Above 25 F Little danger for properly clothed personnel B -25F / -75F Danger, flesh may freeze C Below 75F Flesh may freeze in 30 seconds

Form# XX Reducing Fire Ground Injuries 46

FORM# XXX Reducing Fire Ground Injuries 47

Reducing Fire Ground Injuries 48