Kenneth G. Lavelle, MD, FACEP, FF/NREMT-P
Your EMS unit is dispatched to a working structure fire on a hot summer day. You and others set up the EMS branch and the rehab sector.
Equipment is readied and assignments are given out. Approximately 20 minutes into the fire, the first two companies, eight firefighters total, are assigned to rehab at the same time.
You only get one chance to make a first impression, and emergency services are no exception. These firefighters likely have many thoughts going through their head.
If the fire is not out, they want to get back into the fight. Nobody wants someone's house to burn down, but when it happens, most firefighters want to be involved to try to make a difference. This rehab sector is standing in their way to go back and help.
They may not believe in the concept of rehab. It is hard to believe in this day and age, but understandable, especially if they have had a bad experience with rehab in the past.
Perhaps it was done inefficiently and slowly, delaying them from doing their job. Or perhaps they feel they were inappropriately held in the medical treatment area because of a vital sign that was slow to return to an acceptable level. For whatever reason, they have a prejudice against rehab that we must overcome.
These are just some of the many barriers we must overcome quickly so we can do our job to get these firefighters back at work. I have found that one of the best ways to win them over right away is through efficiency.
All of us in emergency services have to make do with less. We may want to have 10 EMS personnel on scene for rehab and transport. But that is unlikely — two to four is more realistic.
So how can we use these individuals efficiently to screen the incoming firefighters for medical issues and prevent them from wondering away? Here are seven methods I use to improve efficiency.
1. Sit them down
It doesn't matter if it is on a chair, bench or the ground. If you can get their butts down it will delay them from leaving. I explain in advance that sitting down and getting gear off is the best way to help those high pulse rates and blood pressures come down to acceptable levels.
Note that I do not say normal — it is unlikely their heart rates will be 90 and the blood pressures 120/80. And clinically, it does not have to be.
This will often take a bit of couching, but be persistent.
2. Attach an anchor
As soon as possible, attach everyone to a machine. This also makes them less likely to wander off. I often hook a pulse-ox to one firefighter and the automatic BP cuff to another. I carry a co-oximeter as well and will attach that to a third.
This also gathers data. I know that manual BPs may actually be better, and I doublecheck any unexpected values. But this shows them we are moving quickly to get the information we need.
3. Have an attraction
In a perfect world, I like to have most or all of the water in the rehab area so members have to come into the evaluation area to get it. If there is a cooler on every bumper, why do they need to come to rehab?
This may not always be practical, however, because we really do want to encourage fluid intake even when not in the rehab sector. So I try to make sure there is no obvious or visible water within eyesight of my evaluation area, thus they are less likely to wander.
4. Have scribes
Have an established and simple rehab form to gather the name, company and vital signs as well as the entry and exit times. If you have non-medical staff that responded to the scene or a neighboring EMS member, they can assist in writing this info down while the EMTs and paramedics can be EMTs and paramedics.
They should not be random civilians due to privacy concerns, but large fires often draw a number of responders, at least early on.
5. Have a chat
When in the rehab sector, I start chatting with the firefighters coming through. While it is more helpful if I know them, I can still get a pretty good idea of how they are feeling.
It is highly unlikely a firefighter will say, "Hey doc, I feel really lousy; I think I should stay in the sector a bit longer, maybe even go to the hospital." I expect military docs have the same problem to a much higher degree.
Thus, I just get them talking. Often I will ask them about the conditions inside. That also gives me an idea of what to expect injury wise.
If they are talking in full sentences, look good, are not winded, have fairly normal (expected) vital signs and deny and concerning symptoms such as chest pain, shortness of breath or dizziness, then I’m done. I move on to the next.
But if they have a glazed over look, are unable to focus or have difficulty speaking, then I don't care how much they deny — I'm concerned. These get funneled to the medical area for further evaluation and care.
6. Have a plan
Once the set of vitals is obtained and we know we are just in the rest and refresh stage, let the member know what is happening.
"Your heart rate is a bit high at 180 — we need it to be 120 before we can cut you lose. Sit down, cool off, get some fluids and we will re-check it in 10 minutes."
Then enforce it. If they leave before we clear them, I advise the safety officer. Once you do that the first time it will be noticed — and elopers will be less common. But if they see we are wishy-washy and there are no consequences, they are out of there.
7. Be professional
Regardless of how old you are, if you act like a kid you are going to get the respect of a kid. Have a uniform and not shorts and flip-flops.
Make sure your equipment is staged and working; know how to use it. Know what data you need and know your protocols that hopefully the firefighter has been informed of in advance.
These are just a few examples of how to be more efficient in your rehab sector. By being efficient we will make sure we gather the data we need to make an informed decision about when the firefighter can get back in the saddle.
We will minimize the number of firefighters who leave early and hopefully catch any life-threatening conditions early and address them.