Fireground Medical Screening Exam - Epilogue II
|Editor's note: This is part two of the finale of Dr. David Jaslow's Fireground Medical Screening Exam. Don't miss part 1, in which Dr. Jaslow explains how to understand the diagnostic tests commonly used on the fireground.|
On a final note, there are certainly paramedics, fire chiefs and physicians who will use our previous discussion as ammunition to fire back that the lack of scientific research about firefighter rehab and the complexity of decision-making in the rehab sector regarding who is sick and who is not is exactly the reason that "everyone should go to the hospital." I have several retorts to this statement.
First, although I cannot prove this opinion, it has been my experience over more than 20 years in the field that the greater concern about medical evaluation of firefighters is not unnecessary transport but lack of medical evaluation, proper medical evaluation and an understanding of the medical issues we have discussed in this column. The syndrome of panic — throw the firefighter on the stretcher and drive lights and sirens to the hospital — is one which was fine in the 1970s when there were few paramedics and little understanding of emergency medicine. In 2008, there is no excuse for lack of an organized approach to a predictable phenomenon. Firefighters will become exhausted, some will develop illness or injury and the vast majority will emerge in good shape. The challenge for us is to implement a NIMS-compliant operation, build a rehab sector and systematically evaluate these folks to try to pick out those few who actually have an emergent condition. While immediate load and go transport might sound like the easiest solution which prevents mistakes on the part of EMS providers, it ignores the stripping of resources that will occur and the risk that the next firefighter who comes to rehab might actually be the one with the problem when there is no ambulance or EMS provider to address the situation. In essence, we may be sending firefighters to the hospital who seem to have already developed the obvious emergencies (reactive situation), but we are not evaluating or not evaluating properly the firefighters who may be at highest risk for development of fireground medical emergencies in the next half an hour (proactive approach).
Second, the vast majority of firefighters who go to an emergency department without traumatic injuries and without complaints indicative of a medical emergency (chest pain, dyspnea) are discharged in less than one hour. This indicates that they received a medical screening exam and are found to be fine. Or perhaps it means that we are transporting the "wrong" subgroup of firefighters to the hospital! There is no ED treatment for firefighters who inhale a little smoke, have moderately elevated blood pressure or are physically exhausted other than fluids and education about why this occurs. This can be done on scene. It is true that a more highly trained clinician rules out the presence of emergent conditions but this is done with tools available to paramedics and with education that could be and should be available to them. This takes us to Point #3.
The lack of education about fireground medicine, which I know is a problem among EMS providers, can and should be handled immediately. EMS providers must be convinced that simply acquiring vital signs, writing them down and letting the firefighter with uncontrolled hypertension walk away does no good for anybody. It is the responsibility of EMS agency directors and their physician advisors to address these issues. The decision-making algorithms about who needs to go to the hospital should be promulgated by EMS medical directors and fire medical officers and built into SOPs and regional protocols. Nobody is promoting bad decision-making on the part of EMS providers that might endanger firefighters. The opposite is true — we need better education that should in turn produce better decision-making. Then we need to fund the study of this decision-making to validate what we think we know.
Fourth, one can't fix public health problems without a public health approach. The fireground medical emergency issue is largely one of non-life threatening conditions or at least situations where what will be found during the fireground medical screening exam is not imminently dangerous, but could become so at the next incident, in the next year or five years later. (Remember that the purpose of rehab is not early defibrillation for those firefighters that collapse without warning of ventricular fibrillation. This is a Treatment sector issue. Rehab does not prevent heart attacks in real time. Its purpose is to discover conditions that may contribute to cardiovascular disease down the line while the firefighter is being reconditioned after a workout. Anyone discovered to have a medical emergency during rehab or who complains of any abnormal symptom on the fireground consistent with automatic transport (i.e. chest pain) goes immediately to the Treatment sector.) The public health approach is not red lights and siren, it is education and the scientific approach. What this does require is manpower.
Thus, the final point is one about manpower. Treatment and rehab are two separate functions. If the rehab sector crew transports a patient, there is no rehab. At fireground incidents in which rehab will be deployed and performed properly, there can be no less than one dedicated individual to perform this function who is not otherwise tied to Treatment and/or Transport. Typically, this means that a second ambulance is required unless there are single resources available (Chief officers, junior officers, extra EMTs and paramedics who have responded to the scene via POV or Command vehicle) who can accomplish this task. Ideally, at large incidents, there should be two EMS crews committed to rehab who have no other responsibilities other than this function and who are supervised by a Rehab Sector Officer (5th person). What enables EMS providers to do their job efficiently and effectively (read: avoid panic transports) is having the manpower to actually do it.