Operating A Rehab Area - Part 2

Responders who have satisfactory vital signs and no injuries, but are simply tired, should be directed to the rest/hydration/replenishment unit of the Rehab Group/Sector. It is at this location that they will be able to rest, drink fluids to replace those lost through sweating, and get a bite to eat if they are hungry or in need of an energy boost. The person in charge of this function is known as the rest unit leader.

In hot weather and if the rest area is in an air conditioned environment, responders should be allowed to let their bodies cool down at ambient temperatures for a few minutes before entering the air conditioning. Otherwise, the body’s cooling system can shut down in response to the external cooling that is taking place. In cold weather, there should be no delay in getting responders into a warmer environment.

The amount of time that responders will require in the rest area will vary depending on a variety of conditions, including:

• The responder’s level of physical conditioning.
• Atmospheric conditions.
• The nature of the activities the responder was performing before entering rehab.
• The time needed to adequately rehydrate and/or eat.

It is recommended that departments establish a minimum amount of time that all personnel should spend resting in the rehab area. Local policies will vary depending on normal atmospheric conditions and the number of available responders. However, a good rule-of-thumb is that each person should be allowed at least 10 minutes of rest at this stage. Members who still appear fatigued at this point may be allowed additional rest time.

There is no set maximum amount of time that a responder should be allowed to rest. However, any responder who has not recovered sufficiently to return to service within 30 minutes should be sent to the medical treatment/evaluation unit for a more thorough check-up. At this point they will need to receive further treatment or be sent home.

Obviously, the hydration function that occurs in this part of the rehab area is also important to responder recovery. Personnel who are performing heavy work, under stressful conditions, and while wearing heavy personal protective clothing are subject to excessive fluid loss.

While it is obvious that this occurs during hot weather (because of excessive sweating), do not overlook the fact that dehydration also occurs in cold climates. Dehydration is not as evident during cold weather because there may not be as much visible sweat on the responder. That is because cold air tends to have less humidity than warm air; thus, perspiration is more likely to evaporate quickly off of the skin. The various layers of clothing worn by the responder also are likely to absorb any wet perspiration that forms.

The prevention of heat- or stress-related illness and injury is greatly aided by maintaining a sufficient level of water and electrolytes within the responder’s body. Under extreme sweating conditions, it may be necessary for the responder to consume as much as one quart (one liter) of water per hour in order to maintain safe levels in their system. The recommended rehydration drink is a 50/50 mixture of water and a sports activity beverage. This should be served at a temperature of about 40°F (4°C). Caffeinated, alcoholic and carbonated beverages should not be used for rehab purposes because they can interfere with the body’s ability to conserve water.

Drinks should be easily accessible to responders who are in this area. They may be served in individual serving containers (cans or bottles) or dispensed from large coolers. If dispensable coolers are used, there must be an ample supply of disposable drinking cups provided nearby. Responders should be encouraged to drink as much as they feel they need to quench their thirst and replace the fluid in their body. The amount each person needs will vary.

The need to serve food at an incident will not be as common as the need to serve beverages. In general, it is necessary to provide food only at incidents that extend past three hours or when they extend over a period when a normal meal has been missed.

The types of foods that should be served at an emergency scene will vary based on local customs, weather conditions (hot food in the winter, cool food during the summer), time of day and the capabilities of the food provider. Fatty and salty food should be avoided.

If the food that is being served comes in individual packaging, such as high-energy bars or bananas, no special serving provisions need to be made. If food is going to be prepared on the scene and served in portions, such as soup, sandwiches or full meals, the food provider must have the appropriate equipment to store uncooked food, properly cook the food and serve it in a sanitary manner. State or local health department guidelines may apply to these operations. Make sure that disposable dishes and utensils are available.

Medical Evaluation/Treatment Unit

Personnel who did not have satisfactory vital signs at the entry point, who show obvious signs of illness or injury or who have not shown signs of appropriate recuperation in the rest area should be immediately sent to the medical evaluation and treatment unit, herein simply referred to as the treatment unit. A more thorough examination will be conducted at this point.

More aggressive care procedures, such as the application of cooling devices or the establishment of IVs, can take place at this point. The person in charge of this function is known as the treatment unit leader. If the incident involves multiple casualties, not related to the rehab function, it may be desirable to designate this person as the rehab treatment unit leader. This will avoid confusion with the treatment unit leader that will be under the medical branch in the Operations Section.

The treatment unit should be staffed by the highest level of emergency medical care providers on the scene. Ideally paramedics will be available to perform this function. In some jurisdictions, an EMS medical director, fire department physician or other medical doctor may be available.

The role of the personnel who staff this unit of the Rehab Group/Sector is to evaluate the responder’s vital signs, conduct detailed examinations, attempt to identify potential medical problems as early as possible and determine the proper disposition for that responder. Depending on the circumstances, the proper disposition could include any of the following:

• Return the responder to duty.
• Continue the rehab treatment that has been started and continue to monitor.
• Initiate advanced medical treatment and transport to a hospital.

Responders who are in the treatment unit should have access to fluids and food, as their condition allows. In many cases, the symptoms that forced their assignment to this area are easily corrected with fluids and rest. In some cases, however, their conditions will not improve without more significant medical intervention.

Medical treatment for members whose signs and/or symptoms indicate potential problems should be treated and transported in accordance with local medical control protocols. Any members who require advanced life support procedures must be removed from the action for the duration of the incident.

Appropriate documentation should be started on every responder who is assigned to the treatment unit. The standard forms that are used on routine EMS calls will work for this function. The responder’s name and agency should be recorded, along with vital signs and all other pertinent medical complaint and treatment information. If the responder is eventually transported to a hospital, this paperwork should be handed off to the transporting crew. If the responder is not transported, the forms should be made part of the incident report.

Personnel who respond favorably to treatment in this unit may then be allowed to report to the rest-and-hydration area or for reassignment.

Transportation Unit

Personnel in rehab who do not respond favorably to treatment on the scene will need to be transported to a hospital for further evaluation and more aggressive treatment procedures. This responsibility is relegated to the transportation unit of the Rehab Group/Sector. The person in charge of this unit is known as the transportation unit leader. Again, if the incident involves multiple casualties, not related to the rehab function, it may be desirable to designate this person as the rehab transportation unit leader. This will avoid confusion with the transportation unit leader that will be under the medical branch in the Operations Section.

In some jurisdictions, the transportation function is grouped with the evaluation and treatment function. While the fit may seem natural, there are some excellent reasons why this is not the practice of choice in most jurisdictions. First, it may be disruptive to have personnel who are in the process of evaluating/treating numerous responders suddenly have to load one person up and leave for the hospital. This could affect the care of the other responders they left behind.

Another reason that these functions are not combined in many jurisdictions is because it goes against the principles of incident management that are used for multiple-casualty emergency medical incidents. Agencies that are used to operating within an incident management system (IMS) generally find operating the rehab area easier if they follow the same basic principles that would be used to command a multiple-casualty incident. Standard IMS procedures at multi-casualty incidents call for the medical branch to be divided into three distinct groups or sectors: triage, treatment and transportation. If you equate the Rehab Group/Sector to a multiple-casualty situation, parallels to the IMS command structure become evident:

The transportation unit leader is responsible for determining and arranging all of the transportation needs for the rehab operation. The transportation unit is also responsible for patient allocation to medical facilities in consultation with the treatment unit leader and medical facilities.

The transportation unit leader is appointed by the Rehab Group/Sector supervisor to establish a site to manage patient transportation from the rehab area to appropriate medical facilities. The transportation unit leader must “size up” the transportation needs. All requests for transportation resources must be communicated to the next higher level of supervision. Command will then order the required resources. Once resources are on the scene and assigned to the transportation unit, they will report to the transportation unit leader for further direction.

The transportation unit leader must ensure that contact with appropriate medical facilities is accomplished as soon as possible to determine the facility’s capabilities to receive patients. The initial notification should include an advisory of the incident situation and a request to determine the medical facility’s treatment capability. The advisory should include the location of incident, total estimate of the number of patients, and some estimates of the number of patients by triage category. Additional information should be forwarded as more accurate information is obtained and time permits.

Hospital specialty must be considered in treatment capability and patient allocation. Medical control hospitals must be advised of the emergency medical incident situation as standing orders will be the primary method of treating advanced life support patients.

The treatment unit advises the transportation unit when a responder is ready for transport. The transportation unit allocates these patients to medical facilities based on the patient’s illness/injury and priority, hospital capacity and specialty, and by available transportation modes.

Transportation personnel pick up patients from the treatment unit when they are ready for transport, and deliver them to the selected ambulances or other transportation conveyances. Patients should not be removed from the treatment unit until they are ready for transport. Any reports that were started on the patient in the treatment unit should be handed over to the transportation unit personnel. The responder’s accountability identifier should be forwarded to the Accountability Officer or the Incident Commander so that they are aware that the person is no longer on the scene.

The transportation unit leader must assume a visible position in the area. Management of this function may require additional resources to assist the transportation unit leader based on the number of responders to be transported and the complexity of the incident. Additional personnel may be needed for medical communications, transport loading, ground medical transport coordination, record keeping, air medical transport coordination and ambulance staging.

In complex incidents or geographically difficult areas, establishing a specific staging area for medical transportation may be necessary. It may also be necessary for ambulances or other vehicles to transport patients to an air operations landing zone.

The transportation unit leader should be located close to the treatment unit leader since frequent communications and coordination will be necessary between these two individuals. Effective transportation operations will require at least two radio channels. Communication between the transportation unit and hospitals must be established on a separate radio channel that is used by the Rehab Group/Sector. This will avoid interference with the tactical channel that is used by the incident commander. The transportation unit leader must also maintain communications with command on the tactical channel.

Hospitals must be updated with patient information as time and information permits. As patients are transported from the scene, the hospitals should be advised of the estimated arrival time and of basic patient information.

All ambulances must be staged off site and brought in as needed. Ambulances should go to a single central staging area (preferably the same staging area for all resources responding to the incident) and brought to the scene one or two at a time for patient loading. In some situations, a separate ambulance staging area may be required. A staging area manager will be required for each.

Reassignment Unit

Personnel who have made their way through the Rehab Group/Sector will find themselves subject to one of three dispositions:

2. They will be reassigned to another function on the emergency scene.

3. They will be returned to service and sent home.

Obviously, personnel who are transported to a hospital will not make it to the reassignment unit. The reassignment unit will deal primarily with responders who are ready to return the incident operations or who may be released to return to service.

The person in charge of the reassignment unit will be known as the reassignment unit leader. At smaller incidents, the Rehab Group/Sector supervisor may perform this function personally. In larger, more complex operations a separate person is assigned by the Rehab Group/Sector supervisor to handle this chore. Whichever the case, the person handling this function must be capable of making a sound medical judgment as to the readiness of each responder to return to incident activities.

Personnel who are being considered for reassignment should appear rested and must have satisfactory vital signs. The reassignment unit leader should confirm the responders readiness with the rest unit leader and/or the treatment unit leader. Keep in mind that the responders should have entered rehab as a crew, and should not be returned to service unless the entire crew is ready for service.

On some occasions, it may be possible that the entire crew is not ready to return to service at the same time. For example, perhaps three of four crew members are fit and ready for service, but the fourth member was transported to a hospital. In this case, the reassignment officer has several options for the remaining crew members:

• If the fourth member was severely injured or ill, it may be better to remove the whole crew from service and allow the members to direct their attention toward the well-being of their colleague.

• Reassign the crew to a function that may be handled by a three-person crew. If the missing crew member was the leader, or company officer, one of the remaining members should be designated as the new leader.

• Assign the remaining crew members to be part of another crew under a different leader.

With the crew ready for service, the assignment unit leader should notify the incident commander, operations section chief or staging officer that they are available. The size of the incident and the complexity of the IMS that is in place will determine which three of these are to be notified. There are generally four options for a crew that is ready for service:

2. If there is an immediate need for the crew on the emergency scene, they should be given a new assignment. Included in this assignment should be which command officer they will be reporting to, the radio channel they will be operating on and the accountability point/officer that they should report to for that part of the operation. At this point, the assignment unit leader should return the accountability identifiers to the crew, note their release on the log sheet and send them to their destination.

3. For incidents at which a separate staging area has been established – if the crew members are not immediately needed to perform another function on the scene, but their need is anticipated at a later time, they should be released from the Rehab Group/Sector and advised to report to staging. At this point, the assignment unit leader should return the accountability identifiers to the crew, note their release on the log sheet, and send then to staging.

4. For incidents where a separate staging area has been established, if the crew members are not immediately needed to perform another function on the scene, but their need is anticipated at a later time, they should remain in the rest unit or reassignment unit of the Rehab Group/Sector until they are given another assignment. When the next assignment is received, the assignment unit leader should return the accountability identifiers to the crew members, note their release on the log sheet and send them to their destination.

Terminating Rehab Group/Sector Operations

The Rehab Group/Sector supervisor must maintain constant communications with the incident commander to determine when it will be possible to begin scaling down rehab operations. Even though an incident, such as a fire, may be brought under control, often the most physically demanding work, such as overhaul, still remains. There will generally be a need for some form of rehab to continue until all responders have left the scene.

As the number of personnel on the scene begins to decrease, typically the number of personnel assigned to each function within the Rehab Group/Sector may also be decreased accordingly. However, adequate staffing must be maintained to assure that all elements of rehab services are still available to those responders who remain on the scene.

As each company or apparatus that was used for the rehab function is returned to service, the members should make sure that they have properly stowed all the equipment they brought with them. An inventory of expendable supplies that were used at the incident should be taken and every effort should be made to restock as soon as possible.

It is important from both the public relations and safety standpoints that the location where rehab was operated be restored to an equal or better state than it was in before rehab was set up there. All trash should be collected and properly disposed of. Any spent medical supplies should also be collected and disposed of following local protocols. Any areas where food was dispensed should be cleaned so that animals or insects do not gather there.

Conclusion

It is impossible in an article of this length to cover all of the information necessary to run an effective rehab area. However, this article should give departments an idea of the issues they need to consider when establishing a protocol or SOP for rehab operations.

It is best to start with a simple plan and then build it up as you gain confidence in your ability to meet the requirements of the plan. Don’t try to develop and implement a plan to rehab 200 firefighters right from the beginning. Begin with “normal” daily incidents and build from there.

A plan for rehab is like learning to use the IMS: learn and get good on the incidents you use every day. Once you have successfully done this, the “big one” will be more manageable.