Operating A Rehab Area - Part 1

In the fire service the terms "rehabilitation" or "rehab" are used to describe the process of providing rest, rehydration, nourishment and medical evaluation to responders who are involved in extended and/or extreme incident scene operations with the goal of getting them back in the action or back to the station safely. Proper rehab operations ensure that the physical and mental condition of responders operating at the scene of an emergency does not deteriorate to a point that affects the safety of each member or that jeopardizes the safety and integrity of the operation.

Fire departments have made a growing commitment to providing appropriate on-scene rehab procedures since the first edition of NFPA 1500, Standard for Fire Department Occupational Safety and Health Program was released in 1987. Most departments have established plans for rehabbing their personnel in recent years. However, we should regularly review those plans and critique their actual performance to make sure that our rehab operations are still properly serving their target audience: our firefighters and other emergency responders.

The actual method for operating a rehab area will depend on a number of factors, including available staffing, the number of personnel on the scene needing rehab and local standard operating procedures (SOPs). Each jurisdiction must develop SOPs for rehab area operation that are realistic for the resources available to them. Jurisdictions that develop grandiose rehab procedures, but then can assign only two emergency medical technicians (EMTs) to staff the rehab area at an incident, are bound to be disappointed in how the scenario plays out.

Because of jurisdictional differences, this article will not lay out a specific method of establishing, staffing and operating a rehab area. Rather, it focuses on the functions that must be performed in a rehab area. How these duties are divided up or delegated is a jurisdiction-specific issue. However, all of these functions should be accounted for, in some manner, within every rehab area operational SOP.

Rehab Area Staffing

The Rehab Sector/Group should be staffed with adequate personnel to provide medical evaluation and treatment and to assure that firefighters receive sufficient food and fluid replenishment. The definition of what is an adequate number of personnel will vary depending on the scope of the incident and the number of personnel assigned to it.

The most highly trained and qualified EMS personnel on the scene should provide medical evaluation and treatment in the Rehab Sec-tor/Group, unless they are need for treating victims who have serious injuries. At the minimum, the area should be staffed by EMT-Bs. The EMT-Bs assigned to the Rehab Sector/Group must perform several key functions:

• Assure that the sector provides a safe area in which fire and rescue crews can rest and receive rehydration, or replacement of water and electrolytes lost in sweating. During prolonged incidents, food should also be supplied to crews in the rehabilitation area.
• Identify firefighters and rescue personnel entering the sector who are at risk for heat- and stress-related illness or injury.
• Medically monitor crews and determine whether they:
  1. Are fit to return to active fire/rescue duty.
  2. Require additional hydration and rest.
  3. Require transport to an emergency department for further evaluation and treatment.
  
• Assure accountability of firefighters and rescue personnel who enter and exit the sector.
• Give regular reports/updates to the safety officer or the incident commander.

In large-scale incidents or in those where a trend toward serious heat- and stress-related illness is detected among firefighters, paramedics and advance life support (ALS) units should be requested and assigned to the Rehab Group/Sector.

The role of ALS personnel will be to evaluate and treat those responders in rehab who appear to be in need of a greater level of care than EMT-Bs are able to provide. This includes the establishment IVs for severely dehydrated personnel and advanced care of heat- or stress-related illnesses. Often, non-fire service EMS agencies provide medical evaluation and treatment in the Rehab Sector/Group. If such agencies are used, it is essential that they have direct radio communication with command.

If some or all of the personnel assigned to the rehab area are the same people who may be responsible for transporting responders needing further care to the hospital, enough personnel must be assigned to the Rehab Group/Sector to keep it totally operational when one crews leaves on a transport.

Personnel without emergency medical training can play an important role in rehab operations. They may be used for functions such as providing food and fluid replenishment in the Rehab Sector/Group. In many jurisdictions, members of the fire department's ladies auxiliary, an Explorer post or departmental civilian staff members fill this function. In addition, agencies such as the American Red Cross, Salvation Army, local civic organizations (Lion's Club, Rotary Club, etc.) or local food retailers may offer additional nutritional support. When such organizations are involved in emergency scene operations, they must follow the directions of command or the Rehab Sector/Group supervisor. This is especially important in order to assure that proper types of fluids - non-carbonated and caffeine-free - are administered.

Entry Point/Initial Assessment

The process of maintaining an effective rehab operation begins by assuring that all personnel enter the Rehab Group/Sector through a single designated entry point. This will allow all responders to be processed in an orderly fashion that will not be prone to overlooking potential problems. Each person entering the rehab area should be time-logged in by the Rehab Group/Sector supervisor or someone else who is delegated that function. Accountability identifiers should also be collected by the log-in person.

It is highly recommended that entire crews enter and exit rehab as a group. For example, one tired member of Engine 65 should not be sent to rehab while the others continue their business. The entire company should be assigned to rehab at this point and their duties should be reassigned to a fresh company.

Upon entering rehab, firefighters should be allowed to remove their self-contained breathing apparatus (SCBA), hoods and turnout gear. Responders who are working in special protective clothing at a hazardous materials incident should go through decontamination and remove the special protective clothing at the decontamination area before proceeding to rehab.

Once excess gear is removed, each crew member should be evaluated for injuries and for heat- and stress-related illnesses. The first step in evaluation is obtaining entry vital signs, including blood pressure, pulse and temperature. Rehab staff should rapidly question crew members, being alert to potentially life-threatening complaints such as the presence of chest pain or shortness of breath. Remember the goal of the entry medical evaluation is to identify personnel with potential heat- or stress-related illnesses or injuries - not to keep firefighters from rest and rehydration.

When the entry evaluation is complete, sector staff should assign crew members to the rest-and-refreshment area or medical treatment/evaluation area. Patients assigned to the medical treatment/ evaluation area will receive more intensive evaluation and monitoring as well as rehydration and rest. The findings in the entry medical evaluation determine the area to which crew members are assigned. In general, it is recommended that responders with pulse rates greater than 110 beats per minute, a body temperature above 100.6 degrees Fahrenheit (38.1 degrees Celsius) or who have sustained any injuries should be assigned to the medical evaluation/ treatment area.