The Elephant on the Fireground: Secrets of NFPA 1584-Compliant Rehab

BY MIKE McEVOY

Firefighting has the greatest short-term physiological demands of any profession—more demanding than running a marathon. Runners continually train for the scheduled events they run; they prehydrate, pay meticulous attention to nutrition, and are well rested before each race. Marathoners exercise and have ample opportunity to warm up before a run. Firefighters are also athletes and should keep themselves in top-notch physical condition. Unlike marathons, fire, rescue, and EMS calls are not scheduled events. There is no opportunity for warmup—firefighters routinely accelerate from zero to 60 with no warning whatsoever. No wonder firefighting carries a greater risk of death than virtually any other occupation. Athletes know precisely how to hydrate, feed, and rest themselves; the demands of firefighting say that we should, too.

NFPA 1584 AND REHAB

National Fire Protection Association (NFPA) 1584, Standard on the Rehabilitation Process for Members During Emergency Operations and Training Exercises, is designed with this principle in mind. NFPA 1584 was born in 2003 as a recommendation. In 2008, it moved up in rank to “standard” status largely because of the importance of rehabilitation in protecting the life safety and health of firefighters. Firefighting consumes only 10 percent of on-duty hours, yet virtually 50 percent of all firefighter deaths and 66 percent of injuries happen on-scene. Three factors are implicated in firefighter injuries and deaths: medical condition, fitness, and rehab. NFPA 1582, Standard on Comprehensive Occupational Medical Program for Fire Departments, established medical screening standards for firefighters. NFPA 1583, Standard on Health-Related Fitness Programs for Fire Department Members, set fitness standards. Rehab for fit, medically qualified firefighters became the next logical step in injury prevention. We don’t know how many on-scene injuries happen because of fatigue, but occupational studies of other professions suggest fatigue leads to injury.

Modernization of Rehab

In many departments, rehab is perceived as an obligatory or forced medical screening that does little more than remove qualified, willing, and able personnel from the front lines of battle—the quintessential “elephant” on the fireground. As a consequence, chief officers often postpone rehab until they see their troops dropping like flies. Members frequently find every possible excuse to avoid reporting to rehab for fear of being pulled off the fireground by some “know-it-all” EMS provider who lacks understanding of the intense physical demands of firefighting and the corresponding physiologic changes. The NFPA 1584 standard, issued in 2008, was written to modernize rehab; treat firefighters like the athletes they are (or should be); and provide the tools necessary to restore work capacity, afford needed rest and rehydration, and establish a safety net for firefighters too exhausted or unable to recognize when they need a break.

From the beginning of the new NFPA 1584 document, there is clear recognition that no one should have to tell a firefighter when, where, and how to rehab. Firefighters must understand the physical requirements of their job and be as prepared as Olympic athletes for the stressors they routinely face. Ongoing education is a key component of NFPA 1584. Members must understand how to evaluate and maintain their own nutritional and hydration status. Rest, hydration, and nutrition are highly individualized. NFPA 1584 recognizes this fact and presumes each member will be taught to develop a keen sense of self-awareness. The need to prehydrate with 500 ml of fluid at least two hours prior to a scheduled event and rehydrate according to individual needs should be incorporated into every member’s repertoire, no reminders needed. Herein lies the first challenge to departments.

(1) Understanding hydration is critical for firefighters. (Photo by Tom Bendick.)

Take a look at your fellow firefighters. Are they all medically qualified and appropriately fit for the rigorous demands of firefighting? If not, rehab may be too little and too late. For NFPA 1584 to succeed at rehabilitation and regenerating work capacity, medical screening and fitness initiatives are clear prerequisites. Next, what is your department or training academy doing to teach members about hydration, rest, and nutrition? Firefighters are adults, and if we want them to stay on the job, they need to have the education on how to be prepared for the work we expect them to do.

NFPA 1584 makes it official: The elephant on the fireground is here to stay. Rehab is not a luxury and not just for sissies—it’s required. The challenge is implementing rehab that accomplishes what it is intended to do: help every firefighter work as efficiently and as safely as possible without reducing the personnel pool with firefighters sidelined by injury or exhaustion. Every fire department must have standard operating guidelines (SOGs) outlining how they provide rehabilitation at incidents and training exercises. Technically, any incident or training exercise where firefighters are expected to work for one hour or more needs rehab. No organizer of a marathon or other sporting event would consider running the event without supplying athletes with hydration, nutrition, cooling (or warming), and medical consultation. Firefighters are human beings working under the worst of conditions. They deserve the tools necessary to protect their health and safety. The new standard requires departments provide rehab in a consistent and preplanned fashion.

(2) Transport-capable EMS is required at every rehab operation. (Photo by Ron Jeffers.)

Minimum basic life support (BLS)-level, transport-capable EMS is also required on-scene at every rehab operation. Having transport-capable EMS on-scene will challenge some departments. NFPA 1584 does not say these folks are responsible for rehab but must be present and available to deliver any emergency medical treatment or transport needed. Can they be off to the side of a rehab operation, responsible only for members who need ambulance treatment or transport? You betcha. Local policy determines this.

Medical Monitoring vs. Emergency Medical Treatment

There is clear delineation in NFPA 1584 between medical monitoring and emergency medical treatment in rehab. Documentation is kept separately as well. Although the same providers may do both, it probably makes logistical and operational sense to separate them into functional areas. The benefit for many departments is the ability to conduct medical monitoring during rehab using fire department-based EMS providers familiar not only with the intense physical demands of firefighting but also the medical histories, fitness levels, and usual appearances of members coming through rehab. If the fire department has EMS transport capability, it may elect to perform that function as well, perhaps with the same personnel. Otherwise, emergency medical treatment and transport can be provided by a nonfire-based EMS transport service dispatched to stand by at the rehab operation.

ESTABLISHING SOGS

So you want to develop SOGs for rehab? NFPA 1584 outlines who’s responsible for what. The company officer or supervisor is the kingpin. He must assess the crew to determine members in need of rehab at least every 45 minutes. The standard calls for individual firefighters and their supervisors to undergo rehab following the use of a second 30-minute SCBA cylinder, after a single 45-minute or 60-minute cylinder, or after 40 minutes of intense work without SCBA. Supervisors can adjust these time frames depending on work or environmental conditions. The EMS personnel staffing rehab (and providing medical monitoring) must have the authority to detain members in rehab or transport members when there are obvious indications preventing them from returning to full duty. Note, as mentioned previously, these providers may not be the same EMS members responsible for emergency medical care and transport.

Is there anything in NFPA 1584 to stop a company from taking an informal “rest break” during a bottle change or during transitions in activities such as from firefighting to overhaul? Absolutely not. In fact, frequent and informal rehab at the company or crew level is encouraged, especially early in an operation, at short-duration incidents, and whenever an incident commander fails to recognize a need for formal rehab. The tools necessary to accomplish informal rehab include bottled water for hydration, the ability to shelter from the elements, a place to remove personal protective equipment (PPE), and seating for members. Fire apparatus supplied with bottled water will usually meet all these requirements.

NINE COMPONENTS OF REHAB

The NFPA 1584 standard requires nine components of rehab:

1. Relief from climactic conditions. The rehab area must be free of smoke and sheltered from extreme heat or cold. This might be a nonfire floor in a high-rise building, a shaded area upwind from a brush fire, or the heated fire apparatus cab during cold winter months. Rehab should not be too distant from the scene, or firefighters would tire getting to it. It should, however, be sufficiently removed to provide adequate shelter from environmental extremes and adverse conditions present on-scene. A segregated entrance or vestibule where members can remove their PPE before entering the rehab area is also required. This prevents continued exposure to toxicants potentially being off-gassed from PPE in the rehab area itself.
2. Rest and recovery. Members must be afforded the ability to rest for at least 10 minutes or as long as needed to recover work capacity. Typically, members will require from 10 to 20 minutes of rest with each rehab cycle. More thorough medical assessment should be performed on any member who requires longer than usual periods of rest in order not to miss a potentially significant condition needing emergency medical treatment.
3. Cooling or rewarming.Members who feel hot should be able to remove layers of clothing, drink water, and be provided with means to cool off. Members who are cold should be able to add clothing, wrap in blankets, and be provided with means to warm themselves. Provisions should be made to issue dry clothing if needed. Studies have shown that core body temperatures in firefighters continue to rise while resting in rehab even with active cooling measures. Departments should be prepared to provide active cooling measures using a method appropriate for conditions. Active cooling implies external means of lowering core body temperature and includes cold towels, hand and forearm immersion, misting fans and tents, and ice vests. The most effective are cold towels and forearm immersion. Firefighters in two cooling studies found cold towels the most refreshing and effective active cooling measure. Compared to forearm immersion, cold towels require less space and setup time and cost considerably less.

4. Rehydration.This simply means replacing fluid lost through sweating and breathing. Humans working in hot and humid conditions can sweat up to two liters of water each hour. Water is the preferred drink for rehabilitation and must be provided in abundance. Bottled water improves hydration, since consumption is easily tracked and simple to remember. After the first hour, sports drinks containing electrolytes should be made available. Sports drinks should not be diluted; doing so changes their osmolarity, interfering with absorption, which can lead to nausea and vomiting. Carbonated and caffeinated beverages should also be avoided, as they promote fluid loss. Beyond thirst, which is an early warning sign of dehydration, there are few practical ways to assess hydration status in firefighters. Each individual must become familiar with his own fluid needs and take reasonable measures to prehydrate as well as rehydrate. NFPA 1584 recommends firefighters drink to satisfy thirst. Fluids should also be provided to encourage continued hydration after the incident.
5. Calorie and electrolyte replacement.For longer-duration events, such as incidents exceeding three hours or situations where members are likely to work for more than one hour continuously, calorie and electrolyte replacement are necessary. Food must be nutritious and appropriate for the activity and environment. Pizza, sweets, and foods with high-fat content are not appropriate for calorie replacement during firefighting activities. Whenever food is available, a means to wash hands and faces must also be provided. Wipes or alcohol-based gels are acceptable alternatives to running water.
6. Medical monitoring. At minimum, there are six conditions EMS is required to assess in members entering rehab:
   1. Presence of chest pain, dizziness, shortness of breath, weakness, nausea, or headache.
   2. General complaints such as cramps or aches and pains.
   3. Symptoms of heat- or cold-related stress.
   4. Changes in gait, speech, or behavior.
   5. Alertness and orientation to person, place, and time.
   6. Any vital signs considered abnormal by department protocol. If vital signs are taken, parameters for “normal” are set in conjunction with the department administration and the department physician. More on vital signs later.
   
   As mentioned previously, it is extremely important to understand the difference between medical monitoring and emergency medical treatment. Medical monitoring in the rehabilitation area identifies firefighters in need of emergency medical treatment or transport. It can also be used as additional assurance that members who seem to be rested and have recovered work capacity can be cleared for return to active emergency duties. Any member who exhibits signs or symptoms of medical distress should immediately receive emergency medical care. Those who exhibit significantly abnormal signs and symptoms after resting should receive emergency medical treatment. Most medical-monitoring rehab protocols recommend a minimum of 10 minutes of rest followed by an additional 10 minutes if needed.
   Medical monitoring must be targeted not only to the unique physiologic changes associated with the intense work of firefighting but must also be tailored to the medical histories and physical condition of department members. A department with an average firefighter age under 30 would have higher upper limits if it elects to measure vital signs than would a department with firefighters in their 50s. Medical monitoring is documented in the fire department data collection system with documentation of the incident.

7. EMS treatment in accordance with local protocol. A transport-capable, minimum BLS-level ambulance must be available on-scene for members who require treatment or transport. When a member is referred for emergency medical treatment, the department-specific protocols and parameters for medical monitoring are superseded by local, regional, or state EMS treatment, triage, and transport protocols. When EMS treatment or transport is provided, a medical report must be generated and included in the member’s employee medical record.
8. Member accountability. No longer can members in rehab be considered off-scene. The Incident Management System (IMS) must reflect the status and location of every member assigned to an incident or training session. The IMS personnel accountability system must track members as they enter and leave rehab so that the accountability officer can locate every member on a scene.
9. Release. Prior to leaving rehab, EMS personnel providing medical monitoring must confirm that members are able to safely perform full duty.

VITAL SIGNS

Vital signs listed in the 1584 annex include temperature, pulse, respirations, blood pressure, pulse oximetry, and carbon monoxide assessment using either an exhaled breath carbon monoxide (CO) monitor or a pulse CO-oximeter (i.e., a pulse oximeter designed to measure carboxyhemoglobin). Vital sign measurement is not required. We know very little about normal vital signs in rehab and even less about what measurements have any value in the rehab process. What vital sign measurement provides is a certain level of objective assessment that can help a fire department physician set parameters for when a member needs immediate emergency medical treatment, requires more close medical monitoring in the rehab area, and when he can be released from rehab. Medical authorities developing protocols that incorporate vital-sign parameters need to be cautious to interpret measured vital signs within the context of the individual’s overall condition and appearance at the time of assessment.

There is no literature that supports use of blood pressure to determine work capacity. There is plenty of evidence that blood pressure measurement is often inaccurate, time consuming, and a source for spreading bacteria among individuals. Because of the difficulties with measurement in rehab and even greater complexities with interpreting the meaning of readings, many departments do not routinely measure blood pressure. When used, NFPA 1584 suggests that members with a systolic blood pressure above 160 mmHg or diastolic blood pressure above 100 mmHg not be released from rehab. Blood pressure measuring equipment must be decontaminated between each use on a different member.

(3) Medical monitoring in rehab may include assessment of vital signs. (Photo by Barry Hyvarinen.)

Other parameters suggested by NFPA 1584, when departments elect to measure them, are heart rate above 100 per minute, respirations less than 12 or above 20 per minute, oxygen saturation below 92 percent (while breathing atmospheric or room air), and any core body temperature outside the range of 98.6°F to 100.6°F. Two cautions are advised when measuring temperature: Oral thermometers are typically 1°F below core body temperature, and tympanic thermometers are typically 2°F below actual core body temperature. Members outside these normal values should not be released from rehab.

NFPA 1584 also recommends assessment for CO poisoning in any firefighter potentially exposed to CO or who shows symptoms suggestive of CO toxicity, including headaches, nausea, and shortness of breath. This can be done using a portable exhaled breath CO monitor or a pulse CO-oximeter (a pulse oximeter capable of measuring blood levels of carboxyhemoglobin). It is recommended that firefighters not be released from rehab until their CO levels are normal according to local protocols. There are no comprehensive data on normal CO levels in firefighters, although it seems reasonable that any firefighter with a blood CO level above 15 percent be given high-flow oxygen and immediate emergency medical evaluation. Between 10 and 15 percent, members should be assessed for symptoms and treated with high-flow oxygen when appropriate. Many departments proactively screen members in rehab to ensure that no firefighter slips through the system with undetected CO poisoning in the line of duty.

One additional and very serious concern implied in NFPA 1584 is cyanide exposure. Cyanide is ubiquitous in any occupied structure. It is a common poisonous gas released during pyrolysis of many modern-day construction components, furniture, and objects found in homes and commercial structures. Exposure to cyanide can be lethal and is probably the most common cause of death in fires. It is absolutely imperative that the fire department or EMS transport operating in a rehabilitation area have a cyanide antidote kit and protocols to use if needed. When an individual at a fire scene has a low CO level and yet exhibits shock and altered mental status, cyanide poisoning is highly likely. Be mindful that individuals with high CO levels can also have cyanide poisoning. Every person removed from a fire in cardiac arrest should be treated with a cyanide antidote kit as a standard part of the resuscitation procedure.

The secret to successful implementation of NFPA 1584 is never to lose sight of its main purpose: the firefighter. The job of firefighting requires world-class athletes. Every firefighter must be attuned to his needs for rest, recovery, hydration, and protection from the elements. Every department must make the resources available for members to meet their rehab needs at every incident scene. When done correctly, rehab increases the available labor pool at any incident scene by allowing firefighters to work harder, smarter, and longer. Proper rehab also reduces injury and is very likely to reduce firefighter deaths from fatigue and exhaustion.

References

National Fire Protection Association (NFPA) 1584, Standard on the Rehabilitation Process for Members during Emergency Operations and Training Exercises. Quincy, Mass: NFPA, 2008.

NFPA 1582, Comprehensive Occupational Medical Program for Fire Departments. Quincy, Mass: NFPA, 2007.

NFPA 1583, Standard on Health-Related Fitness Programs for Fire Department Members. Quincy, MA: NFPA, 2008.

Kales, S.N., E.S. Soteriades, CA Christophi, and DC Christiani, “Emergency Duties and Deaths from Heart Disease Among Firefighters in the United States,” New England Journal of Medicine. 2007; 356:1207-15.

Rosenstock, L. and J. Olsen, “Firefighting and Death from Cardiovascular Disease,” New England Journal of Medicine. 2007; 356:1261-3.

Dickinson ET, MA Wieder. Emergency Incident Rehabilitation, Second Edition. (Upper Saddle River, N.J.: Brady/Pearson, 2004).

Bull G., “Cold Towels Valuable Rehab Tools,” Fire Engineering. 2008; 161(4):193-202.

Espinoza, N, “Can we stand the heat?” Journal of Emergency Medical Services. 2008; 33(5):94-105.

MIKE McEVOY is the EMS coordinator for Saratoga County, New York, and a clinical specialist in cardiac surgery. He teaches critical care medicine at Albany Medical College. McEvoy is a paramedic/firefighter, a chief medical officer, a board member of the New York State Association of Fire Chiefs, and the fireEMS technical editor for Fire Engineering.