Rehab Revised - Mike McEvoy.com

Report
Rehab Revised:
2015 Changes to NFPA 1584
Mike McEvoy, PhD, NRP, RN, CCRN
EMS Chief – Saratoga County, New York
Rehab Revised:
2015 Changes to
NFPA 1584
Mike McEvoy, PhD, NRP, RN, CCRN
EMS Chief – Saratoga County, NY
EMS Editor – Fire Engineering magazine
Board Member – IAFC EMS Section
www.mikemcevoy.com
Rehab Resources
www.firerehab.com
Disclosures
• I am on the speakers bureau for
Masimo Corporation
• I do not intend to discuss any
unlabeled or unapproved uses of
drugs or products
McEvoy’s Philosophy:
• Creation of 1584 (2008 version)
– Prescriptive
– Evidence basis
McEvoy’s Philosophy:
• Creation of 1584 (2008 version)
– Prescriptive
– Evidence basis
• Real world rehab
– Historical perspective (baggage)
» Who needs it?
McEvoy’s Philosophy:
• Creation of 1584 (2008 version)
– Prescriptive
– Evidence basis
• Real world rehab
– Historical perspective (baggage)
» Who needs it?
» Effect on manpower / personnel pool @ scene
McEvoy’s Philosophy:
• Creation of 1584 (2008 version)
– Prescriptive
– Evidence basis
• Real world rehab
– Historical perspective (baggage)
» Who needs it
» Effect on manpower / personnel pool @ scene
– Firefighters = adults = performance athletes
NFPA Rehab Standard
• Comment period open through
11/15/2013
• www.nfpa.org/1584
But we’re adults…
Firefighters
should know as
much as
professional
athletes about
rest, hydration,
and endurance.
But we’re adults…
Firefighters
should know as
much as
professional
athletes about
rest, hydration,
and endurance.
Firefighting
• Greatest short surge
physiologic
demands of any
profession.
• 10% firefighter time
spent on fireground
 50% of deaths &
66% of injuries
occur on scene.
Firefighter LODDs –
Likely Culprits:
 Medical
condition
 Fitness
 Rehab
What is Rehab?
• “Restore condition of good health”
• Mitigate effects of physical & emotional
stress of firefighting:
–
–
–
–
Sustain or restore work capacity
Improve performance
Decrease injuries
Prevent deaths
Firefighter Rehab – NFPA 1584
• National Fire Protection Association
1584 “Standard on the Rehabilitation
Process for Members During Emergency
Operations and Training Exercises”
• Originally issued in as recommendation
in 2003, became a Standard in 2008,
revision due for release in 2015.
• Every department responsible to
develop and implement rehab SOGs
Elements of Compliance
• SOGs outline how rehab will be
provided at incidents and training
exercises (where FF expected to
work 1 hour or more)
• Minimum BLS level equipment on
scene (= ambulance equipment)
• Integrated into IMS
Elements of Compliance
• SOGs outline how rehab will be
provided at incidents and training
exercises (where FF expected to
work 1 hour or more)
Commence whenever potential
safety or health risk to members or
risk exceeds safe level of physical
or mental endurance.
NFPA 1584: 2015 Revisions
Roles and Responsibilities delineated:
• IC
• CO
• Rehab
Manager
• Members
(FF)
NFPA 1584: 2015 Revisions
Incident Commander:
• Establish rehab
• Assure staffing &
supplies
• Rotate members
• Mental health services available to all members
• If crew member seriously injured or killed, remove
all crew members as soon as possible
NFPA 1584: 2015 Revisions
Company Officer:
• Awareness of FF
physical/mental
condition
• Assure hydration
• Assess his/her company every 45 min
• Wildland: evaluate heat stress
conditions
NFPA 1584: 2015 Revisions
Rehab Manager:
• Operation,
supplies
• Food
• Release
• Records
NFPA 1584: 2015 Revisions
Member:
• Use rehab
• Hydrate
• Advise CO when
performance affected
• Awareness of others
NFPA 1584: 2015 Revisions
Science Updates:
• De-emphasis on sports drinks
• Caffeine permitted up to 400
mg/day
• Energy drinks banned
• Passive cooling before active
• Medical monitoring
parameters are a local decision
Hydration and Prehydration
• Firefighters are often dehydrated
• Prehydrate for planned activities:
– 500 ml fluid within 2 hours prior to event
• Hydrate during events:
– Water appropriate most of the time
– Sports drinks after first hour of intense work or 3
hours total incident duration
• Best to consume small amounts (60-120
ml) very frequently - Typical gastric
emptying time limits fluid intake to no
more than 1 liter per hour.
Hydration and Prehydration
• Firefighters are often dehydrated
• Prehydrate for planned activities:
– 500 ml fluid within 2 hours prior to event
• Hydrate during events:
– Fluids: consume regardless of thirst, continue post
incident
– Sports drinks offered, consumed at FF discretion
– Goal of completely replacing sweat loss deleted
• Best to consume small amounts (60-120
ml) very frequently
Sports Drinks
• Usually contain electrolytes
and carbohydrates
• Osmolarity (concentration) formulated
for maximal absorption
• Absorption limited by gastric emptying
time (COH)
• Dilution will extend gastric emptying
time and lead to nausea / vomiting
Sports Drink Investigation
• BMJ investigative report
– 1035 web pages (listed in magazine ads),
431 performance-enhancing claims on 104
different products
– 47.2% had references, none referred to
systematic reviews (level 1 evidence)
– 84% judged at high risk of bias
– Only 3 (of 74) studies judged to be high
quality and low risk of bias
Heneghan C, Howick J, O’Neill B, Gill PJ, et al. The evidence
underpinning sports performance products: a systematic assessment.
BMJ Open 2012; 2:e001702. doi:10.1136/bmjopen-2012-001702
Sports Drink Investigation
Energy Drinks
Definition: “A type of beverage containing
stimulant drugs (caffeine, and other
ingredients such as taurine, ginsign,
guarana) that is marketed as providing
mental or physical stimulation.”
Not to be confused with Sports Drinks
NFPA 1584 - Overview
1. Ongoing education on when & how
to rehab.
2. Provide supplies, shelter,
equipment, and medical expertise
to firefighters where and when
needed.
3. Create a safety net for members
unwilling or unable to recognize
when fatigued.
Who’s Responsible for What?
• Department: develop and implement SOGs
• Company Officer:
– Assess his/her crew every 45 minutes
– Suggested after 2nd 30-min SCBA bottle
– Or single 45- or 60-min bottle
– Or after 40 min intense work without SCBA
• Company Officers can adjust time frames to
suit work or environmental conditions
What about informal rehab?
• Was acceptable previously, now
encouraged, particularly 1st round
• Company or crew level rehab:
– SCBA cylinder changes
– Work transitions (firefighting to overhaul)
– Small or routine incidents
– When IC fails to recognize need for rehab
Informal Rehab Requirements:
1. Fluids
2. Shelter
3. Place
to remove PPE
4. Seating for members
Nine Key Components of Rehab
1. Relief from climatic conditions
2. Rest and recovery
3. Cooling or rewarming
4. Re-hydration
5. Calorie and electrolyte replacement
6. Medical Monitoring
7. EMS tx according to local protocols
8. Member accountability
9. Release
1. Relief from Climatic Conditions
An area free from smoke and
sheltered from extreme heat
or cold is provided
1. Relief from Climatic Conditions
• Rehab unit or air conditioned
vehicle/room
• Portable heaters, enclosed unit
• Removed, but not too far from
incident
• Vestibule area for removal and
storage of PPE
2. Rest and Recovery
• Members
afforded ability
to rest for at
least 10
minutes or as
long as needed
to recover work
capacity
2. Rest and Recovery
• If not rested,
rest for 10 more
minutes.
• Rest 20 min. on
second rehab
3. Cooling or Rewarming
Better definition
1. Shaded or air conditioned area
2. Remove PPE
–
Gloves, helmet, hood, coat, open
bunker pants (pull down to knees
when seated)
3. Cool fluids
4. Rest
3. Cooling or Rewarming
• Passive cooling initially
• Active cooling when passive
ineffective or member exhibits
heat related illness
Active Cooling: Cold Drinks
• Cold Drinks
– Serves dual purpose
of hydration and
cooling
• Ability to cool
may be limited on
scene
– Drinks usually
stored warm - must
be cooled or only
benefit is hydration
Cold Towel – 3 Bucket System
• Bucket 1: sanitizing solution
– ¼ cup bleach/gallon
• Bucket 2: rinse
– Clear water removes any left over bleach
• Bucket 3: regeneration
– Ice water restores cooling effect
4. Re-hydration
• Potable fluids to
satisfy thirst on
scene
• Guidelines on
beverages revised
to allow caffeine up
to 400 mg per day
and prohibit energy
drinks
4. Re-hydration
The truth about caffeine:
• Increases urine output
• Does not usually dehydrate
(compensatory decline)
• Consumption < 400 mg appears safe for
firefighters
• Reference: EFO paper Stephen Abbott:
Assessing the effect of energy drinks on firefighter health and safety
www.usfa.fema.gov/pdf/efop/efo45842.pdf
4. Re-hydration
• Fluid losses will
often exceed gastric
emptying limitations
• No reliable method
of assessing
hydration status on
scene
– Weights
– Urine specific gravity
– ? Saliva testing
4. Re-hydration
Encourage continued hydration
post-incident
5. Calorie and electrolyte replacement
• Rather than time (3+
hour event), now
consider duration,
exertion, time of last
meal and individual
conditions.
• Whenever food is
available, means to
wash hands and faces
must also be provided.
Food
• Fruits, meal replacement bars,
carbohydrate drinks (15 gm COH)
• 30-60 grams carbohydrate per hour
• High fat foods inappropriate
Medical Monitoring vs. Emergency Care
Medical monitoring: observing
members for adverse health effects
(physical stress, heat or cold
exposure, environmental hazards)
Emergency Care: treatment for
members with adverse effects or
injury.
6. Medical Monitoring in Rehab
6. Medical Monitoring in Rehab
Specifies minimum 6 conditions be screened:
1. CP, dizzy, SOB, weakness, nausea, h/a
2. General c/o (cramps, aches, pains…)
3. Sx heat or cold-related stress
4. Changes in gait, speech, behavior
5. Alertness and orientation x 3
6. Any VS considered abnormal locally
6. Medical Monitoring in Rehab
Local (FD) medical monitoring protocols:
1. Immediate EMS treatment and transport
2. Close monitoring in rehab area
3. Release
6. Medical Monitoring in Rehab
• Vital signs now required:
(For all members entering rehab)
– Temperature
– Heart rate
– Respiratory rate
– Blood pressure
– Oxygen saturation
• Members exposed to fire smoke shall
be assessed for CO poisoning
Vital Sign Parameters
• NFPA 1584 Annex includes
suggested vital sign parameters
• Each department must:
– Set vital sign parameters
– Specify if and when reassessment of vital
signs should occur
Vital Signs
• Many departments do not measure
• No evidence or published studies:
– Determine when treatment necessary
– Predict type or duration of rehab needed
• Vitals may help set parameters for
monitoring, treatment, transport,
release
• Must be evaluated in context
Temperature
• Core temp most accurate
– NL = 98.6-100.6°F (37-38.1°C)
– Best measured rectally or temp transmitter
• Oral or tympanic used in field
– Oral 1°F (0.55°C), tympanic 2°F (1.1°C) less
• Errors common in measuring firefighters
– Oral falsely low from rapid
resps or fluid consumption
– Tympanic less accurate with
significant environmental
influences (hot/cold)
Pulse
• NL = 60-80, many influences.
• Very important to interpret in
context of individual.
• Recovery rate may be more
significant than actual heart rate.
• If > 100 after 20 min rest, further
eval needed before release
• Pulse ox offers accurate measure
Respiratory Rate
• NL = 12 – 20,
should  with
fever and
exercise
• Should return
to normal with
rest
Blood Pressure
•
•
•
•
Most measured
Least understood
Very contextual
Tremendous
potential for error
Blood Pressure
Sources of error:
1. Cuff size
2. Arm placement
3. NIBP
Potential for cross contamination:
- Need to decon between each use
Blood Pressure
• NFPA suggests members with SBP
> 160 or DBP > 100 not be released
from rehab.
Mike McEvoy editorial commentary:
• Several studies have suggested
hypotension (SBP < 80) may be of
far greater concern than high
blood pressure during rehab.
Pulse Oximetry
• Non-invasive measurement
of oxygen and blood flow
• NL = 95-100%
• Most oximeters cannot
differentiate oxyhemoglobin
from carboxyhemoglobin
• Members with SpO2 < 92% should not
be released from rehab
CO Assessment
• Carbon monoxide is present at all fires
and a leading cause of death
• CO monitoring during rehab has
become standard of care
• Exhaled CO meter or pulse COOximeter are two detection devices
Carbon Monoxide
Smoke Characterization
Study
www.ul.com
Smoke Characterization Study
Live Fire Study
• Chicago Fire Dept. – February through
May, 2009
• Rescue Squad Company No. 5
• 44 fires (40 residential and 4 commercial)
• Measurements during all phases of fire
through overhaul:
– Air monitoring (direct air monitoring and personal
monitors)
– Measurement of smoke particle sizes and content
– Gloves and hoods sent to lab for analysis
Peak Gas Concentrations
at Fires
Max (ppm)
Mean
(ppm)
HCN
NH3
SO2
NO2
H2S
NIOSH –
IDLH
(ppm)
50
300
100
20
100
30.0
4.0
150.0*
2.3
133.9
7.0
1.8
31.0*
0.7
18.4
CO
1200
1500*
774*
Gas
* sensor limited values – true values would be higher
Total Gas Concentrations at Fires
Gas
HCN
NH3
SO2
NO2
H2S
CO
NIOSH STEL
(ppm)
4.7
35
5
1
10a
200a
TWA (ppm)
Mean
(ppm)
10b
25
2
5b
10
35
27.4
8.8
200.2*
0.9
146.2
5,313*
a 10 minute exposure limits
b OSHA limit (in general, NIOSH limits are more conservative)
* sensor limited values – true values would be higher
Firefighter Health: the Obvious
New Fire Ground CO Study
• Sacramento Fire: September 2010 through June 2011
• Baseline SpCO at start of each shift for every firefighter
• Remeasured at conclusion of overhaul, apparatus position
noted
• 48 fires with 201 paired measurements
– Baseline 1.0 + 1.6%
No difference
– Following overhaul 1.2 + 1.6%
p = 0.1408
• 10 occurrences of SpCO > 5% after overhaul
Mackey K, Filbrun T, Schatz D, Hostler D, Ogan L. Do carbon monoxide
levels rise in firefighters during overhaul operations following a structure
fire? [Abstract]. Prehosp Emerg Care 2012; 16:153-154.
IAFF Statement January 2008
Routine testing of
any firefighter
potentially
exposed to CO
using a COoximeter
Firefighter Rehab
Cyanide
• Consider at all fire scenes
• All patients in cardiac arrest
• Any patient in shock, especially if low
CO level
• Treat with cyanide antidote kit
Paris Fire Brigade
ROSC = 50%
7. EMS Tx according to local protocol
Documentation changes
• Rehab log minimum:
1.
2.
3.
4.
Unit #
Member name
Time in and out
Disposition
• When EMS Tx given,
defer to HIPAA and
local laws, rules, regs
NFPA Sample Rehab Log
8. Member Accountability
• Track members assigned to rehab
• IC must know whereabouts (i.e.:
when they enter rehab and when
they leave)
9. Release
• Prior to leaving rehab, EMS must
confirm that members are able to safely
perform full duty.
Wildland Firefighter Rehab
• Placeholder inserted
• Potential concerns:
– Acclimatization, hydration, hourly
assessment of environmental conditions
(includes wet
bulb globe
temp to alter
work/rest cycle
to prevent heatrelated illness)
Rehab Research Needed…
Thanks for your attention!
www.mikemcevoy.com
LEAD. EDUCATE. SERVE.
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