A Review of Interagency SOP 503 024 Rehab

A Review of Interagency SOP #503. 024, Rehab Sector Set-Up and Shop 310 REHAB 423 by Kevin Knight, Battalion Chief, CEP, NREMT-P

Purpose & Background GILA RIVER FIRE DEPARTMENT 024 GILA RIVER EMERGENCY MEDICAL SERVICES INTERAGENCY STANDARD OPERATING PROCEDURE #503. #250. 05 SECTION I. PURPOSE To ensure the physical and mental condition of employees operating at the scene of an emergency, training exercise, or other emergency services activity does not deteriorate or does not jeopardize the safety and integrity of the operation. SECTION II. BACKGROUND This procedure shall apply to all Gila River Indian Community Public Safety activities including but not limited to; fire ground operations, EMS operations, training exercises/ drills and long term police situations where strenuous mental and physical activities or exposure to heat or cold exist. Circumstances surrounding each activity/ incident shall be considered and adequate provisions made early in the incident for the rest and rehabilitation for all members operating at the activity/ incident. These provisions are to include: medical evaluation, treatment and monitoring; food and fluid replenishment; physical and mental rest; relief from extreme environmental factors caused by the activity/ incident. During any emergency incident or training activity; all members are to immediately report to their respective supervisor and advise when their ability to perform is approaching a level that could affect themselves, their crew, or the operation in which they are involved. Requests for relief and/or reassignment of work crews shall be through the Incident Command System (ICS). 2

Responsibilities SECTION III. POLICY 3. Responsibilities 3. 1 3. 2 3. 3 3. 4 Incident Commander -The Incident Commander (IC) shall have the responsibility and authority to implement and monitor all provisions of this operational procedure. Rehabilitation shall be conducted at the Advanced Life Support (ALS) level when available. Division/Group Supervisors and Company Officers - shall maintain an awareness of each member operating within his/her span of control and ensure adequate steps are taken to provide for each member's health and safety. Line Personnel -Each member is responsible for his/her preparedness prior to an incident, including; sufficient rest prior to reporting for duty, pre-hydration, proper dress and ensuring that protective clothing and equipment is present and in good working order. Members shall remain aware of the health and safety of other members of their working crew. 3

Definitions SECTION IV. DEFINITIONS 4. 1 4. 2 person Group or Sector – Within the ICS structure, “Group” is a NIMS term and “Sector” is a Regional Fire Ground Command term. The terms “Group” and “Sector” can be interchangeable. For the purpose of this document, Rehab Group and Rehab Sector have the same meaning. Rehab Group Supervisor – Supervisor is the title that NIMS uses for the person in charge of a group. Fire Ground Command uses the term “Officer” for the in charge of a sector. For the purpose of this document, Rehab Group Supervisor and Rehab Sector Officer have the same meaning. 4

Establishment of Rehab SECTION V. PROCEDURES 5. 1 Establishment of Rehabilitation 5. 1. 1 5. 1. 2 5. 1. 3. 1 5. 1. 3. 2 5. 1. 3. 3 5. 1. 3. 4 5. 1. 3. 5 The Incident Commander shall establish Rehab when conditions indicate that rest and rehabilitation is needed for personnel working at an incident scene or training exercise. When possible, the IC shall designate a Certified Paramedic as Rehab Group Supervisor. The Rehab Supervisor shall then act within the ICS command structure. Rehabilitation should consider the scope of the incident, including the following: Time. Extended use of Personal Protective Equipment Complexity. Crime scenes, standoffs, search operations, mass gathering/public events, hazardous materials incidents , etc. Intensity. Mental and/or physical stress on members such as: major extrications, fire attack or interior search and rescue situations, and any other training or operational Public safety activity that is physically or mentally demanding. Climatic conditions such as hot or cold weather. Geography. The size of an incident or terrain may require consideration for access to rehab locations. 5

Location 5. 1. 4 The Incident Commander may designate a Rehab Supervisor during any other Public Safety activities at his/her discretion; climatic, environmental factors and duration need not be the sole criteria or justification for establishing Rehabilitation. 5. 1. 4. 1 Location 5. 1. 4. 1. 1 The Incident Commander will normally designate the location for the Rehabilitation. If a specific location has not been designated, the Rehab Supervisor shall select an appropriate location based on the site characteristics listed below. 5. 1. 4. 1. 2 Multiple Rehab locations may be necessary if the incident is large or divided. In the event there is more than one Rehab location, they shall be designated Rehab 1 and Rehab 2, etc. Each Rehab will have its own Rehab Supervisor who shall report to the Medical Unit Leader or Logistics Officer if established. Each Rehab Supervisor shall be a certified Paramedic when available. 6

Site Characteristics 5. 1. 4. 2 Site Characteristics 5. 1. 4. 2. 1 It shall be in a location that will provide physical rest by allowing the personnel to recuperate from the demands of the emergency operation or training evolution. 5. 1. 4. 2. 2 It shall be far enough away from the scene and with adequate room so that personnel may safely remove and stow their Personal Protective Equipment, and be afforded mental rest from the stress and pressure of the emergency operation or event. 5. 1. 4. 2. 3 It shall provide suitable protection from the prevailing environmental conditions, when possible. During hot weather, it should be in a cool, shaded area. During cold weather, it should be in a warm, dry area. 5. 1. 4. 2. 4 It shall enable personnel to be free of exhaust fumes from apparatus, vehicles, or equipment (including those used in the Rehab Sector). 5. 1. 4. 2. 5 It shall be large enough to accommodate several crews, based upon the incident size. 5. 1. 4. 2. 6 It shall be easily accessible by all vehicles used to transport patients and support the rehabilitation operation. 5. 1. 4. 2. 7 It shall allow prompt re-entry to the incident. 5. 1. 4. 2. 8 It shall be out of the hazard environment. 7

Site Designations 5. 1. 4. 3. 1 5. 1. 4. 3. 2 Tents/Shelters as appropriate An Ambulance will be assigned to the Rehab Division and availability will be maintained by responding an additional ambulance when transportation is needed. School buses, buses or Metro train cars. Nearby buildings, stores or other structures. If in a high-rise, a minimum of 3 floors below the incident. All personnel working in this environment shall be Certified and cleared to don SCBA’s and Protective Clothing. An open area where tarps, fans, heaters, etc can be set up. 5. 1. 4. 3. 3 5. 1. 4. 3. 4 5. 1. 4. 3. 5 5. 1. 4. 3. 6 8

Resources 5. 1. 4. 4. 1 Medical Equipment -The Rehab Supervisor shall maintain at least one, nontransport Advanced Life Support Ambulance for people undergoing rehabilitation in the Rehab location. 5. 1. 4. 4. 2 Medical Personnel - The Rehab Supervisor shall maintain one Certified Paramedic for every 10 people undergoing rehabilitation in the Rehab location. 5. 1. 4. 4. 3 Fluids/Food - The Rehab Supervisor shall provide, or have provided sufficient potable water, oral electrolyte solution, ice and food as may be necessary. Resources such as the OEM should be notified early into an incident to allow for travel and response time. 5. 1. 4. 4. 4 Other Equipment -The Rehab Supervisor shall secure from the Medical Unit Leader or Logistics Section Chief other needed items such as, tarps, lights, fans, blankets, towels, traffic cones, fire-line tape, etc. 9

Establishment, Hydration, Nourishment 5. 2 General Operational Principles 5. 2. 1. 1 5. 2. 1. 2 General Guideline: After drinking two 16 ounce bottles of water, drink one 16 ounce bottle of electrolyte infused fluids. Then repeat. Establishment Climatic or environmental conditions that indicate the need to establish Rehab are a heat stress index above 90 degrees Fahrenheit or wind-chill index below 10 degrees Fahrenheit. On any event or incident lasting more that one (1) hour with long term planning. 5. 2. 2. 1 Hydration During heat stress, each personnel should replace at least one quart of water per hour. Plain water should be used for the first hour of the operations and then supplemented with a commercially prepared beverage such as Gatorade TM. Carbonated beverages, coffee, energy drinks, tea or alcoholic beverages should be avoided. 5. 2. 3. 1 Nourishment If food is required or provided, it shall be soups, broths, fruits (bananas, apples, oranges) or other easily digested foods. Fast food sandwiches, fatty or salty foods should be avoided. 10

Rest 5. 2. 4. 1 Rest shall be provided when possible after the "one bottle rule" or 45 minutes, whichever comes first. For rehab that requires cooling, the members shall completely “dress down”, removing turnout coats, gloves, helmets, and opening bunker pants. Personnel should re-hydrate at least 16 ounces during SCBA bottle change. Rest shall be no less than 10 minutes, preferably 20 minutes and may exceed 30 minutes as determined by the Rehab Supervisor. Personnel requiring rest periods of greater than 30 minutes should be closely monitored for medical conditions. Those who exhibit problems with their baseline medical assessment after 30 minutes should be treated under EMS protocol and transported to a medical facility. Personnel requiring more than one hour of rest should be released from duty and transported to a medical facility. Personnel released by the Rehab Supervisor are to report to the Staging Area, and/or Operations as determined by Command. 5. 2. 4. 2 5. 2. 4. 3 5. 2. 4. 4 5. 2. 4. 5 5. 2. 4. 6 11

Medical Evaluation 5. 2. 5. 1 Rehab shall be staffed with a Personnel ratio of no less than 10: 1, which is to be a Paramedic whenever possible. 5. 2 Rehab medical evaluation shall consist of a minimum of a) mentation, b) visual exam, c) blood pressure, d ) pulse, e ) temperature. 5. 2. 5. 3 Medical Evaluation will be initiated at the beginning of the rest period and repeated every 10 minutes. If the assessment results in findings that are not within normal limits, reassessment is to be done every 5 minutes. 5. 2. 5. 4 Any member who exhibits a body temperature of > 100. 6 F, a consistent pulse rate of > 110 bpm shall not be permitted to wear full protective clothing, including SCBA and shall require additional rehabilitation including cardiac monitoring. 5. 2. 5. 5 Any member(s) who receives any treatment(s) other than oral fluids, food, and/or rest shall be treated and documented as an injury to personnel. As an example, ice for sprains or strains shall be considered injuries rather than rehabilitation. 5. 2. 5. 6 All Rehab evaluations shall be documented on a rehabilitation roster and shall become a permanent record attached to the incident report. Any member that requires more than oral fluids/food/and or rest shall require a patient care report, which shall be attached to the incident report. 5. 2. 5. 7 All injury reports shall remain part of the employee's protected medical file and treated as other confidential medical records. 5. 2. 5. 8 Any/all Rehab reports involving Mutual or Auto Aid personnel shall be made available to their respective departments. 12

Accountability & Release 5. 3. 1 5. 3. 2 5. 3. 3 5. 3. 4 5. 4. 1 5. 4. 2 5. 4. 3 5. 4. 4 Accountability Personnel assigned to Rehab shall enter and exit the Rehabilitation Area as a crew. The crew designation, number of crew personnel, and the times of entry/exit shall be documented by the Rehab Supervisor, or his/her designee on the Individual Rehabilitation Report. Crews shall not leave the Rehabilitation Area unless authorized to do so by the Rehab Supervisor. Crews released from Rehabilitation Area must clear with Command have an assignment or destination prior to reassignment. Crews placed out of service due to a member being placed out of service will report to Incident Command for further direction and assignment. Release of Medical Patients In the event that a crew member is sent to the treatment unit, that crew member should be transported to a medical facility. If the crew member sustains a minor injury or illness and refuses transportation, the treating EMS Paramedic shall complete a PCR documenting the refusal. The refusal must be witnessed by the Rehab Supervisor and that crew members Company Officer. The discussion to allow a crew member that was treated and signed a refusal to return to duty or go out of rehab shall be a consensus decision of the crew member, Rehab Supervisor and Company Officer. The crew members’ Company Officer is responsible for following their Departments Industrial Injury and HR policies regarding an event. 13

Exceptions SECTION VI. EXCEPTIONS Any exceptions will be approved with the IC, with careful consideration given to the safety of the personnel involved in the operation. 14

Algorithm (part 1) 15

Algorithm (part 2) 16

Rehab Report 17

Sector Set-Up 18

Shop 310 Equipment Vehicle Cab ØCommand/Sector Clipboard §Rehab Sector SOP § 30 - Rehab Forms § 30 - HAZMAT Forms § 5 - Treat/Transportation Forms § 5 - IC Forms § 6 - PCR’s Ø 200 -400 - Electrolyte Packets Ø 2 - Exterior Telescoping Scene Lights 19

Shop 310 Equipment Compartment #1 (con’t) Ø Stokes Basket, Frame and Wheel Ø 2 - Flashlights ØTarps § 5 -6 - Red Tarps § 1 - Green Tarp § 1 - Yellow Trap Ø 2 - Ice Chests §Prefilled w/water bottles §Ice to be filled at time of incident Ensure the lid is propped open when OOS for drying. Also, ensure it is placed in the compartment so it can be filled with ice w/out removing it. 20

Shop 310 Equipment (con’t) Compartment #2 Ø 100 - Towels §For active cooling §To be wetted via the water cooler §To be placed over head/around neck Ø 2 - Water Coolers §Water/ice for wetting towels. This water is NOT for consumption! §Water & ice to be filled at time of incident. Ensure the lid is left off the cooler and cooler is upside down when OOS for drying 21

Shop 310 Equipment Compartment #3 (con’t) Ø 1 - Table §For water coolers §For misting fan Ø 8 - Chairs Ø 3 - Benches 22

Shop 310 Equipment Left Compartment #4 (con’t) ØFire Extinguisher Ø 1 - 50’ Extension Cord Ø 3 - Garbage Cans § 1 - Cleans Towels § 1 - Dirty Towels § 1 - Garbage Ø 2 - Buckets §To catch excess water when wetting towels Ø 1 - Grey Water Container Ø 2 - Clamps 23

Shop 310 Equipment Right Compartment #4 (con’t) ØFire Extinguisher ØTool Box ØPortable Lights ØReflector Set Ø 1 - Roll Caution Tape Ø 20 - Large Garbage Bags Ø 10 - Large Red Bags Ø 6 - Flats Water 24

Shop 310 Equipment (con’t) Rear Compartment #5 Ensure the lid is left off the cooler when OOS for drying Ø 4 - Canopies Ø 1 - Water Cooler w/Misting Fan §Water/ice to be filled at time of incident 25

Shop 310 Equipment (con’t) When using the power inverter ensure the unit is running on high idle and that the inverter switch is “on” in the cab. 26

Rehab 423 Process Shop 310 should be; 1. Started every morning or trickle charge the batteries 2. Washed and detailed (including equipment) as needed 27

Rehab 423 Process An incident occurs where Incident Command (IC) requests a formal Rehab Sector be set-up or an agency/department is requesting rehab for a training session. 1. S 423 will be notified via dispatch. 2. The CSO/second on S 423 will place Rehab 423 in service, place ice and water in all coolers and respond to the incident. 3. The assigned Medic Unit, S 423/S 426 and Rehab 423 will set up and run the Rehab Sector. Note: Should S 423 not be available for placing Rehab 423 in service, an EMS Battalion Chief or designee may coordinate a Medic Unit (not the Medic Unit already assigned to the incident) to assist in this process. If resources are not available then Rehab 423 may be delayed or not available for the incident. 28

Rehab 423 Process (cont’d) After the incident is completed, Shop 310 will be taken back to B 100 and placed OOS with the following process completed; 1. 2. 3. 4. Rehab 423 will advise dispatch OOS Wash /dry and replace dirty towels on unit Restock all equipment used Ensure all equipment is cleaned and re-organized in its designated spots 5. Shop 310 will be parked in its designated space **Note: Ice and water left over from the incident can remain in the coolers for the remainder of shift in the case Rehab 310 is requested again. Ice and water will be removed upon shift change with cooler lids being left open so that they can dry out, decreasing the chance of mold growth. 29

Review 1. What is the purpose of the Interagency Rehab SOP? A. To make lots of extra busy work B. To help us all stay in shape C. To ensure the physical and mental condition of employees does not deteriorate D. To make sure we miss the Cardinals game on Sunday afternoon 2. Who has the responsibility to request Rehab 423 and a formal rehab? A. The incident RP B. The incident 425 C. The incident IQ D. The incident IC 3. Who is responsible for his/her preparedness prior to an incident, including; sufficient rest prior to reporting for duty? A. Only EMT’s B. Only Firefighters C. Only Rehabbers D. All Responders 30

Review (con’t) 4. The establishment of rehab is not appropriate during cool, comfortable weather? A. True B. False 5. Fluids such as water, sports drinks and teas are acceptable fluid replacement beverages during rehab. A. True B. False 6. Personnel should re-hydrate at least 24 ounces during each SCBA bottle change. A. True B. False 7. Any member who exhibits a body temperature of > 100. 6 F, a consistent pulse rate of > 110 bpm shall not be permitted to wear full protective clothing, including SCBA and shall require additional rehabilitation including cardiac monitoring. A. True B. False 31

Review (con’t) 8. Per the Rehab Algorithm should your initial medical assessment be outside normal limits, which of the following is most correct? A. Sent automatically to the Treatment area B. Depending on assessment given an additional 20 min rest C. Orally hydrate D. Both B & C 9. When staging vehicles near the rehab sector ensure the exhaust is pointed away from the sector (taking into account wind conditions) and stage a minimum of? A. 15 feet B. 10 yards C. 15 yards D. 10 feet 10. The water coolers used for wetting towels is found in which compartment? A. # 1 B. # 2 C. Left # 4 D. Rear #5 32

Rehab 423 33