By Jay MacNeal with Todd Daniello, Ken Hanson, Mitch Li, Sean Marquis, John Pakiela, Matt Smetana and Chris Wistrom
Many rehab protocols direct the EMS provider to monitor vitals during the on-scene rehab process; however, they don’t usually give safe vital sign parameters. This vagueness has caused considerable frustration to those going through rehab, EMS providers and incident commanders. Without parameters, how do we know who is safe to return to the incident?
Unfortunately, there is no universal set of vital signs that indicate it is safe for an individual to be released from rehab. A recent study done by Barr and colleagues suggested that vital signs of firefighters with medical symptoms were not significantly different from vital signs of firefighters who had an unremarkable recovery.
They studied firefighters over five years on various incidents. The researchers found that of the 13 subjects reporting a medical complaint, the vital signs were similar to those that had not registered a medical complaint . Perhaps showing vital signs may not be the telltale marker for firefighter medical issues in rehab.
The Barr study caused some questioning of our EMS system’s protocols that did in fact have vital sign parameters as part of our rehab process.
So, do vital signs matter in rehab? The answer is we don’t know.
Given that sometimes we don’t know what we don’t know, we as the medical directors for an EMS system in southern Wisconsin have chosen to continue a conservative stance on firefighter rehab. Here is our rationale for this.
Firefighting is an Olympic sport
Firefighting is one of the most physiologically demanding careers possible. Our ramp-up tone study demonstrated that going from a resting state to a full response causes considerable strain on the human body, especially when startled suddenly . Our alerts happen with little warning and many times while a firefighter is sleeping.
On the heels of this alarm stress is the rapidly added psychological and thermal stress of response operations. It is a physiologic perfect storm that can precipitate disaster with any underlying health problem. Firefighting is an Olympic sport – without the warm-up or cool-down phase.
Managing and monitoring risk
In our EMS system, we are trying to break the physiologic disaster cycle. We have worked on reducing the adrenaline and physiologic stress at alert time with ramp-up tones . We aim to manage risk to the individual through on-scene monitoring for signs of physiologic stress by an EMS provider and EMS physician. We have a formal climate-controlled and nutrition-stocked rehab vehicle and rehab team to support major incidents.
Vital signs in rehab are mentioned in NFPA 1584, which states, “Currently, there are no studies that quantify vital sign measurements with the length of rehabilitation or with the need to direct members to a treatment area. Visual signs and symptoms remain the best method to evaluate members in the rehabilitation area. Vital sign measurements can be used as a baseline and can assist to identify other health or safety concerns .”
NFPA 1584 recommends these vital signs for release from the rehab area :
- Temperature: <100.6 F
- Heart Rate: <100
- Respiratory Rate: 12-20
- Blood Pressure: <160 systolic and <100 diastolic
- Pulse Oximetry: >94 percent
The NFPA vitals serve as a reasonable baseline but should only be seen as a reference. In our EMS system rehab protocols, we have followed NFPA fairly closely. We use our rehab vital sign measurements for on-scene rehab discharge decisions and as a tool to screen our firefighters for undiagnosed hypertension.
Understanding that the fireground is stressful, we do not implement any medical treatment for hypertension, but we do have criteria for the firefighter to have a primary care follow-up appointment and hypertension recheck.
Discharge from rehab.
Discharge from rehab.
Removed from active scene work. Light duty until cleared by primary care physician.
Transport to emergency department.
Mercyhealth EMS Blood Pressure Guidelines
Vital signs provide guidance and a baseline to detect abnormalities. They should not be seen as absolutes. Any responder with normal vitals should still receive a thorough medical evaluation if he or she experienced a significant exposure or injury, show any signs of fatigue, have abnormal neurological symptoms or fail to perform duties related to overexertion.
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1. Medical Monitoring During Firefighter Incident Scene Rehabilitation. David A. Barr , PhD, Craig A. Haigh , MS, CFO, EFO, MIFireE, NRP, Jeannie M. Haller , MS & Denise L. Smith , PhD. Prehospital Emergency Care Volume 20, 2016. Issue 4. Page 467-476 | Published online: 08 Mar 2016. http://www.tandfonline.com/doi/full/10.3109/10903127.2016.1139215
2. Effect of station-specific alerting and ramp-up tones on firefighters’ alarm time heart rates. MacNeal JJ, Cone DC, Wistrom CL. J Occup Environ Hyg. 2016 May 12:1-17. http://www.ncbi.nlm.nih.gov/pubmed/27171596
3. NFPA 1584 2015 Edition Annex A. National Fire Protection Association. http://catalog.nfpa.org/NFPA-1584-Standard-on-the-Rehabilitation-Process-for-Members-During-Emergency-Operations-and-Training-Exercises-2015-Edition-P1437.aspx?icid=B484