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EMS standby at structure fire.
We are a volunteer BLS service in a very small town. We are paged to standby at structure fires, which thankfully, we do not have too many. The fire department is also volunteer and I am also a firefighter.
Our protocols demand we obtain consent prior to initiating treatment (of course) and once we have started our assessment/treatment we expect to transport. The patient has the right to decline treatment/transport at any time. Pretty basic I assume.
My question: Do you do anything different when on standby for a fire? Do you follow all protocols, or can you (for example) give a firefighter a little shot of O2 at their request without doing a full workup and transport? As a firefighter we have O2 on our rescue vehicle for just such occasions. As an EMT I don't think I can give O2 unless doing a full assessment and transport. The black and white answer is of course to follow protocol, but is that the only answer? My thought is to direct the firefighters to the rescue vehicle, there are firefighters capable of running the O2. What is the RIGHT way to handle this?
Our protocols demand we obtain consent prior to initiating treatment (of course) and once we have started our assessment/treatment we expect to transport. The patient has the right to decline treatment/transport at any time. Pretty basic I assume.
My question: Do you do anything different when on standby for a fire? Do you follow all protocols, or can you (for example) give a firefighter a little shot of O2 at their request without doing a full workup and transport? As a firefighter we have O2 on our rescue vehicle for just such occasions. As an EMT I don't think I can give O2 unless doing a full assessment and transport. The black and white answer is of course to follow protocol, but is that the only answer? My thought is to direct the firefighters to the rescue vehicle, there are firefighters capable of running the O2. What is the RIGHT way to handle this?
Replies to This Discussion
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Permalink Reply by Kimberly A Bownas on
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In my department we are volunteer and when we have a structure fire the rescue squad responds and sets up rehab. At the rehab (EMS jail is what are guys call it) we check all firefighters that have been in the building fighting the fire. At rehab, we take a set of vitals and then we have them sit and drink some water. After about 10 to 15 minutes, we do a second set of vitals. If their vitals have come down then the firefighter is cleared by the ems crew to beable to go back to work. If it hasn't changed then we make them wait some more and retake the vitals again and go from there. We don't transport every single firefighter that comes to rehab. We only transport who really needs to be transported. As you have mentioned you should go by either your protocol or see what your SOG/SOP's for your department are. I hope this helps and as I stated the best thing to do is check what your departments SOGs or SOPs are on rehab at a structure fire... Good luck and be safe
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Permalink Reply by Donald Canterbury on
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I am on a paid Ambulance that is ran out of volunteer fire dept. We respond to structure fires (only ones in our district unless asked to go on mutual aid for whatever reason) and assist with whatever we can. Most of us are firefighters also, so we can help stretch the line, help with hydrant work, etc. We also, of course, attend to anybody who was a victim of the fire. We also will do as Kimberly mentioned, with the rehab. The rehab is kind of a courtesy to the firefighters. When I am with my home dept. (a volunteer dept.) and come out of a fire, it is good to know that the ems is there if needed. They also do the same thing (two different depts. in two different states) with the rehab as we do at the ambulance I work on. Like Kimberly said, do what your dept. SOG/SOP's state and you should be fine. Take care and stay safe.
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Permalink Reply by chele on
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Thanks for your replies! We are thinking maybe we need to work on the SOP's for our EMS department to deal with this situation so I'm looking for ideas I guess. We don't really have anything specific to this situation. Since none of us are Paramedics we can not diagnose. Since we can't diagnose we can't judge if a firefighter is good to go back to fighting fire or not!
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Go with your gut feeling and with what your training taught you. Check the vitals, give O2 if needed to give them a "breather" and if things aren't any better or worse (God forbid), hold them out and continue to monitor them. If you think that you might need a Medic, by all means, transport and call for ALS assistance in route. Also, go with a general impression of the firefighter to go along with the vitals. Follow that and you should be alright.
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Permalink Reply by Greg on
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Like others have said before you dont have to transport everyone that you give some O2 to. Part of rehab would be a full workup of vitals, get your baselines then reassessed in a few like we learned in every medical class we have ever been to. When its hot out and you have been humping awhile on the firescene, sometimes a couple minutes on a NRB some water that can bring your body back towards going back to work. Follow your SOP's SOG's . Use your bus as a waiting room rehab so to say, ppl can cycle through one door and out the other in the ac you have everything you need. rough on your ambulance by the end of the night.
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Permalink Reply by Ben Waller on
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There are actually different things being discussed here - a firefighter rehab group and a medical group. There is some overlap, but the primary difference is that rehab is oriented toward getting firefighters cooled down (or warmed up), hydrated, and if needed, and energy snack prior to returning to a firefight. The other rehab priority is to identify firefighters who need medical treatment and possibly transport to a hospital for physician evaluation. Conditions that warrent upgrading a firefighter from "rehab" status to "patient" status include, but are not limited to:
Firefighters whose vital signs (BP, respiratory rate, pulse, temperature, and pulse oximetry if available) do not return to within normal limits within a designated time period.
Firefighters who have a medical complaint, especially chest discomfort or respiratory distress.
Firefighters who exhibit altered mental status.
Firefighters who are in visible distress or are otherwise demonstrably too exhausted to return to the firefight.
Firefighters in this group should get more in-depth medical evaluation, and if indicated, be transported to a hospital for physician evaluation with the highest available level of care at the scene and enroute. If a firefighter requires medical care more than oral rehydration, active cooling, and rest, do an in-depth medical evaluation. If the firefighter requires oxygen, IV rehydrdation, or more energy than an energy snack can give, then it's time to tell the Incident Commander that ou're transporting that firefighter.
Additionally, the rehab group should keep written records of the firefighters' post-entry vital signs and other pertinent medical information for future reference. These records should be maintained in a HIPAA-compliant records system.
Firefighters who go to medical do not necessarily need to be transported, but as with any other patient care, err on the side of caution. If a firefighter is complaining of feeling ill after a firefight, LISTEN to them, and don't let them just go home sick. That happened to a friend of mine, who went home sick in the early afternoon after being exhausted during a structural fire. He was allowed to go home, where his partner found him dead several hours later when she came home from work.
Don't let this happen to YOUR firefighters.
Don't let them act like John Wayne. And remember...John Wayne is already dead.
Ben
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Thanks Capt 723! My email is krier@ucom.net I really apprechiate your help!
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You've covered some of my concerns and why I'd like to have some SOP's specific to standby at fires.
There's no problem with the firefighters being pulled from the line if warranted, many of us are EMS and Firefighters, so there's an edge to getting cooperation. The problem is more to treating them and letting them go back to fighting fire! We need ideas on establishing a protocol for dealing with it as a BLS service.
When you refer to "going to medical" do you mean that as an EMS entity, or a fire entity? What I mean is, are EMT's doing the assessments or are Firefighters? Because we have no Paramedics we would have to have very specific guidelines I think, since treating and releasing is technically not within our scope of practice, right?
The fire department has done baseline vitals, now the question is what to do with them, because to just say that a firefighter's BP is higher than his baseline isn't enough. EMS needs guidelines that say, oh - BP X% higher than normal warrants X amount of time in rehab or transport - something to that effect. The fire department policy is 2 bottles and then to Rehab. By Rehab they assume it will be the ambulance during structure fires. I'm thinking it's better to leave EMS for transport only and leave Rehab to the fire department, but I don't know if that's how other departments handle it?
I'm sorry to hear about your friend. We had a firefighter seek treatment at ER following a structure fire. The risk is very real that a sick/affected firefighter could slip through the cracks - the John Wayne thing. We know each other well and try to keep tabs on the "problem" ones, but this guy wasn't one that had ever had a problem before, so he wasn't watched closely enough. He was only in the structure for one bottle too, (because the fire was put out so quickly!) so even that safety net was eluded.
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The NFPA 1584 standard covers Incident Rehab in more detail.
Here's an interpretation from firefighterclosecalls.
http://www.firefighterclosecalls.com/downloads/FireEngineeringArtic...
I don't think a BP of X% higher than normal is a good evaluation tool, because if you have someone whose normal BP is toward the upper end of the normal spectrum, that firefighter can have a larger numerical increase in BP while being allowed to re-enter. That penalizes firefighters with better cardio health and/or shorter recovery times and allows the firefighters with marginal VS more leeway than the ones with better vitals.
There are some objective numbers in various standards, but even the agencies that publish hard-and-fast numbers don't specify a recovery time for individual firefighters to meet the numbers prior to being allowed to re-enter. I hesitate to post the numbers, because they can be very misleading.
As for who operates rehab and who operates the medical group, both need to be operated by certified EMT-Bs, at a minimum, regardless of the agency that provides them. If adequately staffed, rehab/medical can be operated as one group, rather than two. The problem is that if you assign one ambulance to do both, then have to transport a victim or a firefighter, then there's no one left at the scene to do rehab. The NFPA 1984 Incident Rehab standard just requires BLS, but with ALS preferred for rehab.
The bottom line is that rehab is always going to have some subjectivity. The key thing is that if there's doubt - especially in the absence of on-scene ALS - then transport the firefighter in question for physician evaluation and hospital treatment.
RIP Tom Kickler, LODD 5-6-02
You will not be forgotten.
Ben
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Permalink Reply by Andy Entwistle on
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I'm a firefighter. But I can tell you that at a fire our supporting EMS (awesome folks) give us O2 without a work-up or transport expectation. And I think that's how it ought to be. They don't release guys to go back in until the vitals are where they wnat them.
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Permalink Reply by FETC on
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Firefighter comes over to your rig. Obtain consent to treat, assess, treat, give 02, asssess, transport or decline transport is fine, just document in either case. ALS brings people back to life and they can sign off for a no transport (if the are of sound mind) person / place / time.... This is a good question because most firefighters will decline before they go to the ambulance. Command or a sector officer sent them.
Documentation is the key.
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If you are so short of breath or exhausted that you need oxygen, then you should be transported to a hospital and be treated by a physician.
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