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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 Ben Waller on
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Actually, having a Rehab SOG that places the firefighter treatment/transport decision with the Rehab/Medical paramedic or Group Supervisor is much preferred to letting the firefighters John Wayne it and refuse. Paid or volunteer, firefighting medical issues are work-related, and are generally covered by worker's comp. When it's a worker's comp issue, the employee doesn't have the right to refuse medical care. There is a lot of legal precedent that says that volunteers are considered unpaid employees for the purposes of workers comp, too.
If you let a firefighter who is A & O x 4 refuse if he or she is in visible distess - or MAY have distress - and you let him or her sign a no transport waiver, a bad lawyer can toast you in court.
We don't let our firefighters make this decision - it's up to the rehab medic. Even Command can't overrule that decision, because it's a health and safety policy.
Heat stress kills firefighters. Don't let it kill yours, whether they can sign a waiver or not.
Ben
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Permalink Reply by chele on
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I can not Thank You enough! I'll take the SOP's to our Fire Chief, see what he thinks and take it to the EMS Director, she what see thinks and then put it in action! We have talked about a Rehab policy, but really didn't know for sure where to start. This looks like you not only started it for us, you also ended it! Thanks again!
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Thank You very much for that link! I've downloaded it to share with the Fire Chief. The core cooling technique is new to me, and very worthwhile reading! I'll be using it in Rehab for sure!
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I'm hoping that we get good SOP's and implement them strictly enough that our firefighters will not need O2/treatment because they will be in Rehab and be kept properly hydrated etc. to return to the fireline.
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Yup, they will decline if given a chance! We (me in particular with EMS right with me) are pretty proactive in seeking out and keeping an eye on our firefighters. There are some that are particularly susceptible to heat exhaustion that we/I watch very closely. Yet even they won't normally seek out help! We/I pretty much force them to take water and Gatorade while filling their trucks (grass fire rigs) and on scene for structures. The grey area for me is the Scope of Practice limiting what I can do because I am an EMT. With the SOP Capt 723 sent to me I've got a better idea now of how to handle that "problem".
Documentation is key for sure!
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You make a very good point; I've been assuming a Firefighter would be like any other patient - and have the right to refuse treatment. I never thought of it from and employer point of view before; definately something to consider.
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Permalink Reply by anne potter on
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HERER WE CALL IT REHAB EVERY FIREMAN ONCE THE SCOTT PACK GOES OFF MUST GO TO REHAB TO CLEARED TO COME BACK. OR IF THE SAFETY OFFICER FEELS YOU NEED TO BE REHAB.. ALL THE AMBULANCE CREW DOES IS PCR SHEET ON EACH.. THEY DO GIVE SHOT OF O2 ON SCENE IF NEEDED... IF BP IS HIGH MUST SIT TILL CLEARED BY REHAB TO GO BACK ON SCENE.. THEY HAVE BEEN DOING THIS FOR 5 YEARS .. IT IS VERY NICE TO HAVE..... NO YOU DON'T HAVE TO TRANSPORT,BUT HAVE TO FILL OUT PCR PAPERS..
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Permalink Reply by Nicholi69 on
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Well at fire calls ive given IVs to firefighters that needed it without transporting or doing paperwork on it but my sogs were pretty laxed on this issue
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Mandatory fire department rehab policies take away the choice about declining either rehab or refusing transport if the Rehab or Medical Group mandates it.
A good rule is a minimum of 20 minutes of geared-down rest after 2 SCBA cylinders.
That rule can be shortened to 1 cylinder for departments that have 1-hour cylinders or when the weather is in red or black flag heat index conditions.
The current trend toward pushing sports drinks instead of water has a couple of fallacies.
The theory is that the carbs (sugar) and electrolytes in the sports drinks are better for tired and sweaty firefighters than just water. At least initially, I disagree with that - here's why...
When you dehydrate, you lose circulating blood volume, (solvent) which changes the ratio of solutes and non-soluble blood products (sugar, electrolytes, red and white blood cells, and platelets) to a more concentrated solution. Concentrations higher than normal are hypertonic, for those of you who may not be familiar with the medical term. Fluid is drawn from isotonic (normal concentrations) areas to hypertonic areas as a defense mechanism that attempts to reverse localized dehydration. When you drink a sports drink without adequately re-hydrating with water first, you dump a VERY hypertonic solution into the stomach. If you put enough dissolved solutes in the stomach, it will actually draw more water out of the central circulation and make the bloodstream actually even more concentrated than it already is. This can actually increase dehydration effects, at least in the short term.
The answer is to drink a decent amount of plain water to rehydrate the digestive tract and to start rehydrating the central circulation. When the water has had a little time to absorb, then a sports drink will help replace any sugar or salts lost to sweat. I've seen firefighters who got dehydrated guzzle Gatorade or Powerade to the point that they vomited. That's a guarantee of making the dehydration worse. Vomiting also severely limits the firefighter's ability to rehydrate orally, which means the firefighter will probably need EMS transport and IV rehydration.
Good luck with the SOGs.
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Permalink Reply by Spanner 122 on
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We have EMS standing by at structure fires as well. If we need treatment from EMS we are not to return to duties. We can, although, be checked by EMS, but once treatment begins we are transported. We have our own O2, but I don't think you would find anyone using it... I have never seen anyone receive treatment and go back to work at the same incident.
We run our own rehab, EMS will check and record vitals after we have run through a couple of bottles and away we go.
My question is, why are firefighters receiving O2 on a call? Is it the fitness level and they just feel they need it, is it a co build up issue (in which case, their SCBA can't be functioning properly, also known as the facepiece is not on the face), in which case they are putting themselves at risk if they are at the point of needing O2 and then heading back to work.
I would assume you would follow all protocols. Would that not be the "Cover your ass" way? You would think you wouldn't want to administer O2, send the firefighter back in and then he collapses with a heart episode. I dont' know, this question makes me very uneasy. I hope firefighters are smarter than to receive treatment and then believe they are okay to get back in there... there will be other fires.
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That's a dangerous practice. First, if a firefighter is so dehydrated that he/she requires IV rehydration, that firefighter is at high risk for heat stroke and for heat stress-related heart attacks. If that happens, the responsibility is squarely on the EMS providers that did the IV and didn't do a PCR.
Secondly, federal law requires a physician's order for dispensing any medication with a USP (United States Pharmacopia) notation on the label. This includes all IV fluids. It is a violation of the US Food, Drug, and Cosmetics Act to dispense said medications without getting a physician to sign either an order or a written prescription. If you don't do a PCR, there's no written order, and you're violating federal law.
Third, in every state, administering prescription medication - including IVs - requires a physician order. If you don't get a written order (PCR) signed, then you can be accused of practicing medicine without a license, which is a felony in every state.
For both the firefighters' sake and your own, I'd stop the above practices immediately.
It's unlikely that the DEA will come arrest you for it, but it is likely that a firefighter will eventually have a serious medical problem following a no paperwork/IV start/no transport. If that occurs, you're not going to be in a good position if and when the case goes to court.
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