EMS Operations at a Structure Fire

[Guest paramedico987]

I'm all for helping out on scenes and stuff, but "rehab" is outside of my scope of practice... I'll be happy to walk around handing out water etc.

I'm not just saying that to get out of work. I seriously don't have adequate training to recognize when someone is "well enough" to go back into a burining building, and the results of incorrect judgement to that effect could be disaterous.

If you approach me for medical care, whether you're wearing bunker gear or not, I make the same reccomendation, and that is that you unequivically should be transported to the hospital. It actually goes right up my @$$ sideways when I'm asked to "just check out" somebody.

I can't tell if you have CO or hydorgen cyanide poisoning from that hit of smoke...

I don't know if you've lost too much sodium from sweating...

I haven't the faintest idea if you've worked too hard and will drop from a heart attack somewhere in the next five minutes.

I can't differentiate between regular aches and pains and any number of injuries.

I DO KNOW that if you feel sick enough to come and see me, then you're sick enough to be seen by a doctor.

IMHO it's a disaster waiting to happen to have EMT's of any degree of certification recognized by NYS help make a decision about whether or not someone can return to duty.

That being said.... Of course you can sit in my air conditioned ambulance to cool off for a while, just please leave the bunker gear outside [it really bothers the asthma folks that will be tranported by this same unit later on].

[Bnechis 3,961]

Who says that EMS has to run the rehab operation? Ideally, it should be run by people with medical training but that could be other FD resources. If you don't have enough resources, call more - call mutual aid

The problem is right now most FD's in Westchester need to call 8 depts to handle a bedroom fire. Your stripping 15% to 20% of the county of fire protection before you even start rehab. FD's need to start taking a strong look at what they are capable of doing and get their heads out of the sand (was going to say head out of ..........)

As for not calling EMS to the scene of a fire until a second alarm, can't/don't FF get hurt at the first alarm?

Most FD's have SOP's that do not allow any injuries until after the 2nd alarm is placed....LOL

[Bnechis 3,961]

I don't get why people make excuses for their dept not having enough resources. Its your butt that on the line. Make them either increase staffing or call in mutual aid. If there are not enough resources then put pressure on your leadership to get those resources there. Make it their problem and let them deal with it. Now if you don't believe that rehab has anything to offer you or you think having EMS standing by just in case something happens to you is a waste, then so be it. But don't excuse management 's responsibility to protect you because there aren't enough resources.

This is not directed at anyone individual. Just a reference to a general attitude.

Agreed....

"make them increase staffing".........good luck.....HOW?

I know of no VFD's that have been able to do it and very few career depts. And the combo depts. claim they dont need to because they have volunteers, but if none are showing up, they are just under manned depts.

"Mutual aid" - look at what is being called to most minor fire's its like a whose who of dept's. MA is suppose to be for the "big one" not for every one line fire.

I think the main reason that most ff's in Westchester are not fighting for manning is they are afraid that they will bring in career ff's or will disband and merge their social club.

[ckroll 101]

I'm all for helping out on scenes and stuff, but "rehab" is outside of my scope of practice... I'll be happy to walk around handing out water etc.

I'm not just saying that to get out of work. I seriously don't have adequate training to recognize when someone is "well enough" to go back into a burining building, and the results of incorrect judgement to that effect could be disaterous.

If you approach me for medical care, whether you're wearing bunker gear or not, I make the same reccomendation, and that is that you unequivically should be transported to the hospital. It actually goes right up my @$$ sideways when I'm asked to "just check out" somebody.

I can't tell if you have CO or hydorgen cyanide poisoning from that hit of smoke...

I don't know if you've lost too much sodium from sweating...

I haven't the faintest idea if you've worked too hard and will drop from a heart attack somewhere in the next five minutes.

I can't differentiate between regular aches and pains and any number of injuries.

I DO KNOW that if you feel sick enough to come and see me, then you're sick enough to be seen by a doctor.

IMHO it's a disaster waiting to happen to have EMT's of any degree of certification recognized by NYS help make a decision about whether or not someone can return to duty.

That being said.... Of course you can sit in my air conditioned ambulance to cool off for a while, just please leave the bunker gear outside [it really bothers the asthma folks that will be tranported by this same unit later on].

Obviously you do not practice as a paramedic in the Hudson Valley region where ALS protocol SCP-4 Emergency Incident REHAB sets the standard for patient evaluation. Westchester has nothing like it and as protocols are up for discussion at the moment, do people think that Westchester should address REHAB? I'm also not quite sure how ALS rehab is supposed to work in the Hudson Valley region as it is left unclear who is responsible for setting up the framework for rehab.

As a matter of personal practice, if I'm on duty, I 'go out for coffee' if the FD in my territory is dispatched for a structure fire and drink it in the general proximity of the incident until I know that a BLS ambulance is on location. The first few minutes of an incident can be the most dangerous. Most areas have ALS now. Is it an option to have ALS units unassigned but proximally located as an interim measure?

[ny10570 745]

Easier said than done. You dont just go tell the chief you need to increase staffing. It is WAY more complicated than that. If it was that easy every career department would be up to adequate staffing levels as proposed by NFPA. Taxpayers just dont see it like we do and they have the ultimate say.

As far as mutual aid our region does not have enough EMS units available. They are all commercial ambulance services so they are all about the dollars and could care less what we think we need or if we call mutual aid. The ambulance services both commercial and volunteer(not bashing volunteers) have the municipalities dupped into thinking they provide ample coverage.

You know Joe taxpayer gets all upset when there is no ambulance but they dont call or write the Mayor. After their initial anger it all subsides and nothing changes. Then we are left hanging in the wind trying to tell admin and the government we need more resources and they ask "if it is so bad why havent I heard any complaints."

All these situations are why they have created such programs as Fire Ops 101, so these politicinas can unserstand what we do and the difficulties of our job.

These arent excuses brother, this is reality! If you guys have the resources of multiple ambulances and ability to get mutual aid ambulances at a moments notice god bless ya but it isnt that way here.

My point was people need to stop accepting crap situations and fight for what they need to do their job and go home. There are mechanisms for getting this done. No crap, you can't just go to the chief and get an additional man on every rig just because you realized you want one. There isn't an easy solution but saying that it isn't there so we can't get it is guaranteed not to help. If the commercial ambulances don't want to go, what does their contract with the town say? If it says they're required to respond to any public emergency or potential life threat then f-em. They're bound by their contract. If they don't have enough units to cover the area then thats a problem they'll have to figure out. Maybe they'll find a way out of it or maybe the town will realize the gamle they're taking. Either way they're making a decision and thats when you'll have you chance to be heard.

I'm all for helping out on scenes and stuff, but "rehab" is outside of my scope of practice... I'll be happy to walk around handing out water etc.

I'm not just saying that to get out of work. I seriously don't have adequate training to recognize when someone is "well enough" to go back into a burining building, and the results of incorrect judgement to that effect could be disaterous.

Its not about determining them to be fit for duty and able to return to the fire. Its about catch an impending medical disaster. If you're that affraid of big bad DOH then don't provide any treatment. Just asses and send them on their way. If they come to you because they feel sick or think they're injured then thats a different story. Checking everyone regardless of complaint does not open you up any increased liability.

Agreed....

"make them increase staffing".........good luck.....HOW?

If I knew that answer I wouldn't be posting here. The point I was making is that you have to push for the changes you want. They don't just drop out of the sky and land on you. There's a big difference between saying we don't have something yet and saying that its an impossibility. What finally changed to get the regionalization study commissioned? Things change and they can change for the better, it just requires people to be there ready to effect that change.

[Guest]

If the commercial ambulances don't want to go, what does their contract with the town say? If it says they're required to respond to any public emergency or potential life threat then f-em. They're bound by their contract. If they don't have enough units to cover the area then thats a problem they'll have to figure out. Maybe they'll find a way out of it or maybe the town will realize the gamle they're taking. Either way they're making a decision and thats when you'll have you chance to be heard.

Our current system in our municipality is quite unique. We have a "volunteer" ambulance service, which recently began to pay members when no volunteers would show up to work the shifts. This seems like an oxymoron to me due to the fact they are paying EMT's $20 per hour and Medic's $25 per hour. There are a few ambulance members that see the dedication of volunteering for their community, but I believe most see the big nut of a paycheck they can get so they don’t volunteer and choose to take the money. I have no problem with the people volunteering or the people being paid, my problem is with the system itself. The ambulance service has town council members that are or were members and protect them when it comes to town resolutions. Our union has pushed the issue for years with no resolve due to this fact. Up until about a year ago they were the only system I was aware of in the area with volunteer paramedics. Either pay your members and mandate that we have guaranteed ambulance coverage or disband them and either have the FD take over the ambulances or a commercial service that would be held to a contract.

Currently the commercial ambulances serve as a backup service. I am not sure of the exact wording of their contract but I can tell you that we have waited on scene for an ambulance with a code for over 30 minutes, multiple times and nothing has been done to rectify this. As I stated before, the taxpayers are all up in arms when it is their family member but they do not follow through with their concerns.

I am sure many other municipalities deal with similar situations and it is frustrating, but when a system is in place that does not work efficiently and they are protected by the members of your town council and have people in town believing they are providing a great service it is tough to change it. We usually have one ambulance on duty for a town of 56,000 people. By the standards we should have at least 4. The problem is that when we have a parade in town EMS shows up with 150 people to march and the towns people see such a showing and believe that all these people work the bus, which is definitely not the case. We affect so few people through the 911 system that it is an uphill battle to convince the general public what is really going on.

I know that there is a huge crunch in our area for ambulances. The commercial ambulance services that work in this area dont have enough ambulances on the road and they claim this is due to the lack or people to work the rigs, and they overwhelming call volume. As most of you know though they would rather do a transfer than an emergency transport as the company makes more money on the transports. It is a terrible system as a whole and needs to be looked at in depth to try and resolve the issues.

In the mean time it leaves us twisting in the wind, and having to perform to the best of our abilities with what we have.

[GAW6 66]

I think this thread is getting off of the topic started by VACGUY. He was asking what other EMS agency's SOPs are for fire standbys.

If you want to complain about staffing, then start a new thread.

I am sure I will get comments made, as I usually do. I think it might have something to do with that little thing to the left that says "Commissioner", since everyone on here seems to have a dislike for commissioners.

[JJB531 652]

I'm all for helping out on scenes and stuff, but "rehab" is outside of my scope of practice... I'll be happy to walk around handing out water etc.

FEMA and the USFA have set standards for Emergency Incident Rehabilitation. Here's the link to their website which outlines Rehab practices as well as medical guidelines for rehabilitation. A ton of information (174 pages worth...)

http://www.usfa.dhs.gov/downloads/pdf/publ...ions/fa_314.pdf

[helicopper 1,050]

I think this thread is getting off of the topic started by VACGUY. He was asking what other EMS agency's SOPs are for fire standbys.

If you want to complain about staffing, then start a new thread.

I am sure I will get comments made, as I usually do. I think it might have something to do with that little thing to the left that says "Commissioner", since everyone on here seems to have a dislike for commissioners.

You took the words right out of my keyboard... We have departed a bit from the original inquiry but staffing is related so I understand why it came up. SOP's without people to implement them are useless. The sensitivity to staffing makes everyone hesitant to develop an SOP that will "require" staffing rehab at an incident when staffing for the incident is an issue.

Barry's point about the liberal use of mutual aid at "routine" (I use that word reluctantly and only because I can't think of a better one - I know "there's no such thing as routine" so please spare us the lecture!) incidents is valid but since we're doing it already, what's one more department? I'm not saying that there isn't a problem, I'm just saying that we should fix one thing at a time and rehab seems like a pretty easy fix.

As for officer's who don't believe in the importance of rehab, get your head out of the sand - we're not machines, we're not invincible, and we do suffer heart attacks, heat exhaustion, etc. Read ALS's post about the standards out there and ask yourself if you really want to be questioned in front of a jury about why you chose to ignore nationally accepted standards to protect your personnel after a negative outcome.

Spare me the 150 years of tradition nonsense! You want to fly that flag, trade in your spiffy apparatus and get a couple of horses!

[Guest]

If I may interject on this topic- First- In the world of rehab, I am not going to tie up an ALS ambulance to play house boy to the FD. If the job goes to multiple alarms, I would then ASSIST the FD's fire staff to set up a rehab center, but not before I assess the needs of the civilians.

I feel that EMS and ambulance response should be similar to that of an alarm response in a fire situation. For example, first alarm, you get an ALS ambulance. Once the second fire alarm is requested, then a second ambulance and field supervisor go to the scene. The second ambulance assists in establishing a rehab zone, and the supervisor reports to the CP to become an EQUAL part of the Unified command structure. These ambulances, as well as any others, are DEDICATED to the fire scene.

Ambulances at the scene of a fire operation should be out of the way of fireground operations, but readily accessable to the crews standing by. Once the opperation gets above 3 alarms, a field hospital or triage area should be established, and the local hospitals notified that there is a working structure fire with a potential for injuries. I would then also activate the countywide EMS mutual aid protocol, so as not to tax an indvisual agency.

Idealy, EMS crews should be sitting on each corner of the fire building, all being able to correspond with the EMS command/supervisor.

[Guest alsfirefighter]

I agree that NFPA conveniently outlines these guidelines for us but unfortunately CT isnt an NFPA state so trying to get anyone to listen to NFPA in this state is next to impossible.

If no one wants to listen to the NFPA side of it...don't forget OSHA's general duty clause which rehab also would fall under.

While I'm still not sure about the whole "NFPA State" comment that gets tossed around...in most regards yes you are. Every state in this country is and NFPA standards and why you need to follow them has been upheld in criminal and civil court, particularly in NY over the past couple of years. Management only wants to throw out NFPA when its convenient. Buy a new apparatus...NFPA 1901...turnout gear falls under 1971, 1972. Firefighter 1 curriculum NFPA 1001. I know you understand it..but just pointing out for a few others out there that still have a hard time understanding you can't pick and choose what NFPA standard you will follow and won't under the "we're not a NFPA State" "NFPA isn't a regulation." Have something wrong and see what a lawyer or prosecutor will site against you...

[Guest paramedico987]

Hudson Valley Regional Emergency Medical Services Council, INC.

Advanced Life Support Protocol Manual

Special Considerations Protocol-4

(SCP-4)

Emergency Incident REHAB

Indications

This protocol is to be implemented in conjunction with pre-established standard operating procedures that address

REHAB implementation, coordination, location, staffing, and accountability. This protocol is intended to provide ALS

personnel guidelines to evaluate the physical and mental status of rescue personnel who have been working during

an emergency incident or training exercise and to determine what medical treatment, if any, may be necessary.

Considerations

• Rescue personnel should have their baseline vital signs obtained prior to involvement in an incident.

• Rescue personnel should be kept well hydrated and rested to minimize heat exhaustion and/or fatigue.

• Upon arriving at the REHAB medical evaluation/treatment area, all SCBA and turnout gear should be

removed from rescue personnel prior to exam.

• Continuous medical evaluation should be provided to identify early signs of heat or stress related

illnesses.

• Documentation (including name, time, vitals, and triage disposition) should be completed for all

personnel entering the REHAB medical evaluation/treatment area. A PCR should be completed for all

patients meeting triage disposition #3 whether or not they are transported to the hospital.

Any of the following findings indicate mandatory triage to the REHAB medical evaluation/treatment area:

• Heart Rate >120

• Blood Pressure >200 systolic; <90 systolic; >110 diastolic

• Body temperature >100.6F

• Injury of any type

Personnel with any of the above findings should be treated as follows:

1. Provide a minimum of 20 minutes cool down/rest time;

2. Provide oral rehydration and nourishment as necessary;

3. Treat minor injuries as necessary, take vital signs every 5 minutes and document accordingly;

4. Reevaluate status after minimum cool down/rest time and triage accordingly.

Triage Dispositions:

1. Adequately rehabbed/medically sound/vitals within criteria limits – Return to duty

2. Vitals remain outside of criteria limits after initial REHAB treatment – Repeat REHAB treatment one

time

3. Identified or potential for serious illness or injury/vitals remain outside of criteria limits – Remove from

duty

Personnel with any identified potentially serious medical complaints or conditions should be treated

immediately according to the appropriate protocol and transported to the hospital. Signs and

symptoms include but are not limited to:

• Chest Pain and/or Dyspnea

• Altered Mental Status

• Irregular pulse

• Pulse >150 or >140 after cool down/rest time

• Systolic BP >200mmHg after cool down/rest time or Diastolic >130mmHg

• Body temperature >101F or hot and flushed skin that is either moist or dry

Above is a copy of the Hudson Valley REMAC protocol of "REHAB."

I feel the need to further defend my previous position. Firstly, I have little or no consideration for legal liabilty in these matters. We're all on the same team and therefore significanly less likely to file any type of litigation based upon a petty squabble. Also I'm clear to make my opinion of one's medical status known, but am even clearer that studies have shown time and again that EMT's & Paramedics DO NOT make good decisions about whether someone requires transportation and/or hospitalization, as much as we'd like to think that we do.

My argument is simply that ANYONE who gets sick enough that you think I'd better take you blood pressure should go to the hospital.

Furthermore this protocol is flawed in a few ways... namely it is rather vague and depends heavily on provider judgement, which as previously stated is unreliable. It makes mention of maintaining "adequate hydration" without a clear quantitative criteria of what that is. As far as I know, the only difinitive way to determine that is with blood tests. The protocol suggests that a baseline set of vitals be taken before an incident, however that is quite unrealistic, lest they mean that each FF should know his or her norms off hand in a stress situation. This protocol states that anyone with a pulse of 120 or greater needs to be seen in "REHAB" where "documentation" should be done; as per NYS BLS protocols, a PCR must be completed, and by default anyone not going to the hosptal is doing so AMA. Incidentally as I sit comfortably at my computer typing this, my pulse is 104 [mostly cuz I'm way out of shape and take a norepinephre re-uptake inhibitor], just imagine of I was schlepping charged lines around.

I however, do like that what constitutes rehab is somewhat defined, albeit with some ambiguity.

My biggest concern with all of this however, is the possiblity of return to duty. If your system was stressed so significantly the first time around, perhaps a second charge into that inferno with all of the heavy gear isn't such a good idea... I'd be much happier with this protocol if personell who required 2 rounds of rehab could be returned only to "light" duty, say maybe external operations related to logistical support.

[Guest alsfirefighter]

Paramedico...adequate hydration is labeled in the NFPA 1584 standard and also the USFA rehab document and the book that is out there.

Also FYI:

http://westchestergov.com/emergserv/EMS/bu...001-May-08-.pdf

[ny10570 745]

Paramedico...adequate hydration is labeled in the NFPA 1584 standard and also the USFA rehab document and the book that is out there.

Also FYI:

http://westchestergov.com/emergserv/EMS/bu...001-May-08-.pdf

I like the way you worked that plug in there; very smooth.