Firefighter Rehabilitation


Author: Philip L Hayes, EMT, EMS-I, FO

On Sept. 6, 1990, at 11:41 AM, the first Sedgwick County FD engine was dispatched to a brush fire. The Kansas winds were blowing at 17-34 MPH and temperature was in the mid-90s. It took nearly 3 hours and 18 Sedgwick County FD units before the rapidly spreading fire could be brought under control. When the fire was over, and clean-up operations were underway, the body of 25-year old Firefighter Todd Colton was discovered.The last units left the scene at 9:13 PM. According to the County Coroner, the primary cause of death was heat stroke. The cause of the heat stroke was exposure to hot ambient temperature, high radiant heat load, and performance of moderate to heavy work while wearing protective clothing. There were no rehabilitation operations that could have helped prevent Todd Colton's unnecessary death. As a result of Todd Colton's death, NIOSH investigated and issued report 90-935. There were nine recommendations to increase fire safety. Firefighter rehab was included in those recommendations as a primary means of combating preventable firefighter injuries and death.

The Need:


Courtesy of:
Tactical Medical Solutions

The SOGs of a typical fire department usually state, somewhere, that a rest period during firefighting operations is required for safety. If this is the extent of your rehab program, you need to take another look at the whole concept. Are you doing enough to prevent serious trauma from overexertion or sudden death from heart attack or stroke? Both trauma and sudden, serious illness or death are related to overexertion, dehydration and fatigue. The question we should be asking is, to what level does your fire department provide rehab? What medical standards do you use to evaluate firefighters to show that they are sufficiently rehabilitated and fit to return to duty? Some argue that their department can't institute a rehab program because they have limited personnel and that the fireground operations may be compromised while firefighters rest. Several recent studies actually contradict that argument. The findings indicate that a properly implemented firefighter rehabilitation program will result in fewer accidents and injuries. More importantly, properly rehabilitated firefighters return to duty better able to handle the workload, are better hydrated and have more productive capacity. The studies revealed that rehab of personnel actually reduced additional personnel needs over the course of a protracted incident.

Since 1994, the fire service has been averaging between 90 and 105 deaths per year. Heart attacks and strokes still account for the largest number of line of line of duty deaths. While the total number of deaths has generally been declining, the percentage of deaths due to heart attacks and stroke have actually risen. According to the NFPA, these heart attacks and strokes are almost always due to stress and overexertion.

Over the last 10 years, the fire service has been averaging 95,000 - 105,000 annual injuries. Over one-half have been injuries that occurred during emergency operations. Even with the many innovations and improved training programs in recent years, thousands of firefighters continue to be needlessly being injured or become ill on the fireground because of lack of medical surveillance. While we are grateful for better personal protective equipment, the fact is that wearing the equipment greatly increases the exertion / stress levels within the firefighter increasing the need for timely rehab of firefighters.

The Medical Evaluation / Screening Process

The purpose of the medical evaluation / screening process is to look for signs of overexertion and/or heat stress, to assess to what degree it exists and then institute proper rehabilitation measures so that the firefighter can return to duty in optimal condition. Without a SOG in place to dictate when rehab is formally instituted or if it doesn't use clear medical guidelines to assess risk, one of two scenarios may occur:

  1. EMS may not understand the "normal" physiological response to working in fire conditions and transport prematurely or,
  2. Firefighters are not sufficiently rehabilitated and become seriously ill or injured because of the physiological effects of overexertion.

Here's an example: Early one September morning, a fire broke out in a three-story ordinary construction "taxpayer." The first and second alarms brought over 30 firefighters to the scene for what would turn out to require extended fireground operations. This particular department is fortunate since a paramedic level EMS unit automatically responds, and stands-by, at every fire scene. About 1 hour into the incident, several firefighters were evaluated by the EMS crew as they came out of the building. Upon examination of the firefighters, many were found with severely elevated blood pressures, increased heart rate, and signs of dehydration. Six firefighters were transported to the hospital. After careful retrospective analysis, only two firefighters actually needed hospital care. The others were simply experiencing the normal, post-exertion vital sign changes that occur when working in fireground operations. By the time the ambulance reached the ED (5 -10 minutes) the 'abnormal" vital signs had returned to normal.

If a formal rehab policy was in place, the EMS crew would be aware of what would be expected as a "normal" body response when coming out of a fire operation. Four of these six men would have been aggressively rehabilitated and returned to duty within minutes. Two of the firefighters however, did require immediate treatment and transport. One firefighter suffered chest pain and the other was extremely dehydrated and hypotensive. The ambient air was hot and humid increasing the risk of illness due to the heat index. The paramedics knew this and were simply trying to care for the firefighters and prevent any illness or injury. Their decision to transport was not guided by a medical guideline designed specifically to deal with firefighters unique responses to their work environment and this caused an overreaction to the high blood pressure readings they obtained immediately after the firefighters came out of the building. A rehab program would have returned four firefighters back to duty, in fit condition, in an average of 10 - 15 minutes. This would have prevented the loss of four firefighters from the scene.

There is strong debate as to what to include in a rehab guideline. According to FEMA, the purpose of any rehab guideline should be to "ensure that the physical and mental condition of members operating at a scene of an emergency or training exercise does not deteriorate to a point that affects the safety of each member or that jeopardizes the safety and integrity of the operation. Fire departments, while providing for firefighter health and safety, also need to address on-scene manpower issues. For departments with limited firefighters on-duty, depletion of personnel can be disastrous, requiring an excessively large amount of mutual aid. Emphasizing firefighter health and safety must always be the primary concern. However, it is possible to balance it with the size, length and intensity of an incident. Proper education of rehab monitoring personnel can significantly reduce unneeded transports to the hospital and insure firefighter safety while they continue to operate at the scene.

Here is a comprehensive medical guideline / SOG using FEMA's Emergency Incident Rehab SOP, NFPA 1500 (Standard on Fire Department Occupational Safety & Health Programs), NFPA 1561 (Standard on Fire Department Incident Management Systems.)


Click here to view this comprehensive guideline.

Medical References:

  • James S. Skinner, Ph. D.; "Fighting the Fire Within." Firehouse Magazine. August, 1985. pg. 66.
  • Dean Pedrotti; "Heat Stress Rehabilitation". Firehouse Magazine. May, 1989. Pg. 46
  • Occupational Safety and Health Guidance Manual for Hazardous Waste Site Activities. US Government Printing Office. October 1985. Pg. 8-22.
  • Teri Lyn Eisma; "Heat, Humidity, Hard Work Demand Replacement of Depleted Nutrients." Occupational Health and Safety. April 1981. Pg. 36.
  • James Augustine, MD; "In Search of Fatigue Predictors." Fire Command. November 1990. Pg. 13.

Other Reference's:

  • R. Shults, G. Noonan, N. Turner; "NIOSH Health Hazard Report # 90-395." 1990. Appendix II, pg 2.

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