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Rehab SOP

Heat Stress and Firefighter Safety

Firefighting is a tough job - work so physically intense that it demands every ounce of energy a firefighter can muster... and sometimes it takes it toll! Statistics show that most firefighter injuries are caused by physical stress resulting from prolonged exposure to heat.

In a study dealing with firefighter stress, the US Coast Guard reported that during interior firefighting operations, a firefighter's body core temperature often reaches 104 degrees (F).

Imagine performing America's most dangerous job, working under the influence of a high-grade fever!

 Sports Related Heat Stress


Early fall football, cross country, soccer and field hockey practices are conducted in very hot and humid weather in many parts of the United States. Due to the equipment and uniform needed in football, most of the heat problems have been associated with football. From 1995 through the 2005 football season there have been 19 high school heat stroke deaths in football. This is not acceptable. There are no excuses for heatstroke deaths, if the proper precautions are taken.During hot weather conditions the athlete is subject to the following:


SUMMARY - The main problem associated with exercising in the hot weather is water loss through sweating. Water loss is best replaced by allowing the athlete unrestricted access to water. Water breaks two or three times every hour are better than one break an hour.

Probably the best method is to have water available at all times and to allow the athlete to drink water whenever he/she needs it. Never restrict the amount of water an athlete drinks, and be sure the athletes are drinking the water. The small amount of salt lost in sweat is adequately replaced by salting food at meals. Talk to your medical personnel concerning emergency treatment plans.


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 Fire Ground Past & Present

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.

A Working Fire Ground Rehab SOP 

Working SOP for any department

"Medical Evaluation Of Firefighters, EMS And Rescue Personnel During Fire, Emergency and Disaster Incidents"

Simply stated Firefighter Rehab is designed to ensure that the physical and mental well being of members operating at the scene of an emergency (or a training exercise) don't deteriorate to the point where it affects the safety of any other members. After all, "stressed out" is not a good thing when you're working at America's most dangerous job.

The US Coast Guard conducted a study dealing with the effects of interior firefighting on the human body. The results of the study are posted in the Coast Guard's Firefighting Initiative, but in short, researchers noted that our body core temperature (even for short exposures), often reaches 
104 degrees (F) during the firefight.

(1). Primary Mission:

The primary mission for fire command is to identify, examine and evaluate the physical and mental status of fire-rescue personnel who have been working during the emergency incident or a training exercise. Following a proper survey (see below), it should be determined what additional treatment, if any, may be required.

According to FEMA, "Any activity/incident that is large in size, long in duration, and/or labor intensive will rapidly deplete the energy and strength of personnel and there merits consideration for rehabilitation."

(2). Launching The Rehab Operation

A specially designated Rehab Area, (or Group) remote from the fire or emergency incident, should be established at the discretion of the Incident Commander in consult with the senior Safety Officer. If the Incident Commander determines that Rehab is necessary, qualified EMPT-Ps or EMT’s (assigned to the first alarm response) should be assigned to manage the Rehab Sector under the command of a fire or EMS officer or supervisor.

Note the emphasis of the "first alarm response." EMS personnel must be on scene and available to provide treatment to fire-ground personnel at a moment's notice. If EMS does not respond as part of the initial turnout, consideration should be given to the fact that OSHA will certainly as why they weren't... especially if anyone is injured.

Because they work side by side with the front line troops, company officers play an important role in Rehab. In fact, the federal government suggests that the safety of the fire-ground rests here, at the supervisor level. If a company member shows signs of fatigue or illness, the company officer will likely be the first to recognize the problem. 

Anticipate Rehab needs early in the incident. During large-scale operations, Incident Command should consider augmenting existing resources by requesting additional EMS personnel or even another engine company or squad, to assist in the operation of the Rehab Sector.

A Company Officer keeps close watch over a hose-line team under his command.

(3). Locating the Rehab Sector:

It is crucial for Command to establish The Rehab Sector away from any environmental hazards, or by-products of the fire, such as smoke, gases or fumes. During hot months, the ideal location might include a shady, cool area distant from the incident. In winter, a warm, dry area is preferred. Regardless of the season, the area should be readily accessible to EMS-Rescue personnel and their equipment, so they may restock the sector with supplies, or in the event that emergency transport is required.

Rehab sites can also be established in the lobbies of nearby buildings, parking facilities, or even inside municipal buses.

Misting/cooling systems, heating systems, SCBA refilling and canteen service should be stationed in or around this area as well. During large-scale incidents, like multi-alarm fires, Command should consider establishing Multiple Rehab Areas as the situation warrants.

(4). Coordination and Manning:

Command of the Rehab Area should be assigned to a chief or company level officer, who is designated as the Rehab Officer under most Incident Command structures. The incident itself will determine just how many people you'll need to do the job, however a minimum of two trained EMS personnel should initially be assigned to monitor and assist firefighters in the Rehab Sector. Utilize volunteer canteen or auxiliary members to assist EMS personnel in making "working" members as comfortable as possible.

(5). Evaluation of Fire-Rescue Personnel:

It is important for command and company level officers to continually monitor personnel for telltale signs of exhaustion, stress, and or physical injury. Individual members are encouraged to report to the Rehab Sector at any time that he or she feels the need to do so. Symptoms may include weakness, dizziness, chest pain, muscle cramps, nausea, altered mental status, difficulty breathing, and others.

Regardless of physical well being, all fire ground personnel should report to the Rehab Sector immediately following:
(a) Strenuous Activity - Forcible Entry, Advancing Hose lines, Ventilation, etc.
(b) The use and depletion of two SCBA bottles
(c) Thirty (30) minutes of operation within a hazardous/dangerous environment
(d) Failure of SCBA


Factors Affecting Recovery

Personnel in the rehabilitation area should maintain a high level of hydration. Personnel should not be moved from a hot environment directly into an air conditioned area because the body's cooling system can shut down in response to the external cooling. An air conditioned environment is acceptable after a cool-down period at ambient temperature with sufficient air movement i.e. misting fans. Certain drugs impair the body's ability to sweat and extreme caution must be exercised if the member has taken antihistamines, such as Actifed or Benadryl, or has taken diuretics or stimulants.

General Heart Rate And Temperature Parameters

The heart rate should be measured as early as possible in the rest period. If a personnel heart rate exceeds 110 bpm, an oral temperature should be taken. If the personnel temperature exceeds 100.6F he/she should not be permitted to wear protective equipment. If it is below 100.6F and the heart rate remains above 110 bpm, rehabilitation time should be increased. If the heart rate is less than 110 bpm, the chance of heat stress is negligible. Cardiac monitoring will be at the paramedic's discretion.

BLS Medical Treatment for HR>110 bpm and/or temperature >100.6F

The following treatment shall be started:

  • Remove all turnout gear and heavy clothing. Maintain privacy with a sheet.
  • Wet from head to toe
  • Place supine in shaded area with rapidly moving air (fan)
  • Apply cool compresses to axilla and groin


  • Attach To Cardiac Monitor / perform 12-lead EKG as indicated
  • Check Pulse Ox (Consider Possible CO Inhalation)
  • Establish IV Of NS Or LR At Rapid Infusion Rate
  • Prompt transport to hospital, continue treatment per local sponsor hospital guidelines.

It is recommended that re-examination occur at ten-minute intervals. Using standing orders or existing protocol, Rehab Team Members should record examination results on medical evaluation forms as indicated by the local jurisdiction.

(6). Examination of Arriving Personnel

Arriving personnel should be examined by qualified EMS, who should check and evaluate vital signs, and make proper disposition, i.e. return to duty, continued rehabilitation, or transport to medical facility for treatment. The workup should include:.

(a) Scoring for Glasgow coma trauma scale.
(b) Checking Pupils
(c) Checking Vital Signs, such as blood pressure, pulse, breathing rate,
(d) Checking lung sounds 
(e) Administration of a 2-lead EKG, when chest pain or irregular heartbeat is presented
(f) Skin condition and color
(g) Body core temperature

Heart rate should be measured as early as possible in the rest period. If the firefighter’s heart rate exceeds 110 beats per minute, it is recommended that an oral temperature be taken. If body core temperature exceeds 100.6F, the firefighter should not be permitted to wear protective equipment or re-enter the active work environment, until temperature has been reduced and heart rate decreased. 

(7). Treatment During Rehab:

Upon completing the physical examination, the following steps should be taken to minimize further risk to fire-rescue personnel:

Turnout gear, helmets, masks and hoods should be removed immediately. Prior to ingesting anything orally, fluid or solid, it is recommended that the firefighter clean his/her hands and face with water and a cleaning agent, as provided by Rehab Sector personnel. 
(a) The firefighter should re-hydrate
(b) Oral re-hydration and nutrition is recommended in the form of 1-2 quarts of fluids 
over a span of 15 minutes.
(c) Body core temperature should be reduced by cooling the body at an even rate.
(d) Cool body temperatures gradually using misting systems, fans, etc.
(e) Individuals should be offered Oxygen therapy via nasal canula or O2 mask. 
(Humidified or Nebulized).
(f) Standing rest before reporting for further assignments
(g) The firefighter will only report to manpower staging when presentation is deemed 
normal by the attending EMS personnel.

Note: According to FEMA, Water is the best re-hydration agent, however some agencies suggest a re-hydration solution of 50 / 50 mixture of water and a commercially prepared activity beverage administered at about 40F. Avoid cooling the body using ice packs or hose-streams. Cooling should be gradual, limiting further shock to the body.

In the event that presentation appears abnormal, the Firefighter should immediately receive additional treatment, especially if conditions persist following fifteen minutes of rest. As is appropriate in most locales, those complaining of chest pain, difficulty breathing and altered mental status must receive immediate ALS treatment and transport to definitive health care. Follow your local jurisdiction's ALS protocols in this event.

(8). Accountability.

Members reporting to the Rehab Sector / Group should enter and exit the Area as a team. Their company designation, number of personnel, and the times of entry to and exit from the Rehab Area should be documented. This can be done either by the Rehab Officer or his / her designee on a Company Check-In / Out Sheet. Keep crews together, and don't allow overanxious members to freelance the event.

(9). The Vital Importance Of Firefighter Rehab

Very few firefighters who wear the badge are athletes. But, from the moment the alarm is sounded, and that first surge of adrenaline reaches the heart, we're asking our bodies to work triple overtime. Couple that with 55 pounds of business suit, 1200° temperatures and another 50 pounds of hand tools and equipment, and the importance of effective rehabilitation at the fire scene becomes crystal clear.

Thanks to Pembroke Pines, FL Fire and Rescue, Bollingbrook IL Fire Department.


  More on this Firefighter Rehabilitation Article...

Our rehab SOP has set industry standards for implementing fire ground safety and rehab. Our SOP has been referenced and revered for being innovative and groundbreaking. Cool Draft Scientific has been noted for pioneering fire ground rehab.

Physicians and Safety Experts Agree…

...in order to limit serious injuries, the firefighter's body core temperature must be reduced steadily. Forearm submersion not only promotes restriction of the blood vessels and constricts blood flow, but can shock the bodies system by going from one extreme to another. That's where Cool Draft® comes into play!

The chilled breeze generated by 
Cool Draft® gently and safely lowers the body temperature. Combined with an effective Rehab protocol Cool Draft® substantially reduces the dangers associated with heat stress.