Sorry I haven't been posting as much lately, but I got a little overloaded reading about subscription firefighting and at the same time things have been a little miserable at the paying job. I've spent my normal writing time updating my resume' and just finished posting it with a strong prospect. Perhaps in a few weeks I'll be a lot happier than I am now, although the thought of 'starting over' at my age is not encouraging.
But hey, here I am now so lets change the subject. Just because I haven't written anything doesn't mean I haven't been thinking about it.
I wrote about rehab in a very general way a couple of posts back and have been thinking about it more than I have in a couple of years when I wrote a training program on the subject. I'd be happy to deliver it to any agency who wants it. OH Wait, I'm annonomous, so that won't work too well. Never mind.
OK, so let me tell you something that I believe goes to the root of the problem when it comes to training providers in rehab skills. WE DON'T TEACH REHAB....AT ALL. That is a problem. If your program does include any mention of rehab, it is most likely to mention the warning signs to look for, what the 'danger levels' might be for certain presentations, etc.
My problem here is that there are no real standards for vitals, the range all over the map depending on the agency. But my big problem is that we fail to recognize that rehab is not provided in the same way we provide care to our regular patients.
Rehab is VERY different. Think about it. When we see a regular patient, we have been called there by the patient, family member, or other concerned person because there is something to indicate a medical need (at least to them). We have been ASKED to look at this patient. In rehab, most of the subjects did not ask, and even don't WANT you to check them out. We start with what can be an adversarial relationship. This requires different tactics and therefore different training. As a rehab provider you need to make sure you get to see everyone on a regular basis. You NEED to LOOK for problems, because the patient just wants to get back in the fight and will not volunteer any information. It's your job to find any problems that might exist.
So does this mean you need to be aggressive? Sometimes, but usually not. You do need to be assertive though. You are responsible to identify any hidden problems that could take a Brother or Sister down. One way to do this is to make sure the Incident Command System is supporting your rehab unit (even if it's only 2 of you). If the Firefighters know that will be pulled out if they don't comply, that should get rid of the avoidance issue. Next you need to work with your patients and let them know that your job is to check them out, refresh them, and get them back into the fray. It is most likely that very few, if any, require being pulled from the job for real treatment, but they don't know that. You, as the provider need to be even more professional, even handed, and thorough during rehab than you might with a standard patient. These patients know the score and will easily identify sloppy work. By the same token, if you DO find something, they will eventually realize that you did them a favor by providing proper and appropriate treatment. Remember to stay within your protocols. If your Medical Director permits you to clean and dress wounds to return someone to service, then do so, as appropriate. If it's not in your protocols, then perhaps you can work on getting that fixed, but in the meantime, do nothing you are not both trained and qualified to do. (For great training on wound management and infection control, take a Wilderness First Aid class given by a reputable organization like Outward Bound, Wilderness Medical Associates, or SOLO Schools, or go for the Wilderness EMT, it's a WHOLE different deal, I promise.)
Having national standards on Rehab and the training that SHOULD go along with it would make a difference. Having at least a solid set of recommendations would be really helpful, but I think it will take a long time for this to happen. I have read a LOT of guidelines from agencies, organizations, and departments from all over and they vary all across the board. I have seen some that recommend pulling a Firefighter that has a systolic pressure over 135 and some that use 160. Some say a pulse over 90, some say a pulse over 125 sustained (not subsiding after 10 minutes rest). It's no wonder everybody is confused!
This is why I keep going back to the look test. If the vitals are marginal but you have a subject that is energetic, animated, and alert... well then perhaps he/she isn't in such bad shape. Wait ten minutes and do your vitals again. Did they drop? If so this indicates recovery is in progress, and if they didn't maybe you want to get a better history and look a little deeper. When somebody feels like crap, it should be pretty hard for them to fool the provider that is looking very closely. Walk away and do something else. In a few minutes give them a look from a distance. Are they involved in an active conversation or are they slumped in the chair with their head back? The point is, you really have to pay attention and WORK this job. Rehab is not 'going through the motions'. These are your co-workers you're taking care of here.
If you have an interest in putting on some good rehab training, or just training yourself, the International Association of Fire Chiefs published a very nicely done package in August of 2009. I cannot confirm nor deny that I am acquainted with one of the primary authors, but I can say that there was a considerable amount of work done on this rehab program and it is whittled down to a pointed presentation which includes the PowerPoints, instructor notes, and a nicely done 'Brady style' student guide. All inclusive. I believe it is free to members of the IAFC. If not, then the price is worth it. I was given a review copy just prior to publication and was very impressed. It included new research and debunked a lot of rehab myths like drinking coffee on a fire scene is BAD. (As with most things, moderation counts.) Check it out.
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Great post. I hope that the AMR medics in my area are reading this and taking notes since I'll be on the receiving end of the assessment. Although, I admit that I will still be somewhat of an adversarial patient!
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