RIT Revamp

In 2014, the Chicago Fire Department (CFD) identified two significant obstacles when providing effective treatment to a downed firefighter: 1) bunker gear and 2) inadequate information gathering and sharing. To address these issues, the CFD has developed a training program that  bridges the gap between fire suppression and rescue (FS&R) and EMS as they relate to the rescue and treatment of a downed firefighter. The training involved lectures and high-fidelity, hands-on training scenarios.

CFD background

The CFD is one of the oldest organized fire departments in the country. Its first fire company was formed in 1832, and like most departments of that era, it provided fire suppression and rescue (FS&R) services. Ambulances were introduced to the fire service in 1928 primarily to provide first aid to the working firefighters. Large-scale EMS was introduced to the public in 1945, when ambulances began responding city-wide to civilians’ medical emergencies. The service was commanded by returning WWII marine veteran Joseph McCarthy, a Medal of Honor recipient.  

The CFD continued to serve Chicago, with the general consensus that FS&R and EMS were one department, but they maintained separate bureaus. The bureau for EMS ambulances was staffed by two single-role paramedics who weren’t trained in firefighting, while suppression units were staffed with firefighters trained only in basic first aid. FS&R and EMS personnel were not necessarily dispatched together nor did they regularly train together. Prior to the late 1980s, ambulances were staffed with two paramedics and responded alone unless there was a special need for suppression units.

To improve patient care and to reduce EMS response times, the CFD implemented the Ambulance Assist program in 1985. As a result, FS&R companies were given the training and equipment to respond to EMS calls and were dispatched with ambulances. This program was enhanced in the 1990s as paramedics were hired and trained as firefighters to operate on advanced life support (ALS) fire companies as both firefighters and paramedics. These companies were capable of fighting fires and providing the highest level of medical care on the street. The CFD also created the Bureau of Operations, which includes both EMS and FS&R.

A matter of collaboration

Despite these steps to improve service, there remained divisions between FS&R and EMS, particularly in the area of training. There had been very little collaboration between the two groups, even though they were responding to an increasing number of calls together.

The first large-scale collaboration began in a 2012 training class called “Incident Command for Cardiac Arrest (ICCA).” ICCA emphasized each company member’s responsibility and accountability in treating a cardiac arrest victim. EMS and FS&R companies attended this training together. As survival rates in patients improved, instructors realized the value of this collaboration.

In late 2014, FS&R and EMS training instructors came together to discuss the medical treatment of a downed firefighter as it related to rapid-intervention team (RIT) operations. FS&R training instructors saw the need to refresh RIT skills while EMS training instructors saw an opportunity to improve the care delivered to downed firefighters. Instructors also felt that training together would have the greatest impact on the fire department by bringing continuity and cooperation to rescue and treatment.

This new collaborative training program began with several advantages supporting it, including:

• The RIT response structure was in place prior to implementing the program.
• A second ambulance, referred to as a “standby” ambulance in the CFD’s standard operating procedures (SOPs), is dispatched to every working fire along with a RIT ambulance. This policy was implemented when the department realized that the RIT ambulance was often used for civilian patients.
• All members involved in training had a general concept of the RIT’s functions, and all members were currently responding/acting in RIT roles.
• The RIT program is supported by policies and procedures and is a part of the CFD culture.
• The CFD, through grant monies, built a $2.2-million simulation training center. High-fidelity simulation mannequins enable instructors to provide an extremely life-like simulation of a downed firefighter.

The CFD RIT Task Force currently consists of the following EMS and FS&R companies, which are dispatched to every working structure fire:

• (1) RIT battalion chief
• (1) RIT paramedic field chief
• (1) RIT truck company
• (1) RIT ambulance
• (1) RIT ALS engine (high-rise fires only)

The class up close

The collaborative class was designed to take participants from dispatch to the scene of a fire, through the treatment and transport of a downed firefighter to the ER. Class content was derived from reports written by CFD crews that were involved with the department’s most recent line-of-duty deaths (LODDs) and close calls. Other content was derived from listening to tapes of radio transmissions involving downed firefighters from throughout the country and reviewing national reports on firefighter injuries and deaths.

In collaboration with the Illinois Fire Service Institute (IFSI), the CFD implemented its “RIT Revamp” in February of 2015. Three days a week, two trucks, two battalion chiefs, two ambulances and a paramedic field chief report to the Quinn Fire Academy for a six-hour class, with approximately three hours of hands-on training and simulation training. The first morning lecture covers a RIT response as established by CFD SOPs. For most, this is a refresher course that stresses the basics and the importance of preparedness. The lecture also begins to bring EMS and FS&R closer together by looking at communications between the two, clarifying responsibilities and examining capabilities and limitations. The lecture focuses on:

• Following policies and procedures
• Using correct terminology
• Being on the correct radio channels with a focus on mayday procedures
• Listening for company locations on scene and knowing their progress/status
• Ensuring the safety of the EMTs and paramedics who provide medical care
• Establishing cold zones on each side of the structure for gear removal and treatment of a downed firefighter
• Illustrating the need for multiple RIT teams on large structures or structures with poor access
• Understanding the unique problems of cold-weather operations.

The second lecture continues the process of bridging the gap between the two operational divisions. In developing this training, instructors could not possibly account for every variable that would lead to a firefighter becoming incapacitated and require the activation of the RIT. But by examining what caused past LODDs, instructors can focus on the most frequently seen etiologies. Instructors then divide the involved patients into general categories and share how to best minimize chaos and provide the most efficient and effective care.  

Communication is key

Instructors place much emphasis on improving communications between those involved in the rescue and those who care for the victim. Treatment of any patient is guided by the information obtained, and this process should be no different and is equally critical for the rescued firefighter. Based on information obtained, paramedics can make better care decisions. Information that must be passed along to awaiting paramedics includes:

• Smoke conditions present at the time of rescue
• Location and/or position of facemask
• Air supply status
• The member’s condition: Did they fall? Were they exposed to superheated air? Were they unconscious or lose consciousness during the rescue? Did they sustain a crush injury?
• Length of extrication (if applicable) and type of medical care given to the member
• Any other information regarding what happened to the member and how they were found

This information, when given accurately and in a timely manner, will direct EMS to proper gear removal, medical care and airway management.

The modern smoke environment

Instructors provide discussion on the modern smoke environment and the gasses that are produced, as well as the physiological effects these gasses can have on anyone exposed to them. Instructors also examine the three types of smoke inhalation injuries (thermal burns, chemical damage to trachea/bronchi and systemic poisoning) (Hostler, 2014). Knowing where and/or when the downed firefighter was found in relation to the fire can help an EMS team determine treatment. Instructors also stress the importance of watching one another for signs of strange behavior or delayed symptoms of inhalation injury.

LODD causes and treatment barriers

Next, instructors examine the most common causes for LODDs. NFPA reports indicate that since 1977, cardiac arrest has been the leading cause of LODDs (Fahy, LeBlanc, & Molis, 2014). Treating a downed firefighter in cardiac arrest from cardiac etiology is different than almost any other scenario.

Instructors feel that the most profound impact on the member’s outcome is determined by what’s done immediately on the fireground and by staying on scene until a pulse is regained. This belief is supported by NIOSH investigations into LODDs and data from Dr. Mickey Eisenberg in his book, Resuscitate. For every minute compressions are delayed in witnessed ventricular fibrillation arrests, chances for survival decreases by 7–10 percent (Eisenberg, 2009).

It was also determined that turnout gear and SCBA worn by firefighters can be significant barriers for EMS personnel. When interviewed, CFD personnel on the scene of a LODD and/or close call stated that one of their biggest challenges while attempting to provide care was removing bunker gear, particularly if the member was placed in the back of the ambulance while still wearing full turnout gear. So instructors ask the class how best to provide CPR to a firefighter who’s wearing full gear and suffering a cardiac arrest, and how should bunker gear be removed while the firefighter is being treated?

One solution was provided in a CPR video developed by the Leland, NC, Volunteer Fire/Rescue Department. The video demonstrated an excellent base for removing gear while performing compressions (Herbert, 2014). The best and quickest cuts are performed by two members working together, with one member cutting up one arm and halfway across the chest. This technique allows for members to remove the bunker coat quickly while immobilizing the victim (Alexander & Stephens, 2013). With some modifications and fine-tuning, members are now able to remove bunker gear in less than 30 seconds while performing chest compressions. A break in compressions is limited to only a couple seconds during the process.

Lastly, members practice how to remove superheated gear to prevent further burns or injury to a downed firefighter. It’s common knowledge that compression of superheated gear can cause burns to the member wearing it (Brown, 2008). Hands-on practice of proper cutting and removal techniques reinforce the skills and prepare the members for the afternoon scenarios.

In many instances, the fireground can be tumultuous at best. Add in a mayday response and a firefighter in cardiac arrest on the front lawn, and you have a scene that’s extremely stressful and highly emotional. These are ingredients for panic and confusion, both of which will hinder caring for the firefighter turned patient. Immediately beginning CPR as a team while removing turnout gear essentially brings immediate care and treatment to the cardiac arrest victim’s side. Best practices dictate that care be started as soon as possible for the firefighter in cardiac arrest if they are to have the best chance of survival.

Simulation training

In the afternoon portion of the class, students briefly split up to practice and focus on their specific roles. Firefighters review RIT skills and practice lifts, drags and carries out of a two-story drill house. Paramedics focus on medical treatment of injuries and illnesses most likely to be sustained by a downed firefighter.

The groups then reunite and work on two scenarios to close the day. Each mayday scenario involves a downed firefighter in a residential structure. The department has a structure that’s dedicated to RIT training called the “RIT House.” Trainees’ vision is obscured by smoke, and a downed firefighter is placed inside the structure for each scenario. One RIT team is dispatched to the scene as they would be on the streets, and a mayday is requested. A battalion chief serves as the incident commander and all communications are done face to face or over the radio as in a real incident. “Cold” zones are designated to provide medical care if needed. Once the mayday call is received, the RIT truck is deployed to find and retrieve the member. When the downed firefighter is located, the team extracts the member to the cold zone, and they perform their newly learned gear-removal technique while immediately and simultaneously starting CPR. After the turnout gear has been removed, the teams switch to a simulation mannequin where further medical treatment is performed.

These scenarios provide members with “virtual reality files” to store in their memory banks to be used if/when they are faced with a real-life event. The scenarios also reinforce the practical applications learned throughout the day and simulate, as closely as possible, situations in which a downed firefighter’s survival depends on best practices in rescue and treatment.  

After the simulation scenarios, all members gather for a debriefing where instructors provide after-action corrections and clarifications. Feedback is gathered from the crews on what they thought went well and which areas they feel need improvement.

Conclusion

Teamwork is vital to the success of any fire department or first responder. In order to ensure success and the best outcome for injured victims, or downed firefighters, we must train together. Interoperability between FS&R and EMS, or your local police department and other agencies, is key when faced with an operation that involves multiple agencies. Without good communication, collaboration and cooperation, it will be difficult to achieve a positive outcome. The CFD has begun addressing this issue by training together in various simulation scenarios and has seen an improvement in intradepartmental operations.

References

Alexander, J. G., & Stephens, C. T. (2013). How to assess and treat injured firefighters. Retrieved from http://www.emsworld.com/article/10934759/firefighter-injuries

Brown, P. (2008). Doffing superheated turnout gear. Retrieved from http://www.fireengineering.com/articles/2008/06/doffing-superheated-turnout-gear.html

Centers for Disease Control and Prevention. (2013). Airport fire fighter suffers sudden cardiac death while performing airport runway check – Alabama. Retrieved from http://www.cdc.gov/niosh/fire/reports/face201303.html

Eisenberg, M. (2009). Resuscitate! How your community can improve survival from sudden cardiac arrest. Seattle: University of Washington Press.

Fahy, R. F., LeBlanc, P. R., & Molis, J. L. (2014). Firefighter fatalities in the United States 2013. Retrieved from http://www.nfpa.org/newsandpublications/nfpa-journal/2014/july-august-2014/features/firefighter-fatalities

Herbert, M. (2014, October 11). Introduction to firefighter down: CPR. [Video file]. Retrieved from https://www.youtube.com/watch?v=SeNZnm_ayiA

Hostler, D. (2014). Treating smoke inhalation and airway burns. Retrieved from http://www.jems.com/articles/print/volume-39/issue-10/features/treating-smoke-inhalation-and-airway-bur.html