Decontamination Revised: Preparing for Decontamination

Preparing for Decontamination 

There has been an upswing in interest on the topic of emergency mass decontamination driven by the number of "drills" being planned for the summer months. So, for the responders and hospital staff that have called/written in, we've put together Decontamination Revisited; a three-part series that will encourage thinking and provide a unique perspective on healthcare preparedness. Contamination Differences will discuss a few basics on the types of contamination that my be encountered, Big Questions will tackle the question of who should actually "do" decon, and Preparing for Decontaminatio we'll provide a simple wrap-up on the topic. 


Another issue is the logistics of preparedness for decontamination. Tents and shelters must be trained on and practices with. They must be maintained and checked. Self contained breathing apparatus must also be maintained and personnel continually re-familiarized with its use. Other logistical items that are often forgotten are water supply, cleaning solution, lighting, towels, clothing and runoff management.

It is simply not enough for a health care facility to purchase a tent and believe they are prepared.

To wrap this up, let me leave you with a few take-home points:

• Emergency mass decontamination should be done on site of the event whenever possible
• Hospitals need to be prepared for self-referrals who may be contaminated and that self-referrals can pose a serious risk
• Traditional and non-traditional responders must be able to recognize the incident indicators of chemical/biological/radiological exposure
• Keep in mind that simply removing a victims outer clothing can remove 85 to 95% of contamination
• All victims being transported by ambulance must be decontaminated prior to transport regardless of triage score or severity

Decontamination Revisited: Big Questions

Big Questions

There has been an upswing in interest on the topic of emergency mass decontamination driven by the number of "drills" being planned for the summer months. So, for the responders and hospital staff that have called/written in, we've put together Decontamination Revisited; a three-part series that will encourage thinking and provide a unique perspective on healthcare preparedness. Contamination Differences will discuss a few basics on the types of contamination that my be encountered, Big Questions will tackle the question of who should actually "do" decon, and in part three we'll provide a simple wrap-up on the topic. 


The big question is; who should do decon? At an emergency scene the issue is clear that the jurisdiction having authority in a chem/bio/rad event (most often the fire department) should provide or cause to provide decontamination. The use of low pressure, high volume water streams and improvised shelters may be used in emergency mass decontamination, while specially trained hazardous materials teams may provide a more refined and specific decontamination. The problems begin to arise when victims begin to self-refer to emergency departments or clinics... that is they leave the scene prior to the arrival of traditional responders. This poses a major issue as these victims will likely arrive a health care sites with no warning and no clue as to what they may have been exposed to or contaminated with. When this occurs and goes unrecognized, the health care facility, civilians, and health care providers are at risk. Immediate action will be needed to stave off secondary contamination and serious impact.

The bigger question is; who should do decontamination at a health care facility? This argument has been going on for years and opinions are highly polarized. One opinion often held by health care organizations is that the local responders will not be able to provide decon services at a hospital during such a large event. This camp believes that hospitals must be able to provide decontamination on their own for a period of time. Still others believe that traditional responders will be able to provide protective services to health care sites by way of mutual-aid from surrounding departments. Both points have concerns.

How do we expect health care providers, security staff, environmental staff, or others to provide decontamination at a health care site? 

This is often the pool of personnel that is called upon to take training and carry out the functions if needed. The concerns however, loom large. Who will carry out the duties of those assigned to decon? Will the people mentioned above be able to retain the training information and function in protective clothing, including self-contained breathing apparatus? These issues are just the tip of the iceberg.

While many hospitals in the nation have added some type of decontamination shelter or system to meet requirements most (if not all) walk-in care, urgent care and retail health care centers lack this level of preparedness. 

As more and more people turn to these clinics rather than emergency departments for routine care, we must realize that the same level of preparedness must exist for these locations. In the non-hospital clinic setting the need for trained traditional responders doing decon operations is even more vital.


Next: The logistical reality...wrap-up.

MJ 211: Paramedic Ultrasound

Click for MJ Podcast 211

This week on the podcast we move towards innovation and EMS technology...we're talking about Paramedic use of Ultrasound. This is part-one of a two-part series.

Joining Matt and I this week is Peter Bonadonna, CI/C, EMTP.  Mr. Bonadonna has conducted considerable research on ultrasound use in the pre-hospital environment and is considered a local expert on the topic.

In this session we'll review the goals of ultrasound use, diagnostic ultrasound, training programs, and changes to paramedic practice and delivery of care.

This is an outstanding technology that will enhance the ability of Paramedics to assess and prepare to treat a variety of patients. The goal of this series on Mitigation Journal will prepare you for the challenge. We've added a tab on Mitigationjournal.org for Paramedic Ultrasound that will provide you with background infromation, tutorials, links, and study materials. You can also contact Peter Bonadonna directly (www.paramedicultrasound.com) and request additional materials, information, and in-person training.

What to see more? Check out the Training Videos tab on Mitigation Journal...we've posted a narrated video of an actual ultrasound exam...you'll see how easy it can be!

Decontamination Revisited: Contamination Differences

Contamination Differences


There has been an upswing in interest on the topic of emergency mass decontamination driven by the number of "drills" being planned for the summer months. So, for the responders and hospital staff that have called/written in, we've put together Decontamination Revisited; a three-part series that will encourage thinking and provide a unique perspective on healthcare preparedness. Contamination Differences will discuss a few basics on the types of contamination that my be encountered, Big Questions will tackle the question of who should actually "do" decon, and in part three we'll provide a simple wrap-up on the topic.

There have been several instances over the last many years that highlight the need for emergency decontamination at health care facilities. People contaminated with a hazardous material showing up at random to emergency departments or other health care locations poses untold risks to the health care provider, the facility, other patients, and the community. Events at walk-in/urgent care clinics and increasing Consumer-Level Hazardous Materials incidents have underscored these risks. With the number of walk-in care, urgent care and retail health clinics growing, the issue of emergency decontamination needs to be revisited. Let's face it; even routine events have the potential for turning into a contaminated situation for responders and patients. We've seen local situations involving the intentional use of chemicals in violent civilian attacks. Chemical assisted suicide and homemade chemical bombs increase the threat level to responders, healthcare facilities, and civilians.


Lets start with the understanding that there is a difference between chemical, biological, and radiological contamination.

Chemicals and radiological material is perhaps the most concerning as the longer the material remains in contact with the person, the greater the exposure and subsequent effects will be. Also, if externally contaminated the person may be able to "off gas" or spread the contamination. With chemical materials off-gassing can cause serious inhalation and mucous membrane irritation and secondary contamination in other people. The facility can likewise become contaminated.

The spread of radiological contamination has a higher risk of secondary contamination...although the onset of effects will most likely be delayed...and the possibility for occult contamination and extended cleanup measures will be needed. For more on radiological contamination visit the Radiation Emergency Medical Management site, the Radiation Treatment Network or Biological Effects of Radiation Part#1, Part#2, Part#3 and summary (contains references used) in Mitigation Journal.

Biological contamination can take the form of a person ill with a disease (flu) or the presence of disease containing solid material...like anthrax in a powder. We should point out here that a difference exists between exposure, contamination and reasonable risk. Exposure simply means you've come in contact with something and may or may not suffer from it.

When we talk about exposure we usually are not overly concerned with decontamination unless visible product remains on the person or clothing. Contamination commonly indicates that a residue or material remains on the victim and that material is able to be spread. Contamination comes in two forms...external - able to be spread and internal - not able to be spread. A person who ingests a radiological source most likely would not be capable of spreading that contamination nor would a victim exposed to vapor or gases unless the vapors permiated the clothing.

The point is that once a material is inside the body the risk of secondary contamination is much less as is the need for decontamination. Reasonable risk exists when a person has been in an area and, with or without symptoms, is anticipated to have been exposed or contaminated...prophylactic decontamination is warranted.

Next: Decontamination Revisited: Big Questions. 

Kill Smallpox Now

Eradicated from nature, we continue to defend this deadly virus.

Imagine if there were only two nuclear weapons left on earth. You have one, I have one. All the other nuclear bombs and missiles have long since been dismantled, destroyed...eradicated. Can you picture the scene? Just two bombs away from being nuclear weapons free.

While you and I could easily dismantle the last two remaining bombs and rid the planet of the threat, we don't. Instead you and I claim that more study must be done. There's more to learn about nuclear bombs we say.

Now imagine that the threat is not the last two remaining nuclear weapons, but the last two remaining stockpiles of a virus so lethal that, if it should escape its container, could devastate the human race.

It's in our hands to remove the threat...and we're not going to do it. It seems that Smallpox is getting a stay of execution. Again.

Since 1986 the Wold Health Organization (WHO) has been arguing about the destruction of the last two remaining stockpiles of Smallpox, otherwise known as variola. Destruction of these virus reserves would mean the removal of the treat of this virus on our planet. The decision to destroy the remaining samples has been pushed back for further discussion until 2014. A target date for destruction set for 2016.

Smallpox exists today at the CDC in the United States (frozen in nitrogen and under heavy guard) and in Russia (under similar circumstances, we hope).  They're safe. They're secure. That's what the Japanese thought about their nuclear power plants before an Earthquake of historical magnitude redefined disaster.

Smallpox could easily redefine disaster for Planet Earth...

"What would happen if an Earthquake or other natural disaster of historic proportion struck the CDC in Atlanta? How safe would those Smallpox samples be?"

Smallpox has been around for over 3,000 years and was removed from nature by the efforts of science and vaccination. Today, it is that same claim of science that is keeping the stockpiles in the United States and Russia from being destroyed. The claim is that we have more research to do. See Biological Events: Smallpox (Mitigation Journal, Dec. 15, 2010). You can hear my commentary on Mitigation Journal Podcast #191 Smallpox get stay of execution.

I'm not buying it.

We've been researching Smallpox for over forty-years. The virus has 49 identified strains, the genome is known, and we have a vaccine developed. What more study do we need to do? The United States and Russia claim that we need  more research to build new antivirals, create new vaccine. Create new vaccine by 20114? We can't keep routine medications in stock today! What makes you think we'll come up with a new Smallpox vaccine?

How much more are we going to learn about Smallpox between now and 2014?

We have all the data we need.

The Smallpox virus has been responsible for an estimated 3.5 million deaths in the 20th centurry. The death rate from the virus is about 30% (depending on the form) and surviving the pain of having Smallpox means permanent disfigurement. In today's terms, the deaths would be even greater because of the vulnerability of our society and the greater number of people living with compromised immune systems or co-morbid conditions. Worse still, we're a society of anxiety, not preparedness.

We humans have no protection from this virus. In the United States, we discontinued routine vaccination against Smallpox in the late 1970's. Those who were vaccinated may have little protection against the virus today. Those not vaccinated have no protection. In my Maintaining a Culture of Preparedness program, I tell people that one case of Smallpox (anywhere on the planet) is a global health emergency. I usually tell attendees that after I've asked: where do we see smallpox today?...the answer, by the way, is usually given as some third-world country. As responders, we still have a lot of learning to do about this virus and the potential impact. While there are many diseases that give us a concerning rash, none are more deadly than Smallpox.


Destroy the Smallpox virus. The threat is not terrorism...it is our own complacency. Destroy the threat.

Not a current thinker and proud

I've never responded to a statistic.

I've never been called to help a recent study get up off the floor.

I've never been there to calm the family of dying data.

I respond the needs of my community, the needs of people. And so should you. 

Apparently, I'm not a current thinker in emergency medical services. I was told that recently. I was also told that paramedics of my generation aren't relevant because we don't see the bigger EMS picture. We're not in tune with the what is happening in the big cities...what the real EMS systems are doing.

That's crap.

In recent conversation the topic has come up again and again about how large multi-center..."studies show"..."data indicates"..."statistics prove"...the list goes on. What so called current thinkers in EMS are saying when they use these terms is that we would rather let other people think for us rather than think for ourselves.

Don't get me wrong; studies, data, and statistics are important information for us in public service if the information is used correctly. In my opinion, correctly is defined as taking the information presented and applying a healthy dose of critical thinking to it. Decide what (if any) of it actually applies to your location.

Studies done in big cities or multi-center research is great...great for the area that conducted the study.

But we're not here to meet the needs of a "study". We're here to meet the needs of our communities. Only the people who serve that community, those who truly know that community are in a position to decide how to best serve it and meet its needs.

Applying the results of a big city study to your hometown blindly without critical thinking forces your service into a cookie cutter formation that just might not meet the needs of your community.

I found it on the internet...so, it must be true. I read about it in a big city study...so, we'll be cool if we do it too.

Have we gotten lazy de-evolved to the point where we want others to think for us? To tell us what is best for our community? I think so. But, then again, I'm not a current thinker in EMS.

Not a current thinker and proud.

I'd rather read the 'data' and consider the use and impact to my community, to my personnel, to my region before implementing unrealistic changes.

So, go on and implement change based on what works well for Dallas, L.A., D.C., NYC. Chances are you current thinkers won't notice anyway. They've stopped thinking.

Homeland Security: a failed model for preparedness

Its a war on terrorism...the real war is against complacency.

(I can hear the black helicopters over my house already)

Homeland Security...that's the name of the game. The objective of the game is security. Thus, a majority of funding dollars have been dedicated to law enforcement-type agencies; from CIA and FBI to your local police department. All in the name of security. To a lesser degree, Homeland Security dollars have been allocated to other places; CDC, Public Health, USFA and FEMA.

How's it working for us?

I've been critical of the term Homeland Security. I've been critical of the term because "security" implies people with guns, badges, and secret surveillance are needed to make us safe. I've been critical of the logic that makes law enforcement the top recipient of funding at the expense of other public services...EMS, for example. To be fair, I also think the much of the funding and grants that have gone to the fire service in the name of Homeland Security have been poorly allocated if not wasted. Where has Homeland Security improved our response to natural disasters - Katina or more recent floods and hurricanes?

I've been criticized for my views. Recent reports, however, are indicating that I might just be onto something.

One such report indicates that our National intelligence agencies are no better prepared for counter-terrorism than they were on 9/10/01. Other reports indicate that the growing threat of Homegrown Terrorism domestic terrorism is not able to be managed appropriately under the current counter-terrorism structure of the CIA, FBI, or the Department of Homeland Security.

The McKinsey report on the operations of FDNY and NYPD note that incident command, communications and interoperability were lacking during the 9/11/01 attacks. Keep in mind that the shortcomings were not soely related to communication but to organizational structure as well. NIMS, anyone? While FDNY and NYPD are the cited examples...the same shortfalls continue to exist today at the local level. Yes, I realize some areas have tackled these issues better than others; yet, the point remains that little progress has been made after nearly ten years under the Homeland Security  model. Sure we have the Patriot Act, "See Something, Say Something" and, of course the TSA with their pat downs and body scans...but to what success? Our Homeland Security approach didn't do much for our Public Health ability to deal with a naturally occurring biological events...Swine Flu, anyone? Or, how about that fantastic color-coded threat level?

Again, how's all that working?

My solution - Change the name...and change the way of thinking...get rid of Homeland Security and go back to what worked...civil preparedness with an eye toward the all-hazards approach! Civil Preparedness embodies readiness for more than terrorism. Then get the funding (by the way, funding for preparedness is drying up every day) to the local responders who can put it to use for all-hazards - naturally occurring as well as intentional.  Under my view of Civil Preparedness,  training and funding for civilian (individual families, communities) would take a much larger role. And I'm not talking about just another Ready.Gov style approach - I mean actively engaging civilians and communities to be better prepared and as self sufficient as possible. I believe that approach alone will improve local and state responses to natural and intentional events.

Homeland Security...how's it working for you? Isn't time to try a new old approach to preparedness?

MJ 210: Public Service Lay-Offs Part Two

Click image for download

Public Service Lay-Offs: Impact on Domestic Preparedness Part Two

Join Mitigation Journal co-host Matt Comer, special guest Alan Bubel, and me as we tackle the ramifications of public service lay-offs and the impact to local preparedness. In part one, Alan and Matt investigated the ramifications from the fire and EMS perspective (MJ Podcast #209 release date 5/30/11).

In part two, I'll examine the larger picture of local preparedness and we'll pull it all together under the All-Hazards approach in MJ Podcast #210 (release date 6/13/11).

School Security goes in wrong direction: Part Three

School Security goes in wrong direction: Part Three. From Mitigation Journal Podcast.

Click for full audio podcast

The background story can be found here. Several years ago there was a movement to remove decrease the amount of security in public schools. In December, 2006, Mitigation Journal told you about research that indicated school security may actually be doing more harm than good. See School Security Should Go Over the Top (Mitigation Journal 12/06).

We continue to support our position that schools, hospitals, shopping malls and similar locations are soft targets. These soft target locations can also be locations of critical infrastructure and need to be protected. The problem in this situation seems to be that the planning and delivery of the training scenario.

The video from segment 1 and segment 2 of this topic can be found on mitigationjournal.org from our recording of Mitigation Journal #208.

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Pharmaceutical Shortage

Running out of medications? No pharmaceutical tracking or early waring system in place?

How can we be running out of medication used to treat everyting from cancer to medical emergencies? After 9/11, Anthrax, SARS, and more recently, Swine Flu (H1N1)...how is this possible?
Even more perturbing is the revelation that no early warning system is in place to alert the medical community to an impending shortage?

After nearly ten-years of preparedness, billions trillions  a lot of money spent on biological preparedness under Homeland Security we have found (or just awoke to notice) a major hole in our defenses. I must admit that I believed (wrongly) that there was a system in place to detect shortages in raw materials or production. Then again, I must have been blind to it...I remember getting notices from our local EMS system informing us that shortages of epinephrine had occurred almost overnight. I never related the situation to the large picture of Homeland Security Domestic Preparedness. Then again, our obvious inability to ramp-up flu vaccine production should have been a warning, too.

Its one thing to run out of a medication (or any other resource)...its quite another issue to not see it coming. According to media reports, hospitals are postponing or cancelling surgery and delaying cancer treatments due to the lack of medications.

Pharmaceutical shortfalls have been looming for several years. There seems to be several theories as to why, but no firm explanations. With no definition of the problem or cause it seems unlikely that a solution will be found anytime soon. According to 13WHAM (Rochester, NY):

"U.S. Senator Chuck Schumer says the shortages are unacceptable. He is backing legislation that would direct the Food and Drug Administration to give hospitals and pharmacies early warning when there are shortages of certain drugs. He says that would give them more time to find alternative medications."

Legislation (FDA) will not fix this problem. After all the Bioterrorism security preparedness time and money, after all the NIMS training, and after we've been encouraged to "See Something? Say Something" or disrobed, prodded, and felt by the TSA, we have no ability to predict/preempt medication shortages...of medication the health care community uses every day. Imagine what life will be like when some disease gets out of control...naturally or intentionally.

Inhalation Anthrax, for example; can be treated with common antibiotics...if you can get them...but what if antibiotics were in short supply? We've already seen how the media, and by result, the public, response to shortages of medications...real or imagined. For a good reminder about how the public reacts when expectations are not met, review this post from May, 2009. The good news is inhalational Anthrax is not transmitted person-to-person. What if another biological agent (naturally occurring or intentional) like Smallpox? Perhaps a novel Type A Influenza and no vaccine production ability would be another good example.

Would we be able to rely on non-pharmaceutical interventions to prevent the spread of disease? How long would it take to recognize a biological event was unfolding?


We've learned nothing from our experiences with SARS and flu. What will we learn from this little bit of awakening? Will we take some action to prepare ourselves despite the pharm/government failures or hit the snooze alarm...I'll bet most people will remain blind to the fact that  pharmaceutical shortages and lack of an early warning system has a major impact on Domestic Preparedness.

MCC Nursing Class, May, 2011

MCC Nursing Class of May, 2011

Here is a brief video (as taken by my son) during our Nursing Pinning Ceremony on June 2, 2011. The program was about two-hours in length...the video is just over 11 minutes. I obviously had to edit.

Congratulations to everyone!





This video will be co-posted on The Occasional Vagabond.

Go ahead, cut the fire department budget

...But be ready to not get what you need

"Firefighters watch man drown"

"Police and firefighters let man die"

Those are just a couple of the headlines in the mainstream media in response to a recent drowning in Alameda California.

Apparently a 52-year-old man had decided to commit suicide by walking into deep water. The area in which he did so was too shallow for the local Coast Guard to access by boat and the Coast Guard helicopter stationed there was on another mission.

The story by CNN here.
The story by MSNBC here.

Police and fire responders watched the man treading water for nearly an hour according to reports, without taking any action. Eventually, the man did drown and his body was recovered by a civilian swimmer.

This event has generated public outcry and media scrutiny of the actions of the fire department.  The focus of this attention is on the fact that the fire department is ill-prepared to conduct a water rescue. In fact, firefighters are under direct order not to enter the water. An order that resulted from cutting the budget of local emergency responders.

This is also a prime example of one of my biggest concerns -

Decreased local responder preparedness resulting from budget cuts. Emergency service budget cuts and lay-offs of emergency responders are the topic of a two-part series on Mitigation Journal Podcast. You can listen part one now (free) on MJ Podcast #209 here, part two now also available on Mitigation Journal Podcast.

It seems inconceivable that a fire department serving a “beach community” would be unprepared for water events and rescue. The cause of situation however, rests in budget cuts. Two years ago the fire departments budget was cut as was their water rescue program. These cuts resulted in their boat being put in dry dock and trained water rescue personnel being ordered not to enter the water for rescues or training.

That was two years ago. And no one in this “beach community” has taken notice...until now...until something happened...

According to mainstream media sources the budgetary cutting water rescue services to this "beach community" amounted to between 20,000 and $40,000 in savings.

While the mainstream media and the public assaults the fire department for their lack of preparedness in water rescue, I would politely ask a few questions…

Who cut the budget? Further, who decided that the water rescue component in this fire department should be the victim of that budget cut?

Who decided that a fire department serving this “beach community” should deem their water rescue program surplus.

Why didn't anyone in the community speak up two years ago when their fire departments budget was being cut. I'm sure when the budget proposals were being voted on and approved that many people thought cutting the fire department's budget was a good idea at the time. Now it seems that this community is seeing firsthand the results of public service cuts in the impact on local preparedness.

Reports in the mainstream media also display the outcry from the citizen population; all wanting to know “why didn't they do something?” Let's look at it this way; what would the response had been if this suicidal person have been standing atop a building or on the edge of a bridge? Would we expect firefighters or police officers to rush up and grab that person? In those types of situations some level of negotiation and communication takes place. Rushing up to grab a person standing on a bridge or in the edge of a building is likely to result in tragedy. Likewise, sending firefighters without proper equipment or training into open water to effect a rescue of a suicidal person could likely end with the death of the responders as well as the suicidal person.

There are certainly times when E. M. S. personnel, firefighters, and law enforcement officers have to take action that is dangerous. That's part of the job. And this is not the first time we've heard emergency responders criticized for not taking action. Let's look at a few other cases…

In January 1982,  Air Florida flight 90 crashed into the Potomac River. Fire and EMS personnel were ill-equipped to affect rescue in the icy water. In fact, civilians were the only ones to make attempts at water rescue. Other survivors were rescued by helicopter.

In January, 2008, Manatee EMS staff was criticized for not attempting a water rescue of two men who had driven into a retention pond. (Manatee EMS staff training criticized, MJ Blog 1/2008)

In May, 2006 two paramedics in British Columbia, Canada died while attempting to rescue of a man in a mine shaft. These responders entered an oxygen deficient, hydrogen sulfide contaminated atmosphere without respiratory protection. (Play Your Position, Please, MJ Blog 5/2008)

 These cases illustrate the difficult decisions that we often take for granted  in emergency response. The difference between these cases in the situation in Alameda, California, is this…

• in Alameda, the fire department has trained personnel and had a water rescue program that apparently met the needs of the community prior to budget cuts…
• in Alameda, someone (either from in or outside of the fire department) decided that cutting the water rescue program was appropriate…
• an Alameda, the public was either unaware or unconcerned that this “beach community” would be without a functional water rescue program as a result of these budget cuts…

This situation in Alameda, California, should give the public, politicians, responders, and agency leaders a moment of pause to reflect on what happens to your community when you cut local emergency responder budgets.

4 Points that will make Emergency Incident Rehabilitation Functional

 Last week we talked about using the acronym LEVEL to successfully establish and plan for Emergency Incident Rehabilitation (EIR). We've also talked about LOCATE as a means to assessing the situation (LEVEL blog entry or LEVEL podcast). Now lets put it together...

 In this post will talk about my four critical points of making EIR  functional. Gathering the materials and  personnel needed to establish emergency incident rehabilitation is only part of the battle. To be functional,  EIR must become part of the greater planning process.

The four critical points to functional emergency incident rehabilitation are:

#1. Preplanning and Incident Cction Planning:

• Make EIR  part of the pre-planning process.  Including EIR  into the pre-incident plans of any jurisdiction (and sharing that information) will make the establishment of EIR  much smoother. Plan for the site specific needs; access/egress/staging, EIR locations for various conditions, as well as traffic flow from the actual event to the EIR. 
• Make EIR part of the Incident Action Plan. Include EIR as part of each IAP and consider its use at any event when IAPs are developed. Including EIR in the IAP will provide a much needed memory jog for officers. Being part of the IAP will also ensure that the EIR is included operational period plans and meet the need for staffing the EIR through various operational periods.
• Include changes in weather conditions. The EIR staff must be aware of predicted changes in the weather. Temperature changes, precipitation and storms will impact all dynamics on the scene. Weather changes may also cause relocation of the EIR or the need for shelter. 

#2. Make a Commitment to EIR.

• The first commitment to Functional Emergency Incident Rehab is to overcome the myth that surround EIR.
• Make EIR part of your training activities and practice it during training evolutions. Doing so will help make Functional Emergency Incident Rehabilitation more of an automatic, accepted practice.
• Make EIR a priority. Just like the Incident Safety Officer, EIR is often left as an afterthought in the command process. This simply cannot continue. The ISO and EIR are critical to the safety and survival of all responders on the scene. EIR cannot be left up to the last person to show up or simply be delegated to an untrained EMS crew while they stand-by at the scene.

#3. Accountability and Incident Safety Officer

• The practice of assigning an incident safety officer by default shortchanges the members working at an incident and deprives the incident commander of an invaluable resource and places the EIR at significant disadvantage. The ISO should be the interface between the EIR and the incident commander. 
• Accountability systems must be maintained for everyone...including personnel at the EIR and those staffing the EIR. Remember, accountability is for everyone on the scene. 
• Maintain Unit Integrity and eliminate freelancing. Units should report to EIR intact and the order to report to EIR must be followed. Freelancing has no place on the emergency scene...including at EIR.

#5. Make EIR an "All Day" event.

• Keep in mind that your off duty activity/actions/habits dictate you on duty performance. 
• Rehab success will be based on how well personnel are ready for duty (ie: physically fit).
• Responders should understand that their food and fluid choices throughout the day will impact their response to rehab.