High Performance CPR

Richmond Rescue recently joined four other services in Vermont to pilot a new initiative called High Performance CPR. This program has been developed in other parts of the country and has been shown to improve outcomes when CPR is performed. Nothing in the program is particularly high tech or revolutionary. It goes back to the basics and coordinates the efforts of all the responders.

First, the basics.

• Compress the chest 100 to 120 times per minute. Too fast is bad. Too slow is bad. 
• Compress the chest at least 2". 
• Allow the chest to fully recoil after each compression. Without full recoil, blood does not circulate to the heart itself even if the rest of the body is well perfused. 
• Minimize interruptions. You should be doing compressions at least 80% of the time. 

The video below goes into great detail about why the four items listed above are so important. If you have 15 minutes it is well worth watching.

You'll notice that ventilations are hardly mentioned. It turns out that quality compressions will make a greater difference in outcome than ventilations. Often, ventilations take away from the time we are doing compressions and don't greatly improve outcomes. As always, follow your local protocols regarding how CPR is performed.

Historically, Richmond Rescue averages about three cardiac arrests per year. This past year has been much busier than we expected. Below is a breakdown of our cardiac arrest calls from the past year. We have seen 25% of our cardiac arrest patients survive to hospital discharge with no deficits. Is High Performance CPR working? The State will be studying this in more detail and will hopefully be able to give us an answer when they use a larger data set.

A few notes on the chart:

• Most traumatic cardiac arrest victims are not going to be saved by CPR. They need a surgeon immediately. Being 25 minutes from the hospital, as we are in Richmond, generally leads to poor outcomes in traumatic arrests.
• ROSC is an acronym for Return Of Spontaneous Circulation. If ROSC is not achieved during CPR it often means that the patient went without CPR for too many minutes before we arrived. It could also be that the cause of the cardiac arrest was such a grave problem that it could not be corrected in the field, such as a pulmonary embolism, stroke or massive heart attack.

The High Performance CPR program has also improved our attitude going into a cardiac arrest call. We all fully believe that we can save the victim using what we have learned. So far it seems to be working. We are looking forward to this program being rolled out to the rest of Vermont in the next year and are interested to see the effect on patient outcomes.

Helmet Save

Earlier this week Richmond Rescue responded to the call we all dread; "Richmond Rescue respond to car vs. bicycle. Nine year old on the ground". On the way to the call we discussed some of the possibilities of injuries and came up with plans on how to treat them. When we arrived on scene our patient was surrounded by many neighbors and we feared the worst. After walking over to her we found her looking up at us with no obvious injuries. Our initially assessment found nothing significant and we relocated to the ambulance to get the whole story and have a quieter place to talk.

Our patient was out riding on the road and lost control of her bike. The approaching car realized that something was wrong and was quickly slowing down. The two of them collided at a low speed and the biker was thrown to the ground. She hit her head on the pavement but wasn't complaining of any head pain due to the helmet. Upon looking at the helmet we found a big dent in the back.  We also found a small scrape on an elbow that wasn't even band-aid worthy.

The interesting part of this story for us is that she obtained her bike helmet at Richmond Rescue's biennial bike helmet giveaway. Over the course of this program we have given away more than 250 bike helmets and provided trained EMTs to make sure the helmet was adjusted to the rider's head.                     

We are committed to not only providing treatment for people that are sick or injured, we also have a number of programs designed to prevent injury and make our response more timely in the event of an emergency. The programs include free car seat fittings, E911 address signs, the File of Life program and many educational programs at the local schools.

Make sure to look for us in the spring for our fourth bike helmet give away.

Thanks to our patient's mother for allowing us to use the photo. 

Mutual Aid

About 40 times a year a second call for assistance comes in while we are already tied up with another emergency. About 30% of the time we are able to get a second ambulance crew together with volunteers in the community and you will not even notice that we are busy. The other 70% of the time you will be getting a ride from one of our neighboring services.

When a second call for assistance goes out, 90% of the time you'll still get one of our members responding to the scene to provide initial assessment and stabilization. After a short wait, an ambulance will arrive and you'll be on your way to the hospital.

Which back-up ambulance is the best one for your location? We spend a lot of time poring over maps and data to determine which ambulance can reach you most quickly in case we are out. Each year we take some time to reevaluate our choices to make sure it still makes sense. Here is a piece of the current back up matrix. Each dispatch center refers to this when they need a 2nd (or 7th) ambulance.

You can also see that we provide mutual aid to surrounding communities. Most often we end up in Hinesburg, northern Jericho or Williston. Occasionally we end up in a far off land such as Shelburne and have to consult our map book. Last year we provided mutual aid 52 times and received mutual aid 18 times.

We are fortunate to be surrounded by a number of great ambulance services. Whether you end up with an ambulance from Williston, Essex, UVM or St. Mikes you'll be in good hands.

Don't Be Part of the 1%

Where are we?

Finding an emergency can be a bit like playing the lottery. Sometimes everything goes perfectly and we find the house without any trouble. Other days we are just baffled. There is a long list of things that can go wrong:

• The house/mailbox has no markings
• The mailbox number is covered with snow
• The mailbox is missing a number
• The mailbox is marked only on the end and not the sides
• The mailbox number is unreadable
• The mailbox only has a last name listed on it
• We drove past the house (see above) and the next neighbor isn't for half a mile
• A panicked caller gave the wrong address
• It raining/snowing/sleeting/ooblecking and we missed the marking
• We were dispatched to the wrong town. Did you know that there is a Mountain View Rd/Dr in Richmond, Jericho, Bolton and Williston?

We realized that we had a problem since we started tracking this problem back in April. Fifteen percent of the time our response was delayed due to a poorly marked address. Often we had first responders that went through the trouble of locating an address prior to arrival so that number may be even higher. The 1% of calls that had a big delay (>5 minutes) could actually make a difference in a patient's outcome if they were presenting with a serious problem.

We decided we wanted to offer reflective, green, 911 address signs. Although this is not a new concept we wanted to make this the easiest process anyone could imagine and make cost a non-issue for anyone that wanted a sign. 

We were fortunate that the Ketover family of Richmond wanted to fund a project that would have an impact on the community. One stipulation of their donation is that signs should be free for participants in Medicaid, WIC and Dr. Dynasaur. Now that a funding source was available we just needed to figure out how to keep costs down.

Mike mounts a sign in Richmond

We purchased sign blanks with high intensity prismatic sheeting and reflective numbers in bulk quantities so we could realize some cost savings. Next we implemented online ordering (google forms) and payment (Paypal). We also offered free mounting to wooden mailbox posts for anyone that has a power tool deficiency. 

Much better

So far we've sold 27 signs (5 were given away for free) with very little marketing effort. We are slowing down our marketing operation because we ran out of 2s much faster than any other number but we should be fully operational again in early January.

For anyone that would like to order you can go to our online order form. Our supply of 2s should be replenished by early January and we'll take care of our backlog of 2 containing addresses.

Please remember that no sign lasts forever. Even well made signs generally only have a life of 7-10 years. Take a look at your mailbox today and order a sign if it isn't well marked. If you have any questions or have a challenging marking situation get in touch with me and we can work out a solution.

Have You Ever Seen a Dead Body?

When people find out I work as an EMT one of the first questions that comes up is: Have you ever seen a dead body? The answer is yes. It only took a few months of working in EMS to see a dead body. It was definitely an uncomfortable feeling the first time I encountered it. It was an elderly gentleman that died at home in his kitchen. One of his neighbors found him and called for an ambulance. In this case he was already in rigor mortis which generally occurs about 3-4 hours after death. There wasn't much we could do other than to secure the scene for the police and the medical examiner.

Since then I've seen probably 20 to 25 deaths. Some are peaceful and others are traumatic. Each one is different and brings its own set of challenges. The most common scenario we see is a call in the morning for someone that didn't wake up. These are known as "untimely's" in the EMS world. Really though, they are anything but untimely. Typically they are elderly people with a host of medical conditions and it should come as no great surprise that they died. While sad for family and friends I think most of us would prefer to die in our sleep.

Traumatic deaths are a whole different story. They typically occur in car and motorcycle accidents and take people that are younger. Many of them are not wearing seat belts or driving aggressively while others are minding their own business and doing everything right.

By this point I've learned that death is unavoidable. We will all end up there one way or another. We can avoid risky behavior and decrease our chances of a traumatic death. We can exercise and eat well to avoid obesity and heart disease. Sometimes we're stuck with bad genetics and we just have to deal with what we're dealt.

When the time comes we can usually make some choices in how we want to go. There are DNRs, DNIs, living wills, palliative care, organ donation and many other options. The most important thing to do is have a discussion with your family about what you want before and after your death. With a little planning the end of life can be less chaotic and your family can focus on spending their time with you rather than trying to figure out your last wishes.

Can You See Us Now?

Old ambulance markings

A few years ago we made a radical departure from how our ambulances were marked. We realized we were doing a number of things wrong and not maximizing our visibility while operating on the roadways. One of our members did a ton of research and figured out what we could do to make ourselves more visible. This required a huge departure from our current color scheme and took a little while to get everyone to buy in.

The new markings

Color
The first big change was moving from maroon to a yellow and blue color combination. The fluorescent yellow color is highly visible both day and night. The decals are also made with a retro reflective material meaning that they reflect light back to the driver.

Contour stripes

Contours
The entire ambulance is outlined in a retro reflective stripe. Being white it is hard to see during the day but at night it makes it obvious that a driver is approaching an ambulance.




Chevrons

Chevron

Chevron are the inverted V pattern found on the back of emergency vehicles. The idea is that they draw a drivers attention toward the vehicle because it is so unique. Some of the key points to designing an effective chevron are:

• Make each line at least 6" wide. Any less and it makes for odd optical illusions.
• Select contrasting colors: blue & yellow, red & yellow, red & white, blue & white and green & white are recommended.
• Cover only about 50% of the rear of the truck. 100% becomes distracting and costs more.
• Chevrons should only be on the rear of a vehicle otherwise it causes confusion

We've been quite happy with our ambulance design and plan to hold on to it for a long time. In doing this research it is surprising how many ambulances are designed for good looks rather than visibility. If you want to learn more you can check out this FEMA publication.

How to Buy an Ambulance

Purchasing an ambulance is quite an involved process that takes about 9 months from start to finish. Right after the holidays we began working on a list of specifications that we thought were important and began taking a broad look at what was available. After a month we settled on a few companies and had them come out with their vehicles.

We figured out pretty fast that most new, well built ambulances aren't that different. Each has a few features that stand out but in the end it would be hard to go wrong with any of them. A more challenging question for us was which chassis do we put it on. We were unhappy with our current Ford E450 and were  looking for something different. We had our choice of Chevrolet and Dodge.

After much deliberation we decided to mount our new truck on a Chevy C4500 chassis. That information was sent off to two ambulance manufacturers and they came back with quotes a couple weeks later. After more deliberation we decided on a Braun Super Chief XL on a Chevy C4500 chassis.

Then the waiting began. Six months of production and some fine tuning of the design led us to the recent delivery our new truck. Once the truck arrived at our station we still needed to figure out where all the equipment will be located, radios needed to be installed, graphics needed to be applied and drivers needed to be trained. All this took another month and countless hours of work.

We are thrilled with the truck so far. It has been out on four calls in the last two days and has gotten great reviews from crews and patients. Thankfully we only have to go through this nine month long process every 4 years.