UnapprovedUses

In as much as I try to respect patient wishes, my bar for "unable to care for themselves" or "threatening to self or others" is extremely low. I've transported people who are A&Ox4, GCS 15 to the hospital not because they're disoriented, but because I feel they're unable to care for themselves. If you're sleeping on a street, as in the actual lane of travel, you're clearly not thinking coherently no matter what. Either that or you're suicidal. If you drank a bottle of liquid morphine "for fun" whether you're alert and oriented or not, if I meet you we're going to the hospital. If you're profoundly hypotensive and you want to refuse, I'm going to take you by hook or crook if I can. And the reason is that if I leave you at home to die, a smart attorney would say, "he was hypotensive. He wasn't thinking at full capacity. His mentation was altered. You should have transported." And then I'm out of a job. It's a lot easier just to drag them to the hospital. I actually spend less time doing paperwork on transports than I do on refusals. I do an insane amount of documentation on every refusal, I have an additional sheet I have to fill out to give the patient, I have about a half dozen signatures to get, and all sorts of mess to deal with. Taking them to the hospital is so much easier. And that's what I do. When I come across a patient who wants to refuse and I find myself asking, "Are they going to be okay? Are they competent to refuse?" and there's that little bit of doubt like they're probably okay, but maybe just a teensy bit not okay, I'll take them. Unless there's no doubt what so ever in my mind, they go. Yeah, you get a lot of whining and bitching at the hospitals, but they have a physician they can fall back on. They are going to see a physician. If I refuse them, they will not. So for staff and nurses and doctors to whine about it is foolish. I had a nurse the other day, this patient of mine was just annihilated on Xanax and vodka, alert and oriented for the most part, and the nurse was like, "Well, what a waste of time. Why didn't you just send him home to sleep it off?" And I just look at her and said, "It's called implied consent. You take a bunch of Xanax bars, vodka, pass out on a dance floor and get stepped on while you vomit and you're going to the hospital if I find you." But that's besides the point. I don't get hung up on whether someone has been drinking or using drugs. That's not the issue. The issue is their behavior. Sober is not a carte blanche to refuse. So when you get hung up on whether someone has been drinking, you forget that some people can be perfectly sober and be totally nuts. The real issue with refusals is, provided they're A&Ox4, are they "capable of understanding the consequences of their refusal." That's the kicker. You could have an 7 year old who can answer all the questions. Who, what happened, when, where, how, etc... but is a 7 year old (to say nothing of the legal definition of an adult) capable of understanding in a cognitive sense what it means to have long-term morbility from lack of treatment?" I have met adult patients, competent, living independently, who are so ignorant they really don't understand what the consequences of their refusal are. I don't say "ignorant" as to be insulting. I mean people who are not educated. They quit school at 4th grade, can barely read simple books, people who don't know that they need to cut up their children's food into little bits to avoid choking their baby. That kind of ignorant. They understand death, but they don't understand that an untreated wound will become infected, spreading, leading to systemic infections, loss of limb function etc... They don't understand that the albuterol is going to wear off in a few hours and their breathing will diminish. They don't understand that the epi and benadryl are not a long-term fix of the anaphylaxis. Those people will get you in a LOT of trouble. So the bar needs to be really low for your implied consent threshold if you like your job. This myth of "you can't just take them, that's kidnapping" is puzzling to me. We're not grabbing people off the street at random like some Iraqi insurgent. There's a 911 tape that can be played to a jury or attorney. There's your paperwork. There's the statements of eyewitnesses. There's protocols that you hopefully followed. There's "Standard of Care." You're never going to get in trouble erring on the side of transport provide you have the patient's best interest at heart and you follow local protocols. First do no harm. Then, always choose transport when you have the choice. Do that and document well and you'll rarely have any issue.

Here's how I deal with it. Option 1. Walk up patient. "I need to go to the hospital. Take me to the hospital." Me: Why? Patient: I have a cold. Me: Great! There's one next door. Patient: I don't like that one. I just got kicked out of there. Me: Fine. We'll go to the next closest one. Get in. Patient: Here in this side door? Me: Yes. Get in the side, grab a seat on a the bench, put your seat belt on. I'll be back in a second. We have some paperwork to do and some assessment to do. Patient: Ok. Can I finish my beer? Me: If there's any beer in the truck by the time it takes me to walk out of my seat here, around the back to get in, I'm tossing it. This is an ambulance, not a bar. Do what you need to do with that beer, but I don't want to see you drink it and I don't want it in the truck. Same with any drugs. Patient: Ok. I have a crack stem. But I won't smoke. I promise. Me [to EMT]: Let's go. There you have it. Option 2. Call from a nursing home right across the parking lot from a hospital. I generally will do everything required by protocol as if the hospital wasn't right across the parking lot. If that means O2, IV, Monitor, etc...I'll do all that. If the call doesn't require anything more than BLS care, we'll just drive.

I've never understood Newark EMS. How many calls is typical? The mythical average crew, where I work, will run 3.4 calls every 10 hours they're on the clock. It seems that you'd be pushing 8-10 calls for every 10 hours worked with those numbers. Are you just busting nuts to get things done? Is turnover through the roof or do people like the pace of work? You're not going to get bored, that's for sure.

Ok, you need to obtain an application from the Health Department. Consult their website to determine the requirements and verify that you meet them. http://www.kcmo.org/health.nsf/web/licensure?opendocument Paramedic Intern Checklist [hr:f000b659ed] Application, all sections completed: $15.00 fee, non-refundable, payable to the City Treasurer (check or money order only -- no cash) Copy of high school diploma or GED Copy of a physical examination completed within the last year by an M.D. or D.O. (the DOT physical form is preferred but not required) Copy of TB skin test completed within the last six months Copy of required certifications (copy of card - not actual certificate): National Registry EMT-Basic or appropriate State EMT-Basic Basic Cardiac Life Support (CPR) Letter from instructor to state the following: the applicant is an active student in an accredited paramedic program the applicant has an Advanced Cardiac Life Support (ACLS) certificate or has completed the cardiac component of the paramedic program Applicants must present all of the above documents before they will be allowed to to test for their city certification[/font:f000b659ed] So, call a clinic. Find one that does pre-employment physicals or go to your own PCP. Just get a DOT physical. Everyone knows what the DOT physical is, and it will cover all the bases. Ask before you pay. You'll get a very comprehensive screening. Yes, it costs a little more than just the ad hoc physical, but nothing will be missed. While there, get a TB test. Go get it read two days later. Save the results. Do note: it is NOT a physican assistant physical. You need an MD or DO to satisfy the Health Department. Some places have PAs do DOT physicals. Have your instructor write out a letter saying you're actually a student. Make copies of all your certs. Do all that as soon as possible. It will save you the trouble. This isn't a last minute thing. Without that student license, you cannot do any skills as MAST. The city will not permit it. Ok, for the test. You have a few options. Your instructor MAY be able to proctor the city exam at your school location. If they can, more power to you. If they cannot, you will need to make arrangements to take the written test on arrival to KC. Unlike a lot of internship spots, KCMO and MAST are pretty unusual in that they really want you to have a good understanding of local protocols before you start. It's kind of intimidating because it seems unfair. It is what it is. It's by no means impossible or even that hard. You'll need to do it when you start working at your first job, and if you were to stay working at MAST you're already a step ahead. Download the protocols, read them. I don't know what's on the test. It changes. I took it when I got hired, and it wasn't that hard because I studied the protocols, but your test is slightly different. I'll tell you what I think is unique about our protocols which may or may not be on the test. These are things that I found unusual. DOAs - Trauma. A trauma arrest is a trauma death. Patients with obvious trauma that do not possess signs of life (pulses, movement, respirations) at the scene as observed by MAST are dead. They are not viable. We are discouraged, strongly, from application of the cardiac monitor for trauma presumptions. If you apply the monitor, observe PEA, you must run a code. It will be in vain. You will consume vast medical resources for a non-viable patient. Hence, do not apply the monitor unless you are in doubt. DOA medical -- standard as most places. 3 lead showing asystole along with either rigor or lividity. If they're decomposing, don't embarass your self with a 3 lead. They're dead. Termination of resuscitation -- we do it. If a patient has either PEA or asystole as the presenting rhythm, never has V-fib, never has ROSC, and the terminal rhythm is asystole after 20 minutes of ACLS care along with intubation, you can terminate your efforts after calling medical control. There's some things on the TOR checklist that are contraindications. Those are important I think. When in doubt, transport. When in doubt, call medical control. Cardiac arrest: We use a unique protocol for arrests that are primarily of a cardiac nature. 50:2, sets of 200. Keep the compressions fast, hard, and uninterrupted. Keep BVM to a minimum. In fact, you will place a NRB mask on the patient's face in between ventilations. Do not intubate until the 3rd set of compressions. Intubation is not required in v-fib. If you feel you can manage the airway with an OPA, the health department is okay with that. Should you intubate, which you cannot do as a student by the way, it will be done without stopping compressions. Remember, you cannot intubate as a student. There are only three reasons you can contact a hospital. "For information" this is a courtesy to the receiving instution. "For orders" you will contact our central medical control hospital and make your request right to a doctor on the radio. Nurses do not give orders. Only physicians at one hospital. "For information on a critical patient / trauma patient." Patients who are in cardiac arrest, have respiratory failure, profoundly hypotensive, etc...or patients meeting trauma routing criteria need to have the hospital ready. You must call to inform the facility of your arrival. Those are the only three reasons you will contact a hospital. Trauma routing criteria. I will tell you that, even though I have not seen the test and have no knowledge of it, that this will be on there. I'm certain of it. Review the trauma routing criteria, know it, and know it backwords. It will save you so much trouble. Whatever you need to do to remember it, do it. This is very important. Our criteria are not unique. It is the same criteria established by the state of Missouri that most trauma centers base their activations off of. It is fairly specific and almost 100% sensitive, in my opinion. I'm sure there's some rhythm interpretation, some 12 lead stuff, things like that. It's a test to make sure you're not an idiot who will be dangerous. The long and short of it.

Heck no. If I was management, I wouldn't be posting. Period. Not even anonymously. I cannot speak as to the official reason about the LR vs. NS thing. I have my own theories because I've often wondered it. Hospitals that we rarely transport to sometimes cop an attitude about the LR and make a scene about taking our tubing off, popping a lock on, and hanging a bag of NS in such a bold and exaggerated fashion you'd think they were side show performers. Hospitals that we transport to all the time just use their fluid of preference. I can see both sides of it. On the pro side: 1. it's a logistics thing. 85,000 calls a year. 60,000 transports. 55 or whatever number of units, times 7 1L bags of IV fluid per unit. How many IV starts? How much fluid in a year? I don't know. An insane amount. Managing the expiration and consistency of stock is a bit of an issue when you suddenly have two seperate fluids to buy, stock, rotate, and check. 2. LR is the fluid of choice when you require large-volume volume replacement. I will agree with anyone in the peanut gallery that there are some interesting studies that suggest an inflammatory response can develop in response to large amount of LR. However, our protocols permit no more than 2L of fluid replacement for patients presenting with non-cardiogenic shock. You can go up to 4L replacement with medical control. But if you can squeeze 2L into a person in 15 minutes while still getting everything else done, you're a better medic that me. 3. if you want to get down to the brass tacks, large volume infusions of NS will lead to a hyperchloremic state due to the higher amount of Na+ ions, and the resulting depletion of the potassium. Is this an issue prehospitally, no. 4. we don't hang blood, run blood, or even carry blood tubing anymore. So any issues of compatibility with blood products (which is debatable anyway), are not present. 5. In hypovolemic patients or acidotic patients (excepting lactic acidosis), the lactate will help alkalinize the blood. 6. 98% of the time, it works interchangably with normal saline. On the cons side: 1. renal failure patients, CHF patients, hepatic failure patients -- LR is bad. The potassium will cause a lot of problems if given willy nilly. This was brought before the physican advisory board which helps draft new protocols by a very concerned nephrologist here in the past year or two. It is a very legitimate point, and in fact the drug monograph for LR specifically lists certain chronic conditions including renal failure as a contraindication for large volumes of fluid. It is not an absolute contraindication, but a relative one. Who would argue that a renal failure patient who has suffered penetrating trauma to the torso, and presents with a BP of 60/40 should have LR withheld because it might cause them harm? It's about common sense. If they need fluid, do so conservatively. Work least invasive to most invasive. If 250 mL is what you need to do the job, then stop at 250 mL. 2. I am not aware of any medications that we use preshospitally which are incompatible with LR. I cannot find a specific drug compatibility matrix to determine any issues, but I know our med list is vetted to determine incompatibilities. Sodium Bicarb is really the only drug we carry that needs special precautions with respect to compatibility, and its indications are fairly specific and rare. 3. You could argue that NS has a higher osmolarity than LR and cases where cerebral edema was an issue that NS would be preferred. How much fluid are you going to give a head injured patient? I don't know. A lot? Probably not. There always is the neurogenic shock scenario, however. Would it be nice to have NS for medical patients, and LR for trauma patients? Yes. I would prefer that. But I think utility and simplicity outweigh my preferences. It keeps costs down by keeping things simple. I suspect that this is the primary motivation. I think at one time we had NS and LR. But MAST is always doing utilization studies to determine whether we actually use the things we have. For instance, we until about 7-9 months ago, carry two bags of Dope on the trucks and Y-type blood tubing. The blood tubing was used, out of 60,000 transports or whatever, about 10 times maybe. The extra bag of Dope? Not used hardly at all. What are the chances you need to hang a second bag of Dope on a patient because the first ran out, or that you had two cardiogenic shock patients back to back? I haven't used it yet in over a year. Not to say it won't happen, but it simply has not been opportune. Anyway, that's my theory. Who knows? Maybe it's none of the above.

Oh yes. Quite a few. Like someone else said, pretty much all ambulance requests that originate within the borders of Kansas City, MO will need MAST to transport. There's some exceptions, and it's really a bit technical to go into them, but for all purposes, basically whether you call 911, or need to go from the ICU to hospice non-emergent interfacility, you'll get a MAST unit if you're in the city. That includes long-distance transfers, too -- St. Louis, Des Moines, Omaha, Oklahoma City, etc...it also includes people that go from their nursing home somewhere like Olathe, KS (about 25-35 min drive one way) to a hospital in Kansas City. They came to KCMO in a different ambulance. But they must leave KCMO in a MAST unit. We used to have the Power Car. It was like a lot of other service that do a transfer-only unit. The original idea was to alleviate the load on other crews by having dedicated crews that only did transfers. With our newest shift arrangements, there are no more power cars. And truthfully, I was a little peeved since I thought we'd all be doing a whole lot more transfers. But that hasn't been the case. I haven't noticed a difference. It's like anywhere. 911 is the fun. Transfers pay the bills.

I work at MAST. I have nothing but positive things to say about the place. I've worked for other services, and while MAST isn't perfect, it is by far the best place yet. I'll give you a really long answer about it. I've been there for just over a year. First, it's high volume. You sit in a truck for 8-12 hours per day. There are no stations. Your truck is your station. And you move around all the time. You do a lot of driving. You run a lot of calls. A 12 hour night shift might have between 4-10 calls. Your calls are not always very exciting. There's a lot of low-acuity things like 5 day old cat bites, just got arrested now I have chest pain, random intoxicated guy passed out in the weeds. You know the regulars. There are people that call 4 times a week. People you know by name. But you also see a TON of crazy stuff. 8 person shootings, self-immolations, dissecting aortas, high speed car wrecks, tons of cardiac arrests, insane amounts of drug overdoses, and just about every medical problem you can imagine. You will see this in your first year. Transport times are short. There's 3 level 1, and 5 level II trauma centers within a 20 minute drive. There's some 15-20 different hospitals you'll go to in the metro. You will not be spending a lot of time with patients unless they're a cardiac arrest patient. Most transport times are less than 15 minutes, I'd guess. The expectations are quite high. The reality is that if you're not interested in being a great paramedic, MAST probably isn't the place for you. Coworkers expect a lot of each other. The local health department expects a lot of you. The ER docs and nurses expect a lot of you. People know who is mustard and who isn't. Reputation is very important. Without it, nobody will want to work with you and the hospitals will second guess you. You will have trouble getting orders from online medical control if you consistently screw up. People also know that nobody is perfect. Mistakes are expected. But learning from mistakes is required. People that don't learn from mistakes don't stick around very long. People that are dangerous, irresponsible, or heartless won't find anyone to work with them and they'll be asked to consider new employment. You work with one partner all the time. You can choose your partner, your shift, and it doesn't change more frequently than 6 months. There are people who have had the same partner for over a decade. Your partner is either your best friend or worst enemy. A bad partner will get you into trouble, and a good partner will keep you out of it. A good partner makes a 12 hour shift seem like 45 minutes. You have tremendous autonomy. Refer to my paragraph about being a great paramedic. With great responsibility comes great expectations. You are given, by city ordinance, total control over a medical scene. Not the police, not fire, not anyone else but you. MAST and the City of Kansas City are fiercely protective of ensuring your ability to do your job without interference. Some services have supervisors showing up on every call to tell you how to do things. Not at MAST. It can be very intimidating when you're new. People look to you for all the answers and you're all alone. But you learn quickly that this is a blessing, not a curse. You will have more autonomy than at many other services. Especially as a paramedic because nobody else will have your level of training. My first week on my own, I was thrust into doing incident command on an 8 person car accident over a 2 block area with a 5 unit response. First time for me. It didn't go perfectly, but incident command is one of those things you'll pick up real quick at MAST. And you only learn it by doing it. Management can be a bit stringent about following all the rules and regs. Particular with respect to your licenses. There is no leeway. You absolutely CANNOT forget to renew ANYTHING. From CPR to ACLS to ITLS or anything. You, by city ordinance, CANNOT work if your certifications are not valid. NREMT is an absolute must. People have lost their jobs over things like this. At the same time, I have found the supervisors and managers to be very interested in helping field crews do their jobs. I had car problems for two days and a field supervisor gave me a ride to and from work, no questions asked. If you have problems with a particular hospital or another agency, the supervisor can step in to remedy the problem so you're not taking the flak from them. Generally when it comes to coworkers, it's a very congenial and fun environment. There's people for everyone. Some people are light hearted, some deathy serious about their job. Some playful, some somber. Some very straight and narrow, others wild. It's a big organization, so if you're new to the area, you will have no trouble finding people who can give you advice on where to live, or where to find childcare, get your car fixed, what ever. People really want to see you succeed, you just have to ask for help. MAST runs EMT-B/Paramedic trucks with just a few exceptions. That means as a medic, you're doing all the patient care and writing all the charts. The EMT-B cannot run the call even if its a BLS patient. That's a rule according to the city. Protocol wise, you can view the protocols online. It's a public document. http://www.kcmo.org/health.nsf/web/protocols?opendocument Our protocols are very straightfoward. The cardiac arrest protocol is quite unique. Our cardiac arrest save rate is double or triple the national average. We only carry 20 drugs. We carry one IV fluid: LR. Everything is designed for simplicity. A few highlights: Only four things need online med control orders. Lasix for CHF. Bicarb for TCA OD. CaCl for calcium channel blocker OD, and morphine ONLY when it is used for CHF. Some highlights of standing orders: Unlimited NTG in chest pain. We have NTG paste, too. Morphine is standing orders on chest pain. Standing order morphine in qualifying patients for "isolated extremity trauma" e.g. sprains, strains, hips, etc. 2 mg q 5 min max 10 titrated to pain relief, LOC and vitals. Nothing outrageous, but until recently we had to call for orders. Very generous seizure protocol. Have the option of intranasal versed for both pediatrics and adults. Works *extremely* well. Can do up to 10 mg valium on standing orders either IV, or PR. CPAP is coming in two weeks. Technical info about MAST: We have a very good and forward-thinking medical director. We use brand new Zoll M series monitors with NIBP, 12-lead, capnography (for intubated patients only). We have disposable fibreoptic laryngoscope blades. We're moving to an entirely electronic charting system. Tablet PCs. I think this is a Q1 2007 goal. We have GPS-based ambulance tracking and routing. It's not perfect, but we have not missed a response time target in over 2 years. And we have some very tight response times -- 9 minutes MAX from the time the call was received. That leaves, realistically, a 7 minute drive time for the highest priority calls. I love it, but a lot of the old-timers prefer the map book and knowledge way. KC is a big area, so it takes a while to learn the streets. We cover almost 500 square miles. Very neat standby event options. MAST is the only ambulance service that can be used in KCMO. Venues have to have a standby unit for big crowds. The new Sprint Arena brings a lot of famous concerts to the area. The KC Royals and Cheifs all have standby crews on the field and in the stands. Even as a brand new person, you have just as much shot at doing a Chiefs game as a 25 year person. We're upgrading all our ambulances, slowly. We have a fleet that is now about 50/50 older Braun ambulances and a newer type. The "service truck" style. Those are our red and white ones you may see pictures of or if you have seen the show "Paramedics" when MAST was on that show. The newer ambulances are Type III AEV Trauma Hawk units. They have an impossible to miss LED light package that is absolutely blindingly brilliant, about the loudest siren I've ever heard short of a Q. Some people love the air horn. Our trucks still have air horns. I'm not really into it, but it has a place. There's a ton of room in the patient care compartment. Some HR-type info: MAST is a Union shop. We're represented by the IAFF. Very sensitive political issue and I will not comment on it since there's a lot of pro and anti union sentiment on this board. I'm not going to comment on that except to say that I am comfortable with my job benefits and security. Our pay scale is published online. As if the cost of health insurance. Starting pay for a new medic is $16.82/hr. Your health insurance is fantastic. Premiums are $22/month for single coverage. Uniforms are paid for. You get your CEUs paid for. By that I mean the class is free, and you get paid to attend. They teach about 60 classes/month that you can pick from. If you start as an EMT, you can go to the MAST paramedic program free. Good 401k benefits. MAST will simply give you 8% into a 401k. That is not a matched contribution. That's a gift. The vesting schedule is online, too. It's based on a 42 hour week. So you will have 2 hours of OT each week. You get a lunch break. An actual lunch break. 40 minutes where you can relax and have a meal. You still might get a call on lunch, but it's rare since your lunch is usually covered by another unit. The vast majority of shifts will end on time. In the past year, I think I've only been late getting off about 6 times. And it wasn't more than 30 minutes. -- Long and short: There's a ton of services in the KCMO metro. Not everyone will be happy at MAST. I recommend shopping around to find a good fit. You can look at Overland Park Fire Department, which hires medics. Johnson County Med-Act -- well-respected service I think. They have very nice protocols. Raytown EMS. North Kansas City Fire Department. Belton Fire. AMR in Independence. Gladstone Fire. Grandview Fire. Lee's Summit Fire. Bonner Springs Fire. NRAD EMS. Kansas City Kansas Fire. If it is "fire" in the name, you will likely need to have FFI and FFII certifications prior to applying. Not always, but likely. The exception is KCK Fire. Being a medic is enough to get in the door, as they'll train you. So - I love my job. I love where I work, and I love coming to work. It's the best job I've ever had and I don't regret anything about it. That said, not everyone feels at home at MAST and I can understand that. No matter your experience, if you love urban EMS, want to run a variety of calls, and do it with tremendous autonomy, and like being challenged daily, this is the place for you. In an average day, you can find yourself walking into a $4 million dollar home at the start of the shift, transport, then run a call in the most dangerous and economically depressed part of town two hours later. How can you beat that?