Any MAST Ambulance workers?

[Just Plain Ruff]

yes the only service in KC MO that can run ambulance period unless mutual aid is requested.

If you need a transfer from the hospital to home or NH then Mast is it.

[AMESEMT]

So I was looking through the certification requirements for the KC Department of Heath to be a paramedic student doing field internship. What is the city certification test? Anyone certified in Kansas City, MO can you explain? Thanks. I am trying to figure out what I need to do to intern at MAST. Thanks

Ames

[UnapprovedUses]

Great post, UU. Welcome aboard!

Does mast run transfers too, or EMS only?

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.

[Just Plain Ruff]

Hey UU is Jim Jones and Mark Terry still working there? How bout john Tezon?

[Dustdevil]

It's like anywhere. 911 is the fun. Transfers pay the bills.

I wouldn't say "anywhere", because in most places in America, 911 is the fun, tax dollars pay the bills, and private ambulances run the transfers. But I would say, it's just like every other PUM system set up by Jack Stout in the 80s. Too bad.

[UnapprovedUses]

Whats the logic behind LR over NS? My new service only has NS, reason being some drugs should not be given with LR. Just curious. Welcome to the site.

Are you management in disguise? :wink:

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.

[UnapprovedUses]

So I was looking through the certification requirements for the KC Department of Heath to be a paramedic student doing field internship. What is the city certification test? Anyone certified in Kansas City, MO can you explain? Thanks. I am trying to figure out what I need to do to intern at MAST. Thanks

Ames

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.

[AMESEMT]

UnapprovedUses:

Thanks for the info! I downloaded the application and stuff but was not exactly sure on what the test consisted of. That is surprising that MAST does not allow paramedic students to intubate. Though I can see the reasons why. Thanks again for the information and I will get on getting stuff in before we start clinicals/field (in April).

Ames