Difference between BLS and ALS calls?

[Aidey]

I agree. ALS should be dispatched to these calls from the get go.

 

[DesertMedic66]

Some might advocate for sending ALS immediately on dispatch. Sounds like most of the issues in this discussion come not from provider deficiency but system design issues.

Ooh I know about system design issues, any 911 call (I mean any at all) get at least one fire engine responding with 1-4 medics in board, plus an ambulance with 1–2 medics on board. Good old California :rofl:

 

[AnthonyTheEmt]

I wonder how many "CVAs" encountered by EMTs are hypoglycemic patients, where if they called for paramedics when right down the street from the hospital they'd be told "Good job delaying care [and getting us out of our lazy boy]... jackass."

Of course that's why I'm a fan of using the "can we get an updated blood glucose level? You know... for the hospital..." line on SNFs.

When I was working as an EMT, I actually got yelled at by a nurse at a SNF for asking for a BS on an altered patient, and given a verbal warning by my sup for "insulting the nurse by asking for a blood sugar on a non-diabetic patient". That is the kind of idiocy at these BLS companies. So that asking for BGL isnt always an option

 

[abckidsmom]

Ooh I know about system design issues, any 911 call (I mean any at all) get at least one fire engine responding with 1-4 medics in board, plus an ambulance with 1–2 medics on board. Good old California :rofl:

Somewhere between CA and NJ is a near-perfect system that staffs a mix of ALS and BLS units, with a medic or two in a fly car just for fun. The dispatchers are all smart and able to use their judgement to override CAD-driven upgrades to obvious BLS calls (not breathing normally leg pain) and lollipops and rainbows abound.

Somewhere over the rainbow.

 

[JDub]

I ride with BLS partners. Say we get a psych call. BLS right? Say my inexperienced partner says the wrong thing, puts his foot in his mouth, does nothing good for the patient, and magnifies the problem, whatever it is.

I have about 20 times the experience, and 50 times the education in dealing with psych problems.

Who has the responsibility if the patient goes crazy and jumps out the back of the truck?

Who is going to lose sleep at night?

Yeah, I tech in most of the calls. I'm not a paragod type. I really am not. But I don't love the idea of choosing to let inexperienced, undereducated providers "practicing" unsupervised on real sick people. They deserve our best.

Aren't you making a lot of assumptions? You are a educated, experienced paramedic. Are all ALS providers that way? Unfortunately they are not. For every person like you, there is some fresh out of a degree mill paramedic with a god complex that thinks they can do no wrong.

Likewise although there are some inexperienced ignorant EMTs, there are also very experienced and knowledgeable EMTs that for whatever reason have not gotten their paramedic certification.

-----------

As far as drawing the ALS/BLS line, I think that is up to each crew individually. Obviously if the call requires ALS interventions then it will be an ALS call. However I don't think calls should be made ALS just because of a chief complaint.

For example in my system, a nausea/vomiting patient is supposed to be ALS. The reasoning is that a medic can start an IV, give fluids, give anti-emetics and so on. However, a lot of medics will simply choose to take the call and BLS it themselves. Was the patient really helped at all by having paramedic ride that call? Well of course not.

With that being said, that also is sometimes an issue of medics being lazy. But that is a different discussion...

 

[VFlutter]

there are also very experienced and knowledgeable EMTs that for whatever reason have not gotten their paramedic certification.

Regardless of how experienced or knowledgeable an EMT is they are very limited in their scope and ability to intervene in true medical emergencies. Allowing even the most experienced BLS crew to take calls that should be ALS is unacceptable and unsafe. I consider myself fairly intelligent and competent medical provider but I still would not attempt to take on a (Insert whatever ALS patient you claim you can take as BLS) functioning as a Basic, its just poor patient care.

 

[firecoins]

Paperwork

 

[emt11]

And on that note is where the fun of my state being an EMT-I/AEMT is considered BLS and only a medic is ALS.

And on the note of epi, as an AEMT, I dont have epi pens on my truck(then again, I don't recall ever hearing of any trucks around that carry epi pens), I have epi 1:1 vials(you know, the little glass ones that like to cut the s**t out of your finger if you dont do it right) that I would have to draw up to do an IM injection.

 

[EpiEMS]

Regardless of how experienced or knowledgeable an EMT is they are very limited in their scope and ability to intervene in true medical emergencies. Allowing even the most experienced BLS crew to take calls that should be ALS is unacceptable and unsafe. I consider myself fairly intelligent and competent medical provider but I still would not attempt to take on a (Insert whatever ALS patient you claim you can take as BLS) functioning as a Basic, its just poor patient care.

+1. While I don't like to have to ask a medic to take a call in that "could be BLS", I have no qualms about doing it if I feel the patient's condition warrants it. The patients come first, after all.

 

[Tigger]

I don't understand how BLS providers can really claim that they can make the "sick or not sick" determination on their own with an acceptable degree of accuracy.

Obviously there are EMTs out there that have more education than just their initial course and mandated CE hours (I would like to think I am one of them). But clearly, such EMTs are the exception and not the rule. So on what grounds are BLS providers making this determination? Some sort of spidey sense? Surely it was not was taught in the initial course, as that curriculum puts everyone and their sister in the "sick" category.

Some will say experience, which is in no way, shape, or form commiserate to actual education. Saying that you have had thousands of patients contacts somehow makes you capable of figuring out who is sick and who not is bunk. Just because the patient made it the hospital in a condition unchanged as to what you found them in does not mean that they were "not sick." If you run all these calls, there is no way you can go back and figure out from the hospital what the patient's condition was, so how do you know you are ever correct?

It seems to me that many systems are set up backwards. Right now our first line providers are sent out with minimal education and are expected to know when they need help. From a purely patient driven perspective, wouldn't in make a lot more sense to send the providers that actually have some real education in patient assessment first, and if their assessment so warrants it, send them with those less educated?

But then again, what difference does it make? If we overtriage everyone the hospital will just sort it all out and then they will certainly look at us as equals in healthcare. Right?

 

[DrParasite]

I recognise that you're a smart guy, but you need to also appreciate that not everyone acutely sick declares themselves in a clear manner.

absolutely!!! like the stubbed toe might actually be an MI. or the drug seeker might have recently had a silent MI. or the abdominal pain on the bus is actually an MI (actually had a female patient like this, paramedics assessed and released her to BLS, monitor and everything, bloodwork in the ER showed she had an MI). and the person who calls 911 because it burns when he pees? yeah, that person might actually be dying. but if it walks like a duck, talks like a duck, and quacks like a duck, i'm not going to be feeding it peanuts.

I'm sure we've both done lots of chest pain calls. Many of the guys I thought were dying turned out to have non cardiac etiologies, many had simple UA. Some of the mildest chest pain or weak and dizzy all over old ladies have ended up being STEMIs.

ditto, and ditto. but how many 23 years olds with severe chest pain turned out to be cardiac in nature? I can think of one, and she had a history of an implanted AED.

Sometimes it's as important to recognise the limitations of our knowledge, technology and ability to assess the patient in the field. Medic school taught me as much about what I didn't know as it did anything else.

yep. and if you go onto med school, you will be able to recognize more stuff, use more technology, and assess better (the latter is what I have been told). and I have yet to hear a medic ask about family history when it comes to a chest pain call, but most docs do.

Me too. But, part of the responsibility as a paramedic is stepping in when the patient needs an advanced provider, and part of the responsibility as any level is knowing when a patient requires a higher level of care.

and part of being a competent provider (not even good EMT, just competent) is to know when to call for help, or for a more senior or educated person because your patient needs more care than you can provide.

I wonder how many "CVAs" encountered by EMTs are hypoglycemic patients, where if they called for paramedics when right down the street from the hospital they'd be told "Good job delaying care [and getting us out of our lazy boy]... jackass."

I've had two in my career. the first time the medic did call me a jackass, because the patient was loaded and in the truck, full CVA symptoms, and the paramedic checked the BGL as we pulled into the stroke center parking lot. the second time it was a "ahhh, that's what it is, take him out of the truck, put him back into bed, and we will walk him up and raise his sugar up and he will return to normal."

Some might advocate for sending ALS immediately on dispatch. Sounds like most of the issues in this discussion come not from provider deficiency but system design issues.

Depending on criteria, they typically are. I'm not a big fan of ALS on CVA calls (esp if BLS is able to check BGLs) where there isn't an airway compromise, because BLS can do the stare of life just as good as the ALS can (and our BLS crews can activate the stroke team on their own if needed).

Somewhere between CA and NJ is a near-perfect system that staffs a mix of ALS and BLS units, with a medic or two in a fly car just for fun. The dispatchers are all smart and able to use their judgement to override CAD-driven upgrades to obvious BLS calls (not breathing normally leg pain) and lollipops and rainbows abound.

Somewhere over the rainbow.

I'd like to invite you to Newark, Irvington, and Jersey City. Those cities use a system that you describe (with the exception of the automatic dispatch upgrades), and you can judge for yourself how it works.

Regardless of how experienced or knowledgeable an EMT is they are very limited in their scope and ability to intervene in true medical emergencies. Allowing even the most experienced BLS crew to take calls that should be ALS is unacceptable and unsafe. I consider myself fairly intelligent and competent medical provider but I still would not attempt to take on a (Insert whatever ALS patient you claim you can take as BLS) functioning as a Basic, its just poor patient care.

While I agree with you in theory, the question becomes what you define as an ALS call? if a CVA patient has a normal BGL and no airway issues, is it ALS? what is ALS going to do any differently than BLS? or a runny nose? or the flu (with normal vitals)? or a person who drank too much? how about neck and back pain from an MVA? Some will say BLS, some will say ALS. it's all how your system is set up.

 

[DrParasite]

I don't understand how BLS providers can really claim that they can make the "sick or not sick" determination on their own with an acceptable degree of accuracy.

well..... how do ALS providers make that claim? do you think doctors and nurses have the same problem understanding how ALS providers make that claim?

Obviously there are EMTs out there that have more education than just their initial course and mandated CE hours (I would like to think I am one of them). But clearly, such EMTs are the exception and not the rule. So on what grounds are BLS providers making this determination? Some sort of spidey sense? Surely it was not was taught in the initial course, as that curriculum puts everyone and their sister in the "sick" category.

same question, how do paramedics judge sick vs not sick? hopefully they have something more reliable than spidey sense (although my spidey sense has alerted me to a sick patient or two).

Some will say experience, which is in no way, shape, or form commiserate to actual education. Saying that you have had thousands of patients contacts somehow makes you capable of figuring out who is sick and who not is bunk. Just because the patient made it the hospital in a condition unchanged as to what you found them in does not mean that they were "not sick." If you run all these calls, there is no way you can go back and figure out from the hospital what the patient's condition was, so how do you know you are ever correct?

actually, while that is one of the sick vs not sick gauges, add "what would ALS do that would have a positive impact on these patients" and is the delay of definitive care beneficial to the patient?

and we often return to the hospitals (on subsequent visits with new patients), and can get follows up. if we screw up, a complaint is given to our clinical coordinator. or, depending on how well the staff knows you, the ER doctor might just pull you aside and say "hey I need to have a word with you."

It seems to me that many systems are set up backwards. Right now our first line providers are sent out with minimal education and are expected to know when they need help. From a purely patient driven perspective, wouldn't in make a lot more sense to send the providers that actually have some real education in patient assessment first, and if their assessment so warrants it, send them with those less education?actually, if you send out the highly trained people (paramedics or nurse, doctors, etc), and all they see is minor patient, studies have shown that their skills will deteriorate, because they don't see many acutely sick patients that require interventions requiring their care. Just look at California and their intubation numbers. BTW, full time Jersey medics typically intubate patients at least once a week. and that's state wide.

But then again, what difference does it make? If we overtriage everyone the hospital will just sort it all out and then they will certainly look at us as equals in healthcare. Right?

depends on your area, depends on your relationship with the hospital staff, and depends on how you consider yourself an equal.

 

[Veneficus]

It seems to me that many systems are set up backwards. Right now our first line providers are sent out with minimal education and are expected to know when they need help. From a purely patient driven perspective, wouldn't in make a lot more sense to send the providers that actually have some real education in patient assessment first, and if their assessment so warrants it, send them with those less education?

This is definately the smartest thing said in this thread.

After reading through this thread, I would just like to point some things out.

In the life threatening emergencies described earlier, BLS transport is the proper thing to do. The very purpose of BLS is simple but effective life saving techniques. airway obstruction, cardiac arrest, epi pens, etc.

Trauma is the same way, it has been determined by a handful of studies that show trauma patients are better served by BLS transport. The reasons are multifactorial. 1. there is no delay in transport for "advanced procedures." 2. Basics do not provide procedures that actually harm. Like large fluid boluses, 5intubation attempts on scene, or a failed intubation.

Let's not pretend a majority of paramedics can intubate, or intubate effectively enough to allow wide spread use of RSI to manage patients who require it.

Let's not pretend many places have adopted modern trauma techniques and are not still administering large fluid boluses, which in an open circuit increases bleeding and decreases hemostasis. In a closed circuit increases cerebral edema.

In this day, no matter how good the providers on this forum, they are a minority, and ALS does not always help the patient.

The new guy...

NO matter how good any of us are or think we are, we cannot see every patient. The only way new people become experienced old people is to let them take patients and make mistakes. Otherwise, they become inexperienced senior people one day. It is a very difficult thing to do to give up the reins when we know we could do better. Unfortunately, we have to.

Sick and not sick...

I always laugh when I hear basics claim they know what it looks like. I laugh almost as hard when medics claim to. Given the amount of underdiagnosis or misdiagnosis of life threatening conditions by physicians, and the fact that no US EMS curriculum yet contains education on who requires hospital admission or to what unit, or even by what specialty, please, you are not kidding anyone but yourself. (Off hand I know that sepsis is undiagnosed in 40% of the neonatal population. An even greater number I am told in the geriatric population.)

Furthermore, the EMS curriculum teaches about the most common acute disease presentations as they were in the 1960s-1980s, certainly not all of them. Not even a majority.

What is worse, they teach about the late phases, which means you don't know what the early phase may look like. (this should be a very scary feeling)

The idea Basics can decide "sick/not sick" also doesn't account for a majority of ED patients who need medical care but do not need emergency care.

Let me demonstrate, you were all told that severe trauma requires a surgeon. Some of you may even know what some of those procedures are. How many non-physicians here can tell me the indications for various emergency surgeries in trauma patients?

I'll even give you a hint, "bleeding you cannot see" is not one of them. Low grade liver and splenic lacs can be managed without any surgical procedure at all.

When even a nonmedical provider can look at a patient and decide they are F****d up, an EMT being able to do it is not expertise.

 

[usalsfyre]

What is worse, they teach about the late phases, which means you don't know what the early phase may look like. (this should be a very scary feeling)

(bolding, underlining mine)

Huge, huge point here. Most medics don't really know "sick" till it slaps them in the face. I didn't learn early presentation of "sick" until I worked in an ED for a while. The number of patients I wrote of as "BS" that ended up as ICU and tele admissions scared the crap out of me.

 

[DrParasite]

I always laugh when I hear basics claim they know what it looks like. I laugh almost as hard when medics claim to.

and yet, we still want to send medics to all calls.

Given the amount of underdiagnosis or misdiagnosis of life threatening conditions by physicians, and the fact that no US EMS curriculum yet contains education on who requires hospital admission or to what unit, or even by what specialty, please, you are not kidding anyone but yourself. (Off hand I know that sepsis is undiagnosed in 40% of the neonatal population. An even greater number I am told in the geriatric population.)

so if an all educated doctor misdiagnoses or underdiagnosis, patient, what hope is there for EMS personnel?

Furthermore, the EMS curriculum teaches about the most common acute disease presentations as they were in the 1960s-1980s, certainly not all of them. Not even a majority.

What is worse, they teach about the late phases, which means you don't know what the early phase may look like. (this should be a very scary feeling)

that I didn't know, and that is a scary thought. but I would still blame the education system, not the providers themselves. change starts with the initial schooling, so when the newbies become oldies in 10 years, you have overhauled the system.

The idea Basics can decide "sick/not sick" also doesn't account for a majority of ED patients who need medical care but do not need emergency care.
...
When even a nonmedical provider can look at a patient and decide they are F****d up, an EMT being able to do it is not expertise.

please elaborate on your first statement. and as for your second, yes, I agree (we have cops saying the patient is sick all the time), but the EMT (and paramedic) should have a little deeper understanding of why they are sick.

 

[systemet]

or the abdominal pain on the bus is actually an MI (actually had a female patient like this, paramedics assessed and released her to BLS, monitor and everything, bloodwork in the ER showed she had an MI).

This is fairly common.

but how many 23 years olds with severe chest pain turned out to be cardiac in nature? I can think of one, and she had a history of an implanted AED.

Have these 23 year olds been doing cocaine? Just something to think about. In my system we have thrombolysed patients in their 20's, but this is, as you said, extremely rare.

yep. and if you go onto med school, you will be able to recognize more stuff, use more technology, and assess better (the latter is what I have been told). and I have yet to hear a medic ask about family history when it comes to a chest pain call, but most docs do.

I do, because I feel like when I hand the patient over, I should have done as thorough an H&P as I'm capable of. That being said, the familial risk factors are more useful when you're stratifying the patient for different levels of intervention or follow-up, which is something we don't really do as paramedics.

I absolutely agree that physicians are educated far beyond the paramedic level, and recognise that there are some spectacular gaps in my own knowledge. Over the years I've been working on filling some of them. But the reality is, there's a greater gap between the education of an average paramedic and an average physician than there is between an average EMT and an average paramedic.

I think we're actually agreeing here, to some degree. The other thing I'd add, is there's no reason why an EMT shouldn't be able to education themselves beyond the limits of what they learned in a short EMT program and become more knowledgeable about patho, physio, pharm, EKG, etc. than me. Generally, going to paramedic school is going to be an easier way to attain understanding of a basic body of knowledge than trying to self-educate.

 

[Veneficus]

and yet, we still want to send medics to all calls.

In theory, the more educated your provider, the better chance you have of not misdiagnosis or underdiagnosing.

I think the benefit of sending a medic to the call first and then downgrading if the patient can be and is a superior system design.

Along the same lines, I have no problem with a medic responding to a call, like a CVA, deciding there is nothing they can do for them BLS cannot and still turfing them.

With the advances in basic science components in the original medic curriculum, I think that the amount of mis or non dx will go down.

so if an all educated doctor misdiagnoses or underdiagnosis, patient, what hope is there for EMS personnel?.

I think the hope is in the technique. Most doctors, and it is really an individual philosophy, always take the approach of treating horses before zebras. Which is not bad medicine because they will be right more often than not.

However, after many years of practicing this way, they stop looking for the zebras, and consequently never find them. It is my experience that the same thing happens to these patients as does EMS pattients. The docs figure it out when anyone could tell you the patient is messed up.

Those that have worked with me can attest, I am a zebra hunter. I look for them and I find them. But I always consider the lesser common pathologies. I believe it is better to not miss the outliers and to be as accurate as is possible with reasonable effort in the initial Dx.

Treating by numbers has a level of effectiveness, that is why PAs and NPs can post such good results compared to docs doing the exact same thing.

But when it is you or your loved ones, do you want them to be a number or diagnosed as an individual?

I will concede, most of the time they will fall into the most common category, but when they don't how long it takes to discover that could make a major difference.

Any EMS provider can adopt either of these philosophies in their practice. The individual approach to Dx can also be taught in EMS education.

that I didn't know, and that is a scary thought. but I would still blame the education system, not the providers themselves.

I do blame the system. Unfortunately, in order to change the system is to point out the faults. That means dispelling the illusional superiority or ignorance and not only offering a better way, but advocating for it.

change starts with the initial schooling, so when the newbies become oldies in 10 years, you have overhauled the system.

Which is why I point it out here. When the newbies see they don't know it all, they are the most likely to further educate themselves. It is easier to teach a new dog new tricks than get an old one to change theirs.

please elaborate on your first statement.

There have been several studies done, I am just to lazy to hunt them down, (You have to give me a break, I read on average 6-10 studies a day, I don't remember where they all are and I don't get paid to spend time here tracking them down)

As well, anyone who spends any time in an ED can tell you they see a lot of patients who get admitted for non lifethreatening healthcare.

Furthermore, anyone who works on an ambulance, especially in countries like AU, NZ, etc, can tell you a patient may be better served by another healthcare resource than an ED or ICU.

The fact is in the US, the ED, and by extension EMS, is the primary entrance to the healthcare system. (whether or not this is right is a matter of debate, but it doesn't change what is) People who need healthcare but not acute care, engage such as their entrance.

Does every abdominal pain require emergency surgery?
Of course not.

Does every pneumonia patient need to be admitted to an ICU?
Of course not.

But they do need to be diagnosed and treated.

How often has a family member or non EMS friend asked you if they need stitches for a cut?

Certain wounds benefit from suturing, and like all medicine, earlier treatment is better than later.

These are examples of people who need medical care. They need Dx and benefit from treatment. But let's face it, they do not really need an emergency ambulance or ED.

Moreover, the treatment they recieve in the ED may not help their condition at all, because all they are getting is a tempporizing measure for a chronic problem. When that runs its course, they will either be back to the ED for more temporizing, or they will have seen another medical provider who is managing their condition long term.

 

[ZombieEMT]

ALS by BLS

I work in Cape May County in NJ and the issue that we see very often is not having a medic available when needed. Our area of the county only has two medic units (which is typically enough) but when crap hits the fan its kind of up to BLS to transport with out ALS. For that reason, there are many times at which we have a patient that meets ALS dispatch protocols but we recall to save the medic unit for high priority. Some calls meet ALS protocol but ALS does not do much more for the patient than what BLS will do.

Also, we never wait for a medic unit. We load and go and hope to meet in route.

 

[RocketMedic]

This is definately the smartest thing said in this thread.

After reading through this thread, I would just like to point some things out.

In the life threatening emergencies described earlier, BLS transport is the proper thing to do. The very purpose of BLS is simple but effective life saving techniques. airway obstruction, cardiac arrest, epi pens, etc.

Trauma is the same way, it has been determined by a handful of studies that show trauma patients are better served by BLS transport. The reasons are multifactorial. 1. there is no delay in transport for "advanced procedures." 2. Basics do not provide procedures that actually harm. Like large fluid boluses, 5intubation attempts on scene, or a failed intubation.

Let's not pretend a majority of paramedics can intubate, or intubate effectively enough to allow wide spread use of RSI to manage patients who require it.

Let's not pretend many places have adopted modern trauma techniques and are not still administering large fluid boluses, which in an open circuit increases bleeding and decreases hemostasis. In a closed circuit increases cerebral edema.

In this day, no matter how good the providers on this forum, they are a minority, and ALS does not always help the patient.

The new guy...

NO matter how good any of us are or think we are, we cannot see every patient. The only way new people become experienced old people is to let them take patients and make mistakes. Otherwise, they become inexperienced senior people one day. It is a very difficult thing to do to give up the reins when we know we could do better. Unfortunately, we have to.

Sick and not sick...

I always laugh when I hear basics claim they know what it looks like. I laugh almost as hard when medics claim to. Given the amount of underdiagnosis or misdiagnosis of life threatening conditions by physicians, and the fact that no US EMS curriculum yet contains education on who requires hospital admission or to what unit, or even by what specialty, please, you are not kidding anyone but yourself. (Off hand I know that sepsis is undiagnosed in 40% of the neonatal population. An even greater number I am told in the geriatric population.)

Furthermore, the EMS curriculum teaches about the most common acute disease presentations as they were in the 1960s-1980s, certainly not all of them. Not even a majority.

What is worse, they teach about the late phases, which means you don't know what the early phase may look like. (this should be a very scary feeling)

The idea Basics can decide "sick/not sick" also doesn't account for a majority of ED patients who need medical care but do not need emergency care.

Let me demonstrate, you were all told that severe trauma requires a surgeon. Some of you may even know what some of those procedures are. How many non-physicians here can tell me the indications for various emergency surgeries in trauma patients?

I'll even give you a hint, "bleeding you cannot see" is not one of them. Low grade liver and splenic lacs can be managed without any surgical procedure at all.

When even a nonmedical provider can look at a patient and decide they are F****d up, an EMT being able to do it is not expertise.

Which is why I'll literally tell my patients who don't want to go "because you need to see someone with a lot more schoolin' than I have."

 

[KingCountyMedic]

In Seattle & King County Washington any patient that gets an epi pen used on them is always going to get a Medic eval. As far as transport is concerned you will see BLS transport a majority of these patients as most are not complicated and have a documented history of same/scrip for their own epi pen etc. As far as BLS transporting truly sick people with airway issues or serious trauma or any other of the horror stories you hear on here I can tell you it doesn't happen. If I put a sick person in an ambualnce that should have been in my truck under my care I am going to hear about it from the Doctor at the recieving hospital. If it is really bad he will call my Medical Director and if he gets involved then I am in real, real, BIG TIME trouble. Most services do not have any where near the level of Physician involvment in their programs compared to ours. I know because I spent close to 20 years working in Washington State in Pierce, Thurston, and Kitsap County. I spent the majority of my life working Private Ambulance and have been an EMT getting patients from Seattle and King County Medics. No system is perfect. Not even ours! We welcome riders all the time. I know a lot of the people that really trash Seattle & King County and I know for a fact that the majority of people that bad mouth us on here and other forums have not been able to get hired with us. There are also a few fellas that didn't make probation after completing school and so they have big chips as well. I won't get into a public debate with anyone on here but if you have interest or questions about riding send me a message.