Load and Stay and Play: Hurry Up and Wait

Prompt and appropriate initial assessment is often critical to patient outcome. The steps generally follow a standardized format for most patients in order to prioritize potential life threats.

At some point—hopefully early on with a life-threatening condition—the decision must be made if immediate care on the scene is critical and may be lifesaving or if it may merely delay the definitive care that the patient requires. In all likelihood, the vast majority of your cases do not involve critical emergencies and may be dealt with in a controlled and measured manner.

Stay and Play vs Load and Go

For decades those choices have been presented as “stay and play” vs “load and go.” A critical reason to stay is that most medical cardiac arrest patients will likely have a better chance at resuscitation if care is promptly started where found. In contrast, most stroke patients require prompt care at a specialized center for the best possible outcomes.

Over the last few decades a new mode has evolved: load and stay and play. Units often arrive on scene and a provider will lug a humongous backpack into the location. Not finding something critical like a cardiac arrest or airway emergency, an automatic blood pressure cuff will be applied along with a pulse oximeter, some numbers are read off a monitor and assumed to be correct, and the patient will be taken to the vehicle for further care. By the time the report is written, a favorite number will be added for a respiratory rate.

Taking Control

In the absence of an urgent need for advanced hospital care, such as with STEMI, internal hemorrhage, severe trauma, or the previously mentioned stroke, to name a few, and lacking any threat or obstacle to treatment, most care should begin on scene, especially in a private residence. Providers who are uncertain of their abilities will often minimize on-scene time and hasten transport as if a magic cure immediately awaits.

One of my many sayings is that you either take control of a call or it will control you. This applies to any emergency. Lacking a critical need to the contrary, providing care on scene and projecting calm and control goes a long way in reassuring both patients and those around them.

The Waiting Game

If you practice in a moderately busy area it should be apparent by now that immediate care does not occur the minute you enter a hospital. In fact, there is often a wait just to get assigned a bed for your patient. This increased “wall time” has even lead to an app that will track units and advise appropriate hospital and EMS supervisory personnel of excessive delays. It makes little sense to rush and wait for care anyway.

For many years, there was a mentality that arriving at the ER sooner meant more rapid care. This myth has evaporated over the years and led to expanded field care. A good example is the prehospital use of antibiotics for sepsis. Delays in its application, when appropriate, can lead to increased mortality.

First Things First

Most patient encounters are not critical emergencies and should be handled where they are found. If care such as oxygen and IV access is truly indicated, it makes sense to start it before agitating and moving the patient, which is too often accomplished by having them walk to the stretcher. We can easily provide competent and compassionate care in familiar surroundings before moving to our vehicle and transporting them while facing backwards.

In most cardiac arrest situations, the patient will have a better chance by being worked at the scene. This is especially true with pediatric patients where care has often been comprised by a mentality of rushing to the hospital due to our own discomfort. We often move from a large open area to the restrictive confines of a patient compartment.

Confident Care

Stay and play works for most situations. Load and go is appropriate when immediate specialty care is required, as with something that we cannot fix in the field. In the absence of an unsafe or inappropriate scene setting, load and stay and play is rarely the best choice.

Become confident with your care and abilities and take control of the situation. As you assess your patient initially and reassess during a call, a simple question to ask yourself is, should I stay or should I go?

Requesting the Right of Way

One last note that deserves mention. It seems that quite often after an emergency vehicle accident, many “expert” comments from armchair quarterbacks immediately decide that since the vehicle had its “lights and sirens” in use, the fault must lie with the other driver. Especially while transporting, the condition of the patient is known and usually stabilized.

Emergency transports should be rare. If an accident occurs while you are “assuming” the right of way, it is likely the fault of the emergency vehicle operator. Please learn really well what the term “due regard” means. You may request the right of way at an intersection or in situations such as during passing but it may not be given by the driver of another vehicle who is listening to their radio and completely unaware of your existence.

In everything you do, stay safe!!