Stay and Play or Load and Go?
I had many interesting comments on this issue following a brief discussion of a call in my post on scene management called An Unappreciated Skill. While my style is always evolving, these are my current thoughts on the continual question.
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First off, my goal is to arrive at the hospital with an alive patient, a detailed assessment and all treatment done that needs to be done without delaying the patient from receiving life-saving care that I cannot provide.
When I walk into a scene, I am always thinking: How am I going to get the patient to the ambulance? Can we get the stretcher in? Do I need a stair chair? Is the patient ambulatory?
Once I get to a patient, I ask myself: Is this patient about to die? Or is there anything that I need to do for this patient right here that by delaying will harm the patient or make the extrication more difficult and/or harmful to the patient's outcome?
Sometimes the answer is obvious – a first responder is doing CPR; in other cases, I have to talk to the patient, look in their eyes, feel their forehead, feel for a pulse, and if necessary take a blood pressure and or put them on the monitor before I can answer the question.
If the answer to the question is no, which it is 95% of more of all calls, we can then chit chat a little, set the stretcher up, make certain there is someone to feed the dog, water the plants, tell a relative the patient is going to the hospital, make certain they have their keys, and the doors are locked on the way out, etc.
If the answer to the question is yes, I have three choices: Load and Go, Stay and Play or Load and Go to the Ambulance where I can then Stay and Play if necessary (That means if there is just me and my partner, I need his initial help more than I need him to drive).
These patients will get the Load and Go treatment:
Time sensitive trauma or medical call possibly requiring a surgeon to save life or limb or significantly reduce morbidity such as a gunshot to the chest or a AAA.
CVA within the three hour window
ST Elevation MI
And anything the hospital has the ability to fix that I can’t, and any extra time lost on scene or transporting non-emergency may be deleterious to the patient.
If the patient does not meet this criteria, then I have to decide: Do I need to Load and Go to the Ambulance where I can Stay and Play or do I have to Stay and Play on scene(in the 2nd floor apartment, doctor’s office, fastfood restaurnat kitchen, 24th floor office suite, etc)?
Factors I have to consider include: How long will it take to get to the ambulance? How soon does the patient need the treatment? How well can I treat the patient at the scene? (Scene safety, privacy, cleanliness, lighting, access issues). Will moving the patient to the ambulance before treatment harm them? How much help do I have? What are my partner’s capabilities? There is a lot of calculation mental math to do, factoring time, manpower, probablities of success or failure with each approach.
I will pretty much always work a medical cardiac arrest where they fall unless say they have arrested in a car in a parking lot where I can easily pull them out and get them into the back of the ambulance. Anaphylaxis gets an instant shot of epi. An elderly hip fracture I will usually medicate and then wait for the medication to take effect before even putting the patient on a scoop stretcher. An unresponsive hypoglycemic or heroin OD I will usually treat on the spot so they’ll wake up and I won’t have to carry them. An asthmatic I will usually start a treatment on and then carry. A bad CHFer I may or may not treat on the spot depending on many factors. I don’t have CPAP yet. If I think I can slam in a line and start giving him nitro, and then start moving, I’ll do that. If they have poor IV access, I won’t dick around trying to get an IV. I’ll start to the ambulance if it is close, where I have a better chance of quickly and successfully managing the patient. If I think a patient may code, and I don’t think I can stop it with any intervention, I will generally do anything I can to get the patient into the ambulance before they code. Again, I may pop in a quick IV lock for access if I can get it quickly, but I won't sit there looking long for a vein or waiting for a fluid bolus to work.
I much prefer getting the patient into the ambulance. That is my office. The scene is safe. It is clean, well lit and I have all my supplies within arm’s distance and if anything goes wrong, I am or can shortly be on the way to the hospital – not facing a third floor carry down with an intubated patient with multiple lines. And vitally, I believe my ability to successfully manage the patient is often much higher in the ambulance.
Once I am en route to the hospital, I rarely go lights and sirens – only for those patients listed above under Load and Go. The general L&S rule is if the time saved by going lights and sirens will result in the patient receiving treatment in the hospital that will save their lives or prevent further harm in those minutes gained, then it is okay to use L&S. For years I have done most of my treatment (IVs, 12 leads, meds) while en route to the hospital in a non-emergency mode. I have no problem sitting in a hospital parking lot completing my treatment either. Just because you have arrived at a hospital door doesn’t mean you have arrived at treatment. I’ll give my next dose of pain meds in the parking lot. I’ve given nitro in the triage line. Unless the patient is critical, time to the hospital rarely equates to time to treatment.
I have always kept in mind that our job is not just medical care, but also transportation, and that forward moving is what transportation is about. Lately, however (Thanks to the Nadine Levick's lecture on ambulance safety I attended in Baltimore), I have been toying with the idea of doing all of my care in the ambulance on scene, and then securing all the equipment, buckling my seatbelt, putting on a crash helmet and assuming the crash position, before giving the okay to drive to the hospital. But it is hard to change old habits.
Again, these are just my thoughts. I recognize every patient, every scene, every medic, and every system are different, and no variables are ever the same. You do the best you can with your best guess based on everything you know and have learned, and you hope it works out.
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Here are some of the comments I recieved on the previous post expressing different views:
Anonymous said...
I suppose we medics all practice the way we're most comfortable, but this post brings up a good issue. When I encounter a cardiac patient at a pressure of 70/palp who's trapped "several rooms deep in a crowded apartment," I frequently find myself inclined to stay-and-play. That is, before we begin the extrication, I want to have 1-2 IV lines, fluid running wide, pacer pads in place, Aspirin on board, and maybe dopamine, atropine, or whatever other drugs are indicated. You can attach IV bags to the top rung of a stair chair easily enough. My O2 tank has velcro hooks that affix to the top of the stair chair also. Or, if the house's geometry allows, using a backboard is advantageous if/when the need for CPR arises. With these steps I'm prepared if the patient decides to code on the way outdoors, and I've reduced the odds of that happening in any case.
The rationale for deciding to stay-and-play is twofold: a) "I can't deliver this patient to the inside of my truck any faster than X minutes, no matter how hard I try" and b) "There's a Y% chance this guy will code in the next X minutes." If X=5 minutes and Y=25% (for instance) then I choose to stabilize first and extricate second.
In my younger years I found myself grossly underestimating X -- "but the truck's just outside... I can almost see it..." Now I realize that extrications usually require more time than we'd like them to.
I'm curious what X's and Y's other paramedics use to define their own clinical comfort zones.
EricCSU said...
During paramedic school, I rode with a department that had a similar attitude on call management that you have: get the patient into your environment (the ambulance) so you can work most efficiently. I learned that way and never saw it bite us in the ass. I enjoyed nearly always starting IVs from the bench and being in a comfortable, controlled environment. We never had a patient crash during packaging from scene to ambulance. However, as you mentioned before, it does happen.
I always wondered what we would do if that happened. How would we defend ourselves in court when we saw that we had a critical patient and then delayed treating that patient until we arrived at an environment that we were more comfortable in.
After I graduated from paramedic school, I was hired by a service that has a different attitude on call management. The prevailing attitude at my current employer is: start all interventions on scene and then package and transport. The exceptions to this rule are trauma, STEMI alert, and code stroke. For those calls, the goal is a scene time of 10 minutes or less, and we are scored on those times. A commonly heard phrase is "if the patient needed the blank (IV, drug, etc.), the needed it on scene.
This change in attitude has taken some getting used to for me, but I've accepted it. I feel more comfortable knowing that if my patient does crash, I'm ready. The patient has an IV, is on the monitor and already has interventions started.
We are also lucky in that we have the new stryker stair chairs that make for a quick exit and have an O2 cylinder holder underneath the chair.
In this system, they call it "call management". I am graded on my call management skills on every call as well as other aspects of the call.
shane said...
I tend to work most patient's up in the ambulance unless they need an immediate intervention. My reasoning for this is that if the patient does take a turn for the worse, it's easier to make your way to the hospital if need be since that is one of our ultimate goals. I find that it's much easier to talk to a patient and find out what's really going on in the privacy of the ambulance. The patient seems to be more willing to talk and quite often far less distracted. This allows for a better one-on-one conversation with the patient. This also allows for me to reflect on my initial assessment of the patient, and the scene itself so that when we get to the ambulace, I already have a plan in my head and can begin to execute it. Scene management is a priority for any EMS provider, but especially for ALS providers since most others on scene look to us for guidance. The decision of if immediate intervention is needed or not is based on solid assessment skills. While this is not going to work out perfectly 100% of the time, it should be pretty accurate. I'm not totally positive, but I would think that if you were moving the patient to the ambulance for expeditious transport to the hospital, there wouldn't be much that you'd have to defend in court. You have recognized a need for a higher level of care and you are moving there as quickly as possible.
Anonymous said...
Stay and play works well when we can provide immediate and real relief and intervention. Hypoglycemia, APE, some dysrhythmias, narcotic overdose, asthma/COPD, non-traumatic arrest etc.
We can make a real difference in these patients and our care is comparable to the hospital's initial care. Except we're doing it immediately and the patient doesn't have to wait.
Theres a couple cases where I feel that staying and playing is inappropriate. Stroke. AMI and decreasing E2B/D2B time. Trauma.
Thanks to all who commented.
