Load and Go Just Needs to Go


Starting the first day of EMT class, we are taught to “load and go” with priority patients, and to not delay transport while waiting for ALS.  With the recent NFPA ambulance crash data report, maybe we should rethink this.  According to Art Hsieh (who is one of my heroes) on EMS 1, we crash about 11 ambulances a day and kill someone every two weeks.

As a new EMT I did not know the difference between sick or not sick.  I thought lots of patients were sick who weren’t, and I wanted to get them to the hospital as quickly as possible.  Now as an educator, I get frustrated that we teach students that everything is an emergency.  Even though very few patients have an immediate life threat, lab scenarios are full of zebras that students are challenged to pick up on.  As a result, new graduates are unable to recognize which patients are critically ill and which ones are not.  We are left to learn this from experience after bad judgment.

We know that lights and sirens save little, if any, time. We know that a 5, 10, or 15 minute difference in transport time will affect very few, if any, patients. We also get to drive emergency vehicles after a two-day EVOC class. Still, if there is any question about a patient’s stability, transporting lights and sirens is treated as being safer than sorry.

Consider a BLS call for a sick person where a crew discovers a patient has chest pain.  They were taught to load and go to the hospital, and would probably use lights and sirens.  If ALS is available, it is often met at an unsafe location.  When I worked as a paramedic with a chase car service, I frequently intercepted BLS ambulances on the shoulder of busy highways.  Because I assumed responsibility for the patient and would be expected to give a report to the hospital, I usually spend a few minutes on the side of the road to assess them.  In almost all cases, the ambulance used lights and sirens to meet me but continued cold to the hospital.

Poor use load and go and lights and sirens is not limited to BLS.  Just watch a few Discovery Channel Paramedics reruns for examples, where in one episode a speedometer was filmed above 90 mph.

A number of questions must be answered in order to fix this.  For emergency driving, how much initial education should we have for it, and how do we ensure continued proficiency?  When, if ever, is a lights and sirens transport necessary.  For assessment, what is the minimum knowledge base we should expect providers to have about different illnesses?  Is is ever appropriate to wait on scene for ALS? What assessment tools should be available for every patient?  How will new assessment tools, such as lactate meters and ultrasound, be made available to patients before transport is initiated?

I don’t know the answers to these questions, but I know that the way we do it now isn’t working.  Any suggestions?

Comments

  1. Assuming there are too many crashes, then the question becomes: what’s the cause?

    Poor driving skills? We need more driving training.

    Bad driving JUDGMENT? We need better, let us say, orientation — better decision-making.

    An overabundance of caution in patient care versus an inadequate amount of caution in patient transport? We need a change in education.

    Mis-triage of patients into inappropriately high transport priorities based on weak assessments? We need better clinical abilities.

    I vote a little of everything, but particularly column 3. However, I think these things vary a great deal from area to area, based on the local training and culture. No one-sizes-fits-all answer, and in some cases there may not even be a problem.

  2. I’m a paramedic finishing up my degree in GIS. A few years ago I came across an article by Peter T Pons et al. called “Paramedic response time: does it affect patient survival.” It’s a good read and worth checking out.

    From a medic’s perspective it changes one’s mindset to realize that over 4 minutes of travel time it matters very little how quickly we get to a scene. From a GIS perspective, when it comes to optimizing response times it is also important to realize that what is most optimal is getting help to those who call in a reasonable time–it just isn’t possible to have an ambulance always 4 minutes away.

    For me, the bottom line is that we’re providing a help service. We’re of no help if we’re in a crash. We’re of no help if we can’t solve (or identify) the underlying issue behind the call. But, sometimes the solution is getting the patient to the hospital FAST. Knowing how to find the balance is the key.

  3. The primary cause of ambulance accidents during transport is that too many EMTs and paramedics drive like idiots when they are transporting. Load and Go doesn’t mean Load and Drive Like A Maniac. It means minimize on scene time and transport as quickly as safely possible.

    Seems that message gets lost in the translation.

    Has anyone ever done a breakdown of accidents during response versus accidents during transport? Usually the emergency is over once the EMS crew arrives and addresses the immediate problem. Which means that transport shouldn’t be lights and siren most of the time.

    Unfortunately managers both public and private don’t always discourage lights and sirens transport. Doing non emergency transport in a crowded urban area will decrease up time for ambulances and require more ambulances to provide the same level of coverage. That adds expense and managers hate that. It seems it comes down to a cost of insurance claims versus cost of adding vehicles, equipment, and staff.

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