Load and Go vs Stay and Play¶

Category: Concepts Sources: raw/protocols/nm-sop-guidelines-treatment-2022.pdf Last updated: 2026-04-05

Overview¶

Every patient contact requires a transport decision: how long do you stay on scene, and when does treatment happen? "Load and go" means you package the patient rapidly — targeting scene time at or under 10 minutes — and provide treatment en route to the hospital. "Stay and play" means you stabilize on scene before transport. This decision is not a preference. It is determined by whether what is killing the patient can be treated in the field.

This framework is the most important transport decision in prehospital care. It is currently implicit in scene-size-up, primary-assessment, chest-trauma, head-injury-tbi, and elsewhere. This page makes it explicit.

The Core Question¶

The decision turns on a single question: Is the thing that will kill this patient fixable in the field?

If yes, or if the injury is not immediately lethal, stabilize on scene before moving.
If no — if the definitive treatment is in an OR, a CT scanner, a cardiac catheterization lab, or requires ALS medications you don't have — then every minute on scene is a minute the patient is not at the place that can fix them.

This is not a rule of thumb. It is a physiological fact. Internal hemorrhage from a splenic laceration does not slow down because you are doing a thorough secondary assessment. Intracranial pressure does not pause because you are splinting a femur. Tension pneumothorax does not wait for you to complete a full set of vitals before continuing to compress the heart. These processes are ongoing. Scene time is physiological time.

The Physiological Basis of the 10-Minute Rule¶

The 10-minute scene time target for unstable major trauma patients exists because:

Hemorrhagic shock is time-dependent. The transition from compensated → decompensated → irreversible shock is driven by the total volume of blood lost and the duration of hypoperfusion. Every minute of continued internal hemorrhage advances that transition. The only treatment for internal hemorrhage is surgery — which requires a hospital.
Hypoxia and hypotension compound brain injury. In TBI patients, even brief episodes of SpO2 <90% or SBP <110 cause irreversible secondary injury. Each minute of continued hypoxia or hypotension adds to a deficit that cannot be reversed. Transport is treatment for TBI — because transport ends hypoxia faster than any field intervention can fix the underlying cause.
Obstructive shock (tension pneumothorax) is a mechanical emergency. The intervention — needle decompression — is ALS scope. If ALS is not on scene, the definitive treatment is in the hospital. Staying on scene does not decompress the tension.
The secondary assessment can happen en route. The information gathered during a secondary assessment does not change the destination — it informs treatment, which can occur in the ambulance. A thorough scene secondary assessment on a patient with internal hemorrhage is not a net benefit; it is net harm because it delays the OR.

Conditions That Mandate Load and Go¶

For each of the following, there is no field treatment that stops the underlying process. The OR or hospital is the treatment:

Condition	Why You Cannot Fix It in the Field
Uncontrolled internal hemorrhage (abdominal, pelvic, thoracic)	Surgical hemorrhage control — clamping, suturing, packing — requires an OR; EMT-B cannot access the bleeding source
Tension pneumothorax without ALS on scene	Needle decompression is ALS scope; EMT-B cannot decompress; each breath worsens the tension
Multisystem trauma with hemodynamic instability	Multiple simultaneous injuries; no single field intervention addresses all of them; definitive management requires trauma surgery
Airway compromise not manageable with BLS maneuvers	Advanced airway is ALS scope; an airway you cannot maintain on scene is not getting better with more scene time
GCS <8 with TBI mechanism	Secondary brain injury from hypoxia/hypotension accumulates with every minute; transport ends the exposure; no field intervention reverses rising ICP
Major burns >20% TBSA	Fluid resuscitation begins prehospital but burn center care, wound management, and systemic response management requires hospital; transport to burn center is the intervention
Maternal cardiac arrest / complicated OB emergency	Emergency C-section, maternal resuscitation, and neonatal resuscitation all require hospital resources

The Common Student Error¶

Students who understand the secondary assessment sequence well sometimes stay on scene to complete a thorough head-to-toe on a patient who is dying from something only an OR can fix. The error is treating scene thoroughness as a proxy for quality care.

A complete SAMPLE history and a full set of vitals are worthless if the patient is bleeding into their abdomen while you gather the information. The patient who arrives at the trauma bay with a thorough prehospital assessment but arrived 15 minutes later than necessary has been harmed by that thoroughness.

The correct model: the secondary assessment is a tool for identifying what needs to be treated. For conditions that require hospital-level treatment, that identification can happen in the ambulance en route. For conditions that can be treated in the field (isolated extremity fracture, minor laceration, stable medical complaint), scene time to assess and treat is appropriate.

The test is simple: "If I find what I'm looking for in this assessment, can I treat it here, or does the patient need a hospital?" If the answer is hospital, expedite transport now.

The Golden Hour¶

The "golden hour" concept — the idea that trauma patients have a one-hour window in which surgical intervention dramatically improves survival — is widely cited and frequently misunderstood.

What it means: early surgical intervention significantly improves outcomes in major trauma patients. The window is not a guarantee of survival if reached, nor a death sentence if missed. It is an operational target that defines urgency.

What it does not mean: you have 60 minutes from injury to hospital arrival. By the time EMS is dispatched, response time elapses, scene time passes, and transport time accumulates, that hour is often already partially consumed. In rural San Juan County, transport times to the regional trauma center in Farmington — or to Albuquerque for Level I trauma — add to every minute spent on scene.

The practical implication in NM: scene time ≤10 minutes for major unstable trauma patients is the operational target, because rural transport times consume the remaining available time.

What Determines "Stay and Play"¶

You can — and should — stabilize on scene before transport when:

The injury is isolated and the injury is manageable at the BLS level (e.g., isolated extremity fracture with intact PMS, minor laceration)
Vital signs are stable and there is no evidence of internal hemorrhage or shock
The chief complaint is a stable medical condition where treatment in the field is appropriate and the patient is not deteriorating (e.g., stable chest pain awaiting aspirin, minor hypoglycemia responsive to oral glucose)
The patient has a clearly isolated mechanism and a clearly localized complaint

Even for these patients, "stay and play" does not mean unlimited scene time — it means thorough assessment and appropriate field treatment before transport, not instead of transport.

NM Protocol Notes¶

From NM EMS Treatment Guidelines (2022), General Trauma Guidelines:

"Minimize scene time. The goal should be less than 10 minutes for an unstable patient or a patient who needs emergent surgical intervention, with the majority of interventions performed Enroute."

The protocol emphasis for major trauma is: "Rapid assessment and management of life-threatening injuries, safe movement of patient to prevent worsening injury severity and rapid and safe transport to the closest, most appropriate facility."

For extremity trauma: "If the patient is hypotensive, transport immediately and complete the remainder of the assessment and treatment Enroute."

Each jurisdiction in NM develops Trauma Destination Protocols with guidance from the Regional Trauma Advisory Committee (ReTrAC), based on local resources. In San Juan County, significant transport times to both Farmington and Albuquerque make early transport decisions critical.

NREMT Relevance¶

The load-and-go vs stay-and-play decision appears on both trauma and medical skill stations:

The transport decision (priority vs non-priority) is a scored item in primary assessment skill stations
For trauma patients, verbalizing "load and go" and the justification is expected for high-MOI presentations
The NREMT cognitive exam tests this concept through scenario questions where the correct answer requires recognizing that a complete scene assessment is not the appropriate priority

scene-size-up — MOI identification is the first determinant of load-and-go urgency
primary-assessment — transport decision is made here; priority indicators trigger load and go
chest-trauma — tension pneumothorax: the archetypal load-and-go condition
head-injury-tbi — GCS <8 and TBI mechanism: load and go, secondary injury accumulates
shock — decompensating shock: load and go; internal hemorrhage is not a field fix
abdominal-pelvic-trauma — internal hemorrhage: surgical condition, not a field fix
drill-03-trauma-oilfield — applied scenario: fall from height with multisystem trauma transport decision

Sources¶

raw/protocols/nm-sop-guidelines-treatment-2022.pdf — General Trauma Guidelines (p. 59–60); External Hemorrhage/Extremity Trauma (p. 68–69)