Double the Load

You are working with Tracey, a veteran paramedic, on an overnight shift. Tracy is considered to be a solid paramedic with more than a decade of experience. You have worked with her a few times in the past. In general you get along. Tracy is really good at what she does best—taking care of “sick” patients.

The shift is dragging and there is not much activity. Around 10:00 p.m., your ambulance is dispatched to an apartment complex to evaluate an intoxicated patient with a hand laceration. You arrive on location to find an intoxicated male in his mid 40s with a laceration to his hand that will require stitches. After speaking to the patient and bystanders, you learn that the patient cut his hand when he attempted to catch himself after tripping on a loose carpet near a glass table. When he tripped, he extended his hands in an effort to block his fall. Unfortunately his hand went through the glass table. There are no other signs of trauma. The patient has a dishtowel wrapped around his hand.

The patient does not have any transportation options, will need stitches and possibly a tetanus shot. It is determined that the patient should be transported by ambulance to the local emergency department for treatment. Tracy walks with the patient to the ambulance and asks the patient to sit on the bench seat, not the stretcher. Tracy checks the bench seat seatbelt to ensure that it is secure. She then re-wraps the patient’s hands using a bandage.

You begin to drive the ambulance in non-emergency mode to the local hospital. As you pull onto the road you hear on your radio that several calls are being dispatched in your area. One call involves an elderly patient experiencing a medical emergency. The call is less than a block away.

“Want to take the call?” Tracy asks from the back of the ambulance.

You ponder for a second then say, “Sure.” You begin to mentally plan the approach for responding to a second call: The patient with the hand laceration (Patient #1) can sit in the passenger seat of the ambulance. Patient #2 can be transported on the stretcher. Tracy can take care of Patient 2 while you observe Patient 1 in the passenger seat.

You update the dispatcher that you can respond to the call for the elderly patient and that you have an “open stretcher.” Less than two minutes later you arrive on scene at a private residence. Tracy takes a kit with her into the house. You climb into the back of the ambulance and observe the patient with the hand laceration.

Within only a few minutes Tracy calls you on the radio and updates you that patient #2 will need to be transported by ambulance. Additional first responders arrive on scene and you relay this information. The first responders assist Tracy with the stretcher and on-scene logistics. You move patient #1 to the passenger seat of the ambulance.

A few minutes later the stretcher is loaded into the back of the ambulance with patient #2. Tracy tells you that she is “all set.” You check patient #1 and ensure that he is safely seated in the passenger seat of the ambulance. You depart for the local hospital with two patients from two different scenes.

Your ambulance is a few blocks away from the hospital stopped at a red light. You hear a “click” and patient #1 jumps out of cab. You curse under your breath as you turn on the emergency lights. Next you jump out of the ambulance and chase patient #1, who has tripped over a curb and is stumbling to regain his footing. You quickly catch patient #1 and escort him back to the passenger seat of the ambulance.

After re-securing the patient in the passenger seat and locking the doors, Tracy mentions from the back of the ambulance that she and patient #2 are doing well. Three minutes later you arrive at the hospital and safely deliver patients 1 and 2.

Situation Analysis

In the above situation the EMS crew “doubled-up.” In the past this practice may have been accepted in EMS systems. Today it is not always encouraged. Here are some factors to consider prior to “doubling-up” or “double-loading.” (Please note that the above example and following discussion regarding “doubling-up” does not apply to exceptional situations such as mass casualty incidents. For this discussion, doubling-up is when a crew assigned to a single call volunteers to respond to a second call.)

EMS crew focus: If an EMS crew responds to two separate calls that are in different locations at the same time, will the individual crew members be able to function effectively with potentially two or more patients?

Patient deteriorates: If your crew “splits” and responds to a separate call, will the individual providers be able to manage any potential challenges/difficulties presented by either patient? 

Resources: Resources can be quickly depleted when one patient is critical. Are back-up resources available if needed? In the above scenario, if the second patient becomes critically ill, which crew member will stay with patient #1 until additional resources arrive?

EMS crew safety: It is not possible to predict scene dynamics. Ensuring that the providers are safe should be a primary concern. Entering a scene without a partner can potentially place the crew’s safety at risk. Having two patients from two separate scenes in an ambulance may require additional attention. It can potentially distract the EMS crew. 

Patient safety: Will the patient’s safety be placed at risk if the original call was limited to one patient and the EMS crew decides to add additional patients from non-related calls? What happens if the patients have a confrontation in the ambulance? In the above scenario an intoxicated and sober patient are transported in the same ambulance. This may not be an ideal situation.

Intoxicated/inebriated patients: Patients under the influence of alcohol or illicit drugs can be unpredictable. In the above scenario, patient #1 jumped out of the ambulance. This was a significant risk. 

Critical/Non-critical: Not including unique situations such as mass casualty incidents (MCI), is it appropriate to transport a potentially critical patient in the same ambulance as a non-critical patient?

HIPAA/patient confidentiality: Are there HIPAA and/or patient confidentiality concerns if two patients from separate calls are transported together?

Disease transmission: Is there a risk of infectious disease transmission if two patients from two different scenes are transported together?

EMS policy: Is the transportation of patients from different scenes against EMS policy? What if some of the patients are intoxicated? What happens if a crew violates the policy?

Family/bystander reaction: What may start as a calm scene may erupt into confusion if family and/or bystanders note that patient #2 is “sharing” an ambulance with a second patient.

The previous discussion highlights a scenario that is not likely to be common in today’s EMS systems. While a few examples of possible outcomes were presented, it should be recognized that there are numerous potential implications when “double-loading.”  

Paul Murphy, MSHA, MA, is a regional sales manager with InTouch Health. He has administrative and clinical experience in healthcare organizations.

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