The Explosion at the Fairgrounds: Triage, Transport, and the Load-Sharing Problem
You are the EMS branch director at a county fairgrounds where a propane tank explosion has occurred near a food vendor row at 18:30 on a Saturday. Initial reports: 14 patients. You arrive to find: 2 patients in cardiac arrest, 3 with severe burns over 30–50% TBSA and inhalation injury, 4 with blunt trauma (2 with suspected pelvic fractures, 1 with an open femur fracture, 1 with a head injury and GCS 12), and 5 with minor lacerations and abrasions. You have 4 ALS units, 3 BLS units, and 2 mutual-aid ALS units 10 minutes out. The nearest burn center is 45 minutes by ground; a level 1 trauma center is 20 minutes; the nearest community ED is 8 minutes. A helicopter is 25 minutes out. The fairgrounds has one access road, currently blocked by a fire engine.
1. How do you triage and allocate transport in the first 15 minutes?
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Use a mass-casualty triage framework (e.g., START or a similar system) and allocate by resource, not by individual need. The 2 cardiac arrests are expectant in a resource-limited MCI - do not commit an ALS unit to them while 7 patients with survivable severe injuries are untreated. The 3 severe burns with inhalation injury are priority; the 2 pelvic fractures and the open femur are priority; the GCS 12 head injury is priority. The 5 minor patients are delayed and can be held in a casualty collection point. Transport allocation: send the 2 mutual-aid ALS units (when they arrive) and 2 of your ALS units to the level 1 trauma center with the trauma patients; send 1 ALS unit to the burn center with the most severe burn (or hold for the helicopter if the burn center is the only destination); use BLS for the minor patients to the community ED. The teaching point: the cardiac arrests are not the priority in an MCI - the survivable severe injuries are.
2. The helicopter is 25 minutes out and the burn center is 45 minutes by ground. How do you decide whether to wait for the helicopter?
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Decision rule: compare time-to-definitive-care, not time-to-arrival. Ground to burn center is 45 minutes; helicopter arrival is 25 minutes plus flight time to the burn center (unknown, but likely 15–20 minutes), so total time by air may be 40–45 minutes - roughly equivalent. The helicopter's value is in freeing a ground unit and in clinical capability, not necessarily in speed. If the burn patient is unstable and the ground unit can leave now, send ground. If the patient can be stabilized and the helicopter can take a more critical patient while ground units handle the trauma patients, use the helicopter for the highest-acuity burn. Do not hold a patient on scene waiting for a helicopter unless the air asset clearly shortens time-to-definitive-care. The teaching point: air medical transport is a resource-allocation decision, not an automatic upgrade.
3. The access road is blocked by a fire engine. What is your operations decision, and what is the communication priority?
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Operations decision: request the fire engine be moved or, if it cannot, establish a secondary access route and a patient collection point at the nearest clear point. Assign a triage officer at the collection point and a transport officer at the loading area. Communication priority: establish a single command channel, notify the receiving hospitals of the MCI and approximate patient counts by acuity, and request the county MCI plan be activated if patient count exceeds local capacity. The teaching point: in an MCI, the branch director's job is flow - access, triage, transport - not hands-on care. The blocked road is a flow problem, and flow problems kill patients as surely as the injuries do.