The Overcrowded Resus Bay: A 3 a.m. Triage Decision
It is 03:10 on a Saturday. Your department has 4 resuscitation bays, all occupied. Bay 1: a 78-year-old with a ruptured AAA, hypotensive (BP 78/50), awaiting theatre. Bay 2: a 24-year-old post-motorcycle crash, GCS 7, intubated, awaiting CT. Bay 3: a 62-year-old with an inferior STEMI, pain-free after aspirin and heparin, awaiting PCI transfer in 20 minutes. Bay 4: a 45-year-old with severe asthma, silent chest, SpO2 88% on 15L, exhausted. Ambulance patch: a 30-year-old with a stab wound to the left chest, BP 70/40, GCS 13, ETA 6 minutes. Two of your four nurses are on a mandatory break; one is in Bay 4. Your registrar is in Bay 2. The ED consultant is not on site until 07:00. The theatre coordinator says Bay 1's patient cannot go until the anaesthetist finishes an emergency Caesarean in 25 minutes.
1. What is your immediate operational plan for the incoming penetrating trauma patient, and how do you justify it against the competing demands of the other three bays?
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Immediate plan
Call in the second nurse from break and page the on-call surgical registrar and anaesthetist - this is a time-critical penetrating torso trauma with hypotension. The patient needs a resuscitative thoracotomy-capable team, massive transfusion protocol activation, and immediate transfer to theatre if positive.
Clear a space. Bay 3's STEMI patient is the most physiologically stable and pain-free; move them to a monitored cubicle in the main department with a nurse and continue the PCI transfer. This frees a resus bay without compromising the STEMI pathway, because the patient is already reperfused pharmacologically and is awaiting transfer, not active intervention.
Do not wait for the anaesthetist. The 25-minute delay applies to Bay 1's theatre. The stab wound patient needs the resus bay now; the surgical registrar can assess and, if indicated, proceed to theatre with the on-call anaesthetist who is already in the building finishing the Caesarean.
Justification
- The penetrating trauma patient has the highest immediate mortality risk (hypotension plus penetrating torso injury = probable massive haemothorax or cardiac injury). Time to haemostasis is the only modifiable variable.
- Bay 1's AAA is also time-critical, but the constraint is the anaesthetist, not the bay. Moving Bay 3 does not delay the AAA.
- Bay 4's asthma patient is deteriorating but has an assigned nurse and an active treatment plan; the registrar can be freed from Bay 2 once the intubated patient is handed to the CT team.
- The consultant's absence is a governance issue, not a clinical one: activate the on-call consultant by phone for advice and document the decision.
Documentation should note the triage reasoning, the redeployment of staff, and the escalation calls made.
2. The stab wound patient arrives with a systolic BP of 70, distended neck veins, and muffled heart sounds. Your registrar asks whether to do a FAST or proceed straight to theatre. How do you decide?
Read the worked answer
Recognise the triad and act on physiology, not imaging.
Beck's triad (hypotension, distended neck veins, muffled heart sounds) in penetrating chest trauma is highly specific for cardiac tamponade. In a patient this unstable, the decision is not whether to image but whether the patient will survive the next 10 minutes.
Decision framework:
- If the patient arrests or peri-arrests in the resus bay: proceed to resuscitative thoracotomy (left anterolateral) as a bridge to theatre. Do not delay for FAST.
- If the patient is haemodynamically unstable but not arresting: a subxiphoid or parasternal FAST can be performed in under 60 seconds by an experienced operator and will confirm pericardial fluid, but it must not delay transfer. If the operator is not immediately available, proceed to theatre - the surgical registrar can perform a pericardial window or sternotomy on arrival.
- Do not order a CT. The patient is too unstable.
Justification: In penetrating cardiac injury, the mortality benefit is almost entirely from time to surgical decompression. A FAST that takes 10 minutes and delays theatre by 10 minutes is a net harm. The registrar's question is really about diagnostic certainty versus time; in this physiology, time wins.
Communication: Tell the theatre coordinator to prepare for an immediate sternotomy. Activate the massive transfusion protocol. Notify the cardiothoracic surgeon if one is available; if not, the general surgeon proceeds.