Multivehicle Collision with Two Casualties
You arrive first on scene at a two-vehicle collision on a highway shoulder at dusk. A small car has rear-ended a pickup. In the car, the driver, a 30-year-old woman, is awake and screaming, with an obvious deformed right forearm and a bloody scalp laceration. She is trapped by a jammed door but the car is stable and not smoking. In the pickup, the driver, a 55-year-old man, is slumped over the wheel, breathing noisily at about 8 breaths per minute with snoring sounds and a weak, fast radial pulse. He has a steering-wheel imprint bruise on his chest. A bystander is trying to open the car door and another is filming. Traffic is passing at highway speed. You are alone with a first-aid kit and an AED; your ambulance is 6 minutes out.
1. Describe your scene size-up and triage decisions, and justify why you prioritize the way you do.
Read the worked answer
Scene size-up first: the scene is not yet safe. Traffic is moving at highway speed, so position your vehicle to shield the scene, turn on hazard lights, and direct bystanders to set warning triangles or flares if available. Move the filming bystander back and assign someone to traffic control. Note that the car is stable and not smoking, so there is no fire or fuel hazard forcing immediate extrication. Do not enter moving traffic lanes.
Triage: the man in the pickup is the priority. He has a reduced level of consciousness, snoring respirations at 8 per minute, a weak fast pulse, and a chest-impact bruise suggesting serious internal injury. Airway and breathing come before the screaming patient's painful arm. The woman is awake, talking, and has isolated limb and scalp injuries; her screaming indicates a patent airway and adequate perfusion, so she can wait briefly. This is the ABC priority rule, not a judgment about who is suffering more.
Actions: approach the man, open his airway with a head-tilt or jaw-thrust if trauma is suspected, and support ventilation with a bag-mask at an appropriate rate while waiting for the ambulance. Keep his spine still as much as possible. Tell the woman clearly that you see her and will be with her as soon as you can, and ask a bystander to stay with her and apply direct pressure to the scalp wound. Request additional resources and law enforcement for traffic control.
2. Your ambulance arrives with one partner. Explain how you divide the two patients and what you communicate to the receiving hospital.
Read the worked answer
Division: your partner, who can drive and assist, takes the stable but painful woman once she is extricated, and you stay with the man, who is the unstable patient. If extrication of the woman will take time, treat her in place: direct pressure on the scalp, splint the forearm in the position found, keep her warm, and reassess distal circulation, sensation, and movement. Do not delay the man's transport to wait for her extrication. If only one ambulance is available, the unstable man goes first and a second unit is requested for the woman; she is not left alone, and a bystander or law enforcement stays with her.
Communication to the receiving hospital: give a concise report. For the man: mechanism (high-speed rear-end, steering-wheel impact), reduced level of consciousness, respiratory rate about 8 with snoring, weak fast pulse, suspected chest and head injury, airway support in progress, and estimated arrival time. For the woman: trapped but stable, deformed forearm, scalp laceration with controlled bleeding, and estimated arrival after extrication.
Also communicate with the incident commander or dispatch about the need for a second ambulance, fire extrication, and police traffic control. Reassess both patients en route and document times, vitals, and interventions. The key judgment is that scene safety and airway precede everything, and that a stable patient can be temporarily delegated without being abandoned.