Seven Casualties, Two Ambulances and One Helicopter
At 14:20 on a clear, dry day a minivan carrying six people crosses the centre line on a rural highway and is struck on the passenger side by a loaded grain truck. The truck blocks both lanes; the minivan is on its side in the ditch. You arrive first with three colleagues in a rescue vehicle; two ALS ambulances are 12 minutes out, a BLS ambulance 20 minutes out, and a helicopter is 25 minutes away. The nearest trauma centre is 45 minutes by road; a small clinic is 10 minutes away. Traffic is backing up and a smell of diesel is noticeable.
Casualties: (A) 34-year-old, unresponsive, RR 6, weak radial pulse; (B) 8-year-old, crying, RR 28, capillary refill 4 s; (C) 45-year-old, walking, neck pain; (D) 60-year-old, open abdominal injury, pale, pulse 130, RR 24; (E) 27-year-old, deformed right thigh, screaming; (F) 70-year-old, confused, RR 32; (G) 19-year-old, 4 cm scalp laceration, walking.
1. Assign a triage category to each casualty and justify it. Which categories are most at risk of being wrong, and why?
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Using START and treating every casualty as potentially unstable:
- A (RR 6, unresponsive): immediate/red. Ventilation is inadequate; open the airway and assist with a BVM.
- B (8 y, RR 28, cap refill 4 s): immediate/red. The delayed perfusion overrides the apparently acceptable rate; children compensate and then crash.
- D (open abdomen, pale, pulse 130): immediate/red. Signs of class II–III shock and a time-critical surgical abdomen.
- F (confused, RR 32): immediate/red. RR >30 plus altered mental status.
- E (deformed femur, screaming): delayed/yellow if bleeding is controlled; screaming means a patent airway. Re-triage to red if the thigh is expanding or the pulse is lost.
- C (walking, neck pain): delayed/yellow - walking is a green criterion, but neck pain and mechanism warrant spinal precautions.
- G (walking, scalp laceration): green/minor. Report a casualty count early. Over-triage of B and under-triage of E are the practical risks.
2. With two ALS ambulances, one BLS ambulance and a helicopter 25 minutes away, describe your transport plan and the reasoning behind it.
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Transport is a resource-allocation decision, not just a severity list.
- A needs bag-valve ventilation and airway support now; without it he will arrest at the scene. Put him in the first ALS unit with F (also red) and move.
- D has an open abdomen and shock; surgery within the hour is his only definitive treatment. The helicopter avoids the 45-minute road leg and is best used for D, with B if the aircraft can take a second patient.
- E needs analgesia, haemorrhage control and traction splinting; he can go by BLS to the trauma centre after the reds, or to the clinic only if the clinic can splint and transfer.
- C and G are green; they can wait for the second BLS unit or police transport after assessment.
- Do not send a red patient to the clinic 10 minutes away unless it can provide airway or surgical care; the clinic is a treatment stop, not a destination for D. Reassess at loading and on arrival; the plan changes if A arrests or D's mental status drops.
3. What scene hazards and command/communication actions do you take in the first 10 minutes?
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Hazards and command.
- Diesel smell plus a loaded grain truck means fire risk and possible cargo shift; establish an upwind staging area, no smoking, and keep vehicles off spilled fuel.
- Request fire for fuel control and extrication, police for traffic, and additional ambulances.
- Assume the role of incident commander until relieved, then hand over with a structured briefing. Assign triage, treatment, transport and safety officers; one person should not triage and treat.
- Use METHANE: Major incident declared, Exact location, Type (two-vehicle collision with entrapment), Hazards (diesel, traffic, unstable minivan), Access (northbound lane), Number of casualties (seven, four red), Emergency services present and required.
- Keep a written casualty list with triage tags and update dispatch as categories change; this prevents a patient being loaded twice or missed.