Godown Fire: Triage With One Ambulance
A godown fire in a market lane has been knocked down. Eight casualties are lying on the road outside. The nearest ambulance is 25 minutes away and only one is coming. A medical officer with two first-aid kits and four volunteers is on scene. Casualty A is a 46-year-old man with deep burns over the face, neck and chest, about 30% of body surface area; his voice is hoarse, there is soot around his nose, and his respiratory rate is 30/min. Casualty B is a 28-year-old woman with no visible burns, who is confused and coughing persistently, with a respiratory rate of 34/min. Casualty C is a 24-year-old man with a 6 cm forearm cut, bleeding controlled by direct pressure, walking and asking for water. Casualty D is a 62-year-old man clutching his chest, sweaty, with a respiratory rate of 24/min, and a known history of diabetes. Casualty E is a 9-year-old child crying loudly with no visible injury. Three more people are walking out of the smoke.
1. Set a treatment and transport order for A, B, C, D and E, and justify it using mass-casualty triage logic rather than diagnosis alone.
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Use a simple triage logic: airway and breathing first, then circulation, then the walking wounded, while remembering that a mass-casualty scene gives priority to those who can be saved with the resources present.
- A - immediate, first transport. Hoarse voice, soot and facial burns point to inhalation injury and impending airway swelling. His airway can close within hours. Keep him upright, give high-flow oxygen if available, and prepare for early airway management. Do not delay transport for burn dressings.
- B - immediate, with A. Confusion, cough and a high respiratory rate after smoke exposure suggest carbon monoxide poisoning or another inhaled toxin. She needs oxygen and monitoring; she may deteriorate quickly even though she has no burns.
- D - urgent, next. Chest pain in a diabetic is a time-critical cardiac event. He is not in immediate airway danger, but he should not be left to walk or wait indefinitely; send him on the ambulance's return trip or arrange the second vehicle.
- C - delayed. The bleeding is controlled and he is walking. Recheck the dressing, treat for shock, and do not let him drink large amounts.
- E - delayed but not ignored. A crying child with no injury is low medical priority, but needs a responsible adult, warmth and reassurance; keep her away from the scene.
The three walking wounded should be held in one area, counted, and observed for delayed collapse from smoke or crush injury.
2. What immediate first aid should be given to A and B, and what common practices should be avoided?
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For A:
- Move him to fresh air, sit him upright if his blood pressure allows, and give high-flow oxygen.
- Cover burns with a clean, dry, non-fluffy cloth or sterile sheet. Do not apply ice, toothpaste, oil, turmeric or cotton.
- Do not burst blisters and do not rub soot from the face.
- Remove rings, watch and tight clothing before swelling, but do not pull clothing stuck to burnt skin.
- Monitor breathing continuously and be ready to assist the airway; a hoarse voice is a warning, not a minor symptom.
For B:
- Give high-flow oxygen and keep her sitting up; do not let her lie flat if she is breathless.
- Check for other injuries and monitor consciousness; confusion after smoke exposure is a red flag.
- Do not give sedatives or make her walk long distances.
Avoid for both: large-volume water cooling of extensive burns, which causes hypothermia; oral fluids in a drowsy casualty; and sending them in a vehicle without oxygen if oxygen is available. The reasoning is that airway and oxygenation determine survival in the first hour, while burn dressing can wait.
3. The single ambulance can carry only two lying patients. How should the medical officer use it while waiting for more help?
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The ambulance should be treated as a shuttle, not a one-off taxi.
- First run: A and B, because both have airway/breathing threats and can deteriorate within minutes. Send a volunteer with the ambulance to give a handover: burns, soot, hoarse voice, oxygen given, and observed confusion.
- Second run: D, the chest-pain casualty, with aspirin if not contraindicated and no history of allergy, and with the first-aid kit's oxygen if available. Chest pain is time-critical and should not wait for a 'quiet' moment.
- Scene hold: C and E remain under observation with the volunteers. C's wound is rechecked for bleeding; E is kept warm and supervised.
- Communication: inform the receiving hospital and the 108 control room of the number and type of casualties, and request at least one more ambulance. Keep a written triage tag or note on each casualty.
The judgement is that transporting the walking wounded first would waste the only vehicle and leave the two most likely to die on the road.