Three casualties, one health worker: triage and airway at a road crash
At 4:15 p.m. on a state highway 6 km from your sub-centre, a jeep has hit a motorcycle. You are the first health worker on the spot; the 108 ambulance has been called but is 25 minutes away. Three casualties are on the road. Casualty A is a man of about 30, lying on his back, unresponsive, breathing noisily with blood and vomit pooling in his mouth. Casualty B is a woman of about 25, sitting up and screaming, with bright red blood spurting from a cut on her left forearm. Casualty C is a boy of about 12, walking and asking for water, his right forearm bent at an unnatural angle. About 20 villagers have gathered; one is pulling casualty A by the arms towards the roadside, and two others are arguing about pouring water into his mouth. Traffic is still moving on both sides of the road, it is 42°C, and your kit contains gloves, gauze, roller bandages, a splint, a pocket mask and no tourniquet.
1. In what order do you act during the first 3–4 minutes? State what you do for each casualty and for the crowd, and justify the order.
Read the worked answer
1. Scene safety first. Park off the carriageway, ask two bystanders to slow traffic, and put on gloves before touching blood. A second casualty made by a moving vehicle helps nobody.
2. Stop the dragging. Pulling an unresponsive trauma patient by the arms can turn a stable spine into a cord injury and kinks the airway. Ask that man to support the head instead, keeping it in line with the trunk, and to stop anyone pouring water.
3. Delegate before you treat. Casualty B is spurting arterial blood and can exsanguinate in minutes, but A's airway is also immediately life-threatening. Send a second bystander to press gauze hard on B's forearm and hold it up; tell them not to release until you come. This is why you do not simply work down the row of patients.
4. Airway for A. Remove only visible solid matter from the mouth - no blind finger sweeps. Use the pocket mask with a jaw thrust and in-line head support, then place him in the recovery position if he is breathing, so blood and vomit drain out.
5. Then B and C. Bandage B firmly over the gauze and check that her fingers stay pink and warm. Splint C's forearm in the position found - never straighten a deformed limb.
6. Recheck A's breathing every 2 minutes until handover. Order: airway → catastrophic bleeding → limbs, with delegation so nothing waits.
2. The crowd insists that you pour water into casualty A's mouth and give casualty C a drink. How do you respond, and what are the clinical reasons?
Read the worked answer
Refuse both, and say why out loud so that nobody does it behind your back.
Casualty A (unresponsive): fluid poured into the mouth of an unconscious person runs into the lungs, not the stomach. He already has blood and vomit in his pharynx and is breathing noisily, so his protective reflexes are unreliable; adding water causes aspiration, choking and later aspiration pneumonia. The correct action is to keep the mouth clear and the head turned, not to give fluid.
Casualty C (conscious but injured): he is kept nil by mouth because (a) trauma patients often vomit, and a stomach full of water means aspiration; (b) he may need sedation or surgery within hours and must have an empty stomach; (c) if there is an abdominal injury, oral fluid worsens vomiting, distension and pain and blurs the clinical picture. He is not dehydrated from a 25-minute wait.
What to do instead: moisten C's lips with a clean wet cloth, let him rinse and spit if he is thirsty, and reassure him that help is coming. Tell the crowd a health worker has assessed him and that a drink now could kill him. Record in your notes that oral fluids were withheld and why, and mention it in handover so the hospital does not think he has been starved accidentally.
3. Give the handover you would make to the ambulance crew. List at least six specific items and explain why each matters.
Read the worked answer
Use a structured SBAR-style handover, spoken and then written on the referral slip:
Situation and scene: jeep-versus-motorcycle on the state highway, 6 km from the sub-centre, at 16:15; three casualties, all unidentified; one bystander moved casualty A by the arms before your arrival. Why: the receiving team needs to know a spinal injury is possible and how long the patients have been down.
Casualty A: adult male, unresponsive, breathing spontaneously, airway cleared of blood and vomit at 16:20, recovery position, no external bleeding seen, pocket-mask ventilation not required. Why: the airway is his main threat and they must recheck it first.
Casualty B: adult female, arterial bleeding from the left forearm, controlled by direct pressure from 16:22, pressure bandage applied at 16:26, fingers pink and warm, radial pulse present. Why: they must know the exact time bleeding was controlled; a tourniquet may still be needed.
Casualty C: boy about 12, closed deformity of the right forearm, splinted as found at 16:30, nil by mouth, conscious and talking. Why: splint time and nil-by-mouth status affect anaesthesia.
Interventions and times - nothing given by mouth, no drugs, no tourniquet available in your kit.
Receiving hospital and contact, estimated ambulance arrival, and your name and designation. Why: a handover that is not written and signed cannot be traced if the patient deteriorates.