Four Casualties, One Trained Rescuer: Triage and First Aid on the Highway
It is 7:40 p.m. on a highway in Uttar Pradesh, 24 km from the nearest community health centre. The ambulance has been called and will take about 25 minutes. A private bus has overturned. There are four casualties and you are the only person with any first-aid training; a shopkeeper is helping. Casualty A is a man of about 40, unresponsive, with no visible bleeding; after you open his airway and reposition his head he is still not breathing normally and has no pulse at the neck. Casualty B is a woman of about 30, conscious, with bright red blood spurting in pulses from a wound on the front of her thigh. Casualty C is a boy of about 8, conscious and crying, with a scald on the right forearm covering about 9% of his body surface, blisters intact, skin red and wet. Casualty D is a man of about 50, shouting in pain, with his lower left leg bent at an unnatural angle, swelling, no open wound, and a warm foot with a pulse. Your first-aid box has gloves, gauze, roller bandages, a triangular bandage, tape and antiseptic. There is no AED, no oxygen, no tourniquet and no splint.
1. Set out your order of action for the first ten minutes and justify it, including the decision about casualty A.
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Order: B, then D, then C - and A is tagged expectant.
Use simple mass-casualty triage. A is unresponsive and, after the airway is opened and the head repositioned, is not breathing normally and has no pulse. With one trained rescuer, no AED, and an ambulance 25 minutes away, survival from out-of-hospital cardiac arrest is very close to zero. If you start CPR you are locked in place, and B - who is salvageable and will bleed to death in minutes - is lost. So: gloves on, check A's airway and breathing, tag and move on. If a second trained person arrives, hand A to them for compression-only CPR while you take B.
B first: spurting bright red blood is arterial. Direct pressure immediately, before anything else. D next: a deformed leg with a pulse is not immediately life-threatening, but splinting prevents shock and further injury. C last: a 9% scald is painful but not immediately fatal; cooling can wait a few minutes.
Meanwhile the shopkeeper: calls 108, notes the time, stops traffic and stands at the road with a torch to flag the ambulance.
2. How would you control casualty B's bleeding using only gauze and bandages, and when would you improvise a tourniquet? Why is a tourniquet wrong for casualty C?
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Controlling B's bleeding:
- Wear gloves. Press a gauze pad firmly on the wound and hold continuous direct pressure for at least 10 minutes without lifting it to look.
- If blood soaks through, add more pads on top - do not remove the first ones.
- Elevate the limb if there is no fracture.
- If the wound is deep, pack gauze into it and keep pressing.
When to improvise a tourniquet: only if arterial bleeding is not controlled by pressure and packing, or if you must leave B to treat other casualties. Place it 5-7 cm above the wound, not over a joint, pad it, tighten until bleeding stops, write the time on the skin, and do not loosen or cover it. A tourniquet is a last resort because it can cause limb ischaemia and nerve damage.
Why not for C: a tourniquet controls bleeding from a limb wound. C has a burn with intact blisters and no bleeding; a tourniquet would do nothing for the burn and would cut off blood supply to an injured limb. Keep B lying and warm and watch for shock while you wait.
3. Describe your care for casualty C's burn and casualty D's leg while waiting, and list what must not be done.
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Casualty C, the burn:
- Remove rings or tight clothing near the burn if they are not stuck to it.
- Cool the forearm under clean running water for about 20 minutes. Clean water, not ice.
- Do not burst the blisters - they are a sterile dressing.
- Cover loosely with clean, non-fluffy cloth or cling film laid on, not wrapped around, the limb.
- Keep the child warm, reassure him, and give small sips of ORS if he is thirsty and not vomiting. A 9% scald in a child needs hospital referral.
Casualty D, the leg:
- Do not straighten it. Immobilise it in the position found, using the triangular bandage and an improvised padded board, or bind it to the other leg if nothing else is available.
- Check the foot pulse and sensation before and after splinting.
- Apply a cold pack wrapped in cloth over the swelling and keep him still.
- Give nothing by mouth, since surgery may be needed.
Must not be done: no ice, toothpaste, oil or turmeric on the burn; no tourniquet on C; no attempt to straighten D's leg; no food or water for D; never leave the casualties alone; and record the time of every intervention.