Six Patients, Two Ambulances: Night Highway MCI
You are the first AEMT on scene of a six-car pileup on a rural two-lane highway at night. Weather is clear. Your ambulance is on scene with a second ambulance 12 minutes out; the nearest helicopter is 25 minutes out. Patients:
- P1: 30s, walking, crying, small scalp laceration.
- P2: 50s, seated in a car, RR 34, radial pulse present, confused, cannot state her name.
- P3: 20s, supine on the road, RR 6 and agonal, no radial pulse, unresponsive.
- P4: 60s, RR 22, radial pulse present, follows commands, deformed thigh.
- P5: 40s, pulseless and apneic with obvious massive head trauma, remains apneic after airway positioning.
- P6: 20s, walking, refuses care, asking to leave.
1. Assign a triage category to each patient and justify each one.
Read the worked answer
Using a START-type approach:
- P1 - Green (minor). Walking, crying, minor wound.
- P2 - Red (immediate). RR 34 is above 30 and she is confused; both are red criteria.
- P3 - Red (immediate). RR 6 / agonal with no radial pulse. Needs ventilation now.
- P4 - Yellow (delayed). RR 22, pulse present, follows commands; the femur is significant but not immediately life-threatening once splinted.
- P5 - Black (deceased/expectant). Pulseless, apneic, and remains apneic after airway positioning, with obvious massive head trauma.
- P6 - Green functionally, but a refusal, not a triage category. Walking wounded who wants to leave; capacity must be assessed and documented.
The key judgment is P2 and P3 are both red, and P5 is not a resuscitation candidate in a resource-limited scene - moving providers to P5 would cost P3's life.
2. With one ambulance now and a second in 12 minutes, how do you allocate people and transport order?
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Now:
- Put your most airway-capable provider with P3 and start BVM with 100% oxygen and an oral airway; if breathing does not improve, P3 is the highest-priority transport.
- Assign a walking wounded patient (P1) or a bystander to hold c-spine and keep P5 covered and out of the way; do not start CPR on P5.
- Rapidly splint P4 and keep him ambulatory-capable for a yellow slot.
Transport order:
- First ambulance: P3, with a provider ventilating continuously. Without ventilation this patient dies in minutes.
- Second ambulance (12 min): P2. Confusion plus RR 34 means she needs assisted ventilation and a trauma center; she can be ventilated by the provider on scene until the second unit arrives.
- Then P4, then P1/P6.
Acknowledge the trade-off explicitly: P2 waits 12 minutes with a single provider, which is why reassessing her every 2-3 minutes and calling for additional resources immediately is part of the plan.
3. P6 wants to leave before EMS evaluation. What do you do, and what changes if she is the only walking patient who can help?
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Assess capacity and competence: is she alert, oriented, and able to understand the risks? At 20 years old she is an adult. If she has capacity, she may refuse - but explain the risks (neck pain, delayed symptom onset), offer evaluation, and document the refusal, her words, and the witnesses. If she lacks capacity - head injury, intoxication, confusion - she cannot refuse and should be transported.
What changes if you need her help:
- You may ask for assistance, but you cannot detain or conscript her; a refusal is a refusal.
- Use bystanders instead, and request additional resources early (fire, law enforcement, more ambulances).
- Do not let a refusal pull your only provider away from the red patients; hand the refusal paperwork to a later-arriving unit or law enforcement.
The judgment being tested is that scene control and documentation are clinical interventions, not paperwork after the fact.