Nine Patients, Two Paramedics, One Leaking Truck

Scene safety and command first - the fastest way to turn nine patients into eleven is to walk into the leak.

1. Park upwind and uphill, well back from the truck (100 feet minimum), and leave the emergency lights on for visibility in the rain.
2. Assume the leak is hazardous until proven otherwise: acrid odor, unknown cargo, no placard visible in the dark. Do not approach the cargo area or enter the hot zone. Note the wind direction.
3. Establish command - announce '[unit] command established' and name yourself. Assign your partner as triage or group supervisor.
4. Give a concise size-up to dispatch with a resource request: additional medic units, fire, HazMat, law enforcement for traffic control, and air medical. Poor radio coverage means you may need to relay through a unit on high ground - decide that early, not at minute 20.
5. Move the walking wounded away from the wreck and upwind into a cold zone. They self-extricate; you do not enter the hazard to get them.
6. Triage from the perimeter. You can categorize patients you can see and hear without entering the contamination area.

What you do not do: start an IV, splint a wrist, or commit to one patient before the scene is triaged.

A - Immediate (Red). Fails three screens at once: respiratory rate above 30, absent radial pulse (poor peripheral perfusion), and altered mental status. This is decompensated shock and he will die soonest without intervention.

B - Expectant (Black) under MCI triage. An apneic patient who remains apneic after airway repositioning is triaged as deceased/expectant in a resource-limited mass casualty situation. This is the hardest call on the scene. It is defensible because you have nine patients and two paramedics; it would not be defensible if she were your only patient and you had a unit available to transport. Document the time, the repositioning attempt, and your reasoning.

C - Immediate (Red). Respiratory rate and perfusion screens pass, but she fails the mental status screen. Any patient who cannot follow simple commands in a mass casualty incident is immediate. A teenager who withdraws but does not obey is a likely head injury and needs a trauma center.

The judgement point: A and C are both red, but they are not equally urgent. A's absent radial pulse tells you he has minutes; C has an hour. Triage category tells you who needs resources; it does not tell you the order among reds.

Load and go with A. Your partner stays to hold triage until the next medic unit arrives.

Reasoning:

• A is the patient with the shortest interval to death (RR 36, no radial pulse, altered). He is also the patient for whom a 34-minute trauma center transport may be too long; the 18-minute hospital is the right destination for him unless he has an isolated head injury.
• C can wait for the second unit. She is red, but perfusing and breathing at a rate that will not kill her in the next 12 minutes.
• Consider air medical for C, specifically to the Level II trauma center, so ground resources are not tied up in a 68-minute round trip. Request it now, not after you have loaded A.
• Do not delay A's transport to also load C. One paramedic in the back cannot monitor two critical patients.

Using arrivals: fire handles traffic, extrication, and hazard perimeter; the next medic unit takes C; HazMat establishes the hot/warm/cold zones and identifies the product. Hand off written triage categories, patient counts by color, and the times you assigned them.

Documentation: every patient gets a triage tag and a time. In a nine-patient incident, the run report you fail to write is the one that ends up in a deposition.