Four-Patient MCI With Limited Transport Resources
You are the first ALS unit on scene of a four-vehicle collision. A helicopter is 20 minutes out, two additional BLS ambulances are 10 minutes out, and you have one fire engine with three firefighters. Four patients are visible. Patient A is a 41-year-old woman walking around with a scalp laceration, GCS 15, RR 18, and a radial pulse. Patient B is a 63-year-old man sitting in a car, RR 32, radial pulse present, follows commands, and has abdominal tenderness. Patient C is a 25-year-old man unresponsive behind the wheel, RR 6, no radial pulse, GCS 3. Patient D is a 55-year-old woman with an open femur fracture, RR 24, radial pulse present, follows commands, and is pale. You are incident command until relieved.
1. Assign triage categories and immediate priorities for each patient.
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Using START: Patient A is green-ambulatory, normal respirations, perfusing. Patient B is red because RR is 32 (>30), even though he follows commands. Patient C is red-RR 6 (<10) and unresponsive; open the airway and give BVM ventilation, then reassess. Patient D is yellow-RR 24, radial pulse present, follows commands-but control the open femur fracture bleeding and splint. Immediate priorities are C's airway/ventilation and B's rapid transport; D needs hemorrhage control but can wait briefly; A can be walked to a treatment area. Triage is dynamic-reassess B and D because they can deteriorate.
2. How do you allocate the one helicopter and two BLS ambulances?
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Send the helicopter to Patient C: unresponsive, RR 6, needs definitive airway and has the highest likelihood of dying without advanced care. Use your ALS unit for Patient B, the other red, because of abdominal tenderness and tachypnea suggesting internal injury. Send one BLS ambulance for Patient D after bleeding control and splinting; send Patient A with the remaining BLS ambulance or with law enforcement/fire if permitted after evaluation. Do not hold the helicopter for a yellow patient. If the helicopter is delayed, C goes by ALS ground to the trauma center and B by BLS, with early notification. The principle is reds first, then yellow, and do not let a green patient consume a transport resource.
3. What incident command actions do you take in the first 5 minutes?
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Establish command, confirm scene safety and traffic control, and request additional ALS and law enforcement. Assign triage, treatment, and transport roles; keep one person tracking patients and destinations. Set up a treatment area away from traffic and a landing zone for the helicopter. Communicate with the receiving trauma center early. Do not personally get locked into treating one patient if you are the only command; delegate. Document triage tags, times, and interventions. Reassess the reds frequently and update command as resources arrive.