Seven Casualties, One Ambulance: Triage and Destination on a Rain-Slicked Carriageway
At 02:10 on a rain-slicked dual carriageway a minivan carrying a family collides head-on with a parked truck, and a third car rear-ends it. You arrive with one basic-life-support ambulance (driver plus two EMTs) and one rescue tender. The DHQ hospital is 25 minutes away and has no surgical cover after midnight; the trauma centre is 45 minutes away and its CT scanner is out of service until 06:00. There are seven casualties. A: 34-year-old man trapped at the wheel, GCS 13, respiratory rate 26, palpable radial pulse, deformed left femur. B: 28-year-old woman ejected, not breathing after one airway repositioning, no palpable pulse, obvious head injury. C: 6-year-old crying, respiratory rate 22, capillary refill 2 seconds, bruising across the chest. D: 60-year-old man walking, neck pain. E: 45-year-old woman with a 10 cm scalp laceration, bleeding controlled by direct pressure. F: 19-year-old man, GCS 8, respiratory rate 8, weak carotid pulse. G: 70-year-old woman, pale, respiratory rate 30, pulse 130, rigid abdomen. Rain continues; traffic is passing at motorway speed.
1. Apply START triage to casualties A to G and give the loading order for the first run, given exactly two stretcher spaces and one seated position.
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START uses respirations, perfusion and mental status. Red (immediate): F, with a respiratory rate of 8 and GCS 8, needs airway opening and assisted ventilation now; G, respiratory rate 30, pulse 130, rigid abdomen, is decompensating from a probable solid-organ injury; A is currently borderline at GCS 13 and respiratory rate 26, but he is trapped, has a femur fracture with concealed bleeding and will deteriorate, so plan him as immediate for the second run. Yellow (delayed): C, respiratory rate 22, capillary refill 2 seconds, chest bruising - children compensate and then crash, so reassess every 5 minutes; E, bleeding controlled and otherwise stable. Green: D is walking, so green by triage despite neck pain, which is a mechanism issue rather than a triage category. Expectant: B has no breathing after one airway manoeuvre and no pulse; with seven casualties and two rescuers, do not start CPR.
First run: F and G on the stretchers and C in the seat, because a compensating child cannot be left with a green tag. Second run: A once hydraulically released, plus E; D walks or waits with police. Document the times of each tag and every reassessment, because triage categories change.
2. F and G both need surgery, but the trauma centre is 45 minutes away and its CT is down until 06:00. Where do you take each, and why?
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Separate the patients by what will kill them in the next hour. F's problem is ventilation: GCS 8 with a rate of 8 needs bag-valve-mask ventilation with an oropharyngeal airway and continuous observation. A BLS crew can do that but cannot intubate, and 45 minutes of hand ventilation in a moving ambulance with one EMT is not sustainable. So F goes to the DHQ, 25 minutes away, for airway support and stabilisation; the CT being down does not affect F's first-hour survival, and a scanner at 06:00 does not help a patient who arrests at 03:00.
G's problem is bleeding: a rigid abdomen with pulse 130 and respiratory rate 30 is a surgical abdomen, and the DHQ has no surgeon after midnight, so arriving there converts a 45-minute transport into a 45-minute wait plus a further transfer. G goes to the trauma centre despite the extra 20 minutes, with a pre-alert on the radio naming the suspected injury and the ETA.
If only one vehicle is available, the decision must be made with medical direction on the radio and documented: G first, with F ventilated on scene by the second EMT and a backup ambulance requested by priority.
3. Traffic is passing at motorway speed and a bystander is about to drag D clear of the vehicle. What do you do, in what order, and why?
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Scene safety comes before patient contact, because a second collision would generate more casualties than two crews can manage. Order of actions: position the ambulance and tender as a shield upstream of the wreck, angled with hazard lights on, and place triangles or cones at least 100 m back on the approach side; assign one person solely as lookout, with a torch and hi-vis, and give that person the authority to stop all work; stop the bystander physically if necessary, because D is walking and talking with neck pain and a panicked drag can turn a stable patient into a spinal cord injury. If D must be moved because of fire or a fuel leak, use manual in-line stabilisation with three people and a board; otherwise D stays where he is.
Then request motorway police and a second ambulance by radio with a precise location marker, and resume triage. The principle being tested is that the untrained rescuer is a hazard, not a helper, unless he is given a safe, bounded task such as holding a torch on the traffic side. Document the intervention and reassess D's neurology after any movement.