Triage Under a Single Ambulance
A flash flood has isolated a market area. A mobile health team of one nurse and two community health workers has a single ambulance and basic trauma supplies. Four casualties are reported within 200 m of each other: (A) a 60-year-old man with crushing chest pain, sweating, and pain radiating to the left arm, conscious and talking; (B) a child, approximately 6 years old, with a deep laceration to the forearm, bleeding controlled with direct pressure, crying loudly; (C) an unconscious adult pulled from water, not breathing, with no palpable pulse; (D) a woman with an obviously deformed, angulated femur and pale, clammy skin. The ambulance can take one priority patient plus one walking wounded per trip; the hospital is 25 minutes away.
1. Apply a triage framework and justify the order of transport.
Read the worked answer
Use a recognised triage logic (e.g., simple triage and rapid treatment / colour tagging) and reason explicitly:
- (C) Unconscious, apnoeic, pulseless - in a mass-casualty context this is expectant/deceased (black). Prolonged CPR is not resource-appropriate when other salvageable patients exist and transport is scarce. Document and, if possible, leave with a marker and notify.
- (A) Chest pain with radiation and diaphoresis - high suspicion of acute coronary syndrome; time-critical but currently stable and conscious. Priority (red/yellow).
- (D) Deformed femur, pale and clammy - signs of hypovolaemic shock from a long-bone fracture and possible pelvic involvement; needs analgesia, splinting, and IV fluids if available. Priority (red).
- (B) Child with controlled bleeding - distress is high but the airway/breathing/circulation threat is controlled; can travel as walking wounded once bleeding is secured and the child is calmed.
Order: D and A are the true reds; the single ambulance means the nurse must decide who goes first. D's shock signs suggest deterioration faster than A's currently stable angina-equivalent, so D first with the nurse escorting, A second, B as walking wounded on the return leg or with a CHW. C is not transported.
The key exam point is that loudest ≠ sickest and dead ≠ priority.
2. The child's parent insists the child go first because 'children always come first.' How should the team handle this?
Read the worked answer
The team must balance clinical priority, ethical duty, and trust.
- Acknowledge and validate the parent's fear; do not dismiss it.
- Explain in plain language that the child's bleeding is controlled and the child is stable, while the woman with the leg injury is showing signs of shock that can become life-threatening within minutes - this is why the order is what it is.
- Assign a named carer: a CHW stays with the child and parent, maintains pressure, monitors for deterioration (pallor, confusion, rising pulse), and has a clear trigger to escalate if the child's condition changes.
- Do not promise a false order; if the child deteriorates, re-triage immediately and the child becomes priority.
- Document the triage decision and the communication.
This tests whether the candidate can hold a clinically defensible line while preserving dignity and consent - a core protection/ethics competency, not a recall fact.