Scenario: High-Speed MVC — US-550 South of Bloomfield¶

Difficulty: HARD Category: Trauma — Multi-system / Multi-patient Generated: 2026-04-04

Dispatch¶

Unit 1 and Unit 4, respond to US-550 milepost 42, southbound — two-vehicle MVC, head-on collision. One vehicle a pickup truck, one a passenger car. Multiple patients reported. Caller says at least one person is trapped. NM State Police and Fire are en route. Time out: 1504.

Scene Size-Up¶

US-550 on the mesa between Bloomfield and Cuba, high desert terrain, no cell service noted on approach (relay via radio). You arrive first. Scene: - A northbound F-250 pickup has crossed the center line and struck a southbound Honda Civic head-on at high speed - Pickup driver: airbag deployed, driver still seated, not moving. Door accessible. - Civic: severe frontal crush. Driver door pinned. Driver visible, moving, screaming. Passenger (front): not visible — possible ejection, or down in footwell. - Bystander points to a figure approximately 40 feet off the road in the scrub. - Fluid on roadway — unknown if fuel or coolant. - Traffic is backing up. No fire visible yet.

You have 2 units. How do you triage and assign resources?

Patient Presentations¶

Patient A — Pickup Driver (accessible, not moving)¶

50s male, unresponsive
Airway: head slumped forward, snoring respirations
Breathing: 6/min, agonal
Circulation: carotid pulse present, faint. Massive facial trauma. Blood in airway.
Pupils: unequal — right blown (6mm, NR), left 3mm reactive
Visible: airbag abrasion, head laceration, deformed steering wheel

Patient B — Civic Driver (trapped, screaming)¶

30s female, alert, screaming in pain
Airway: patent, speaking
Breathing: 26, labored, splinting left side
Circulation: HR 130, weak. BP unknown (cannot access yet). Skin pale, diaphoretic.
Visible: left chest deformity, steering wheel imprint on chest, bilateral leg entrapment in crushed footwell
SpO2: 88% (bystander's device)

Patient C — Possible ejection (~40 feet from road)¶

On approach: 20s female, supine, not moving, no response to shouting
Further assessment pending

Patient D — Civic Front Passenger (found in footwell)¶

~6-year-old child, crying, alert, no obvious major injuries
Moving all extremities, no major bleeding visible

Assessment Steps

Triage first — you have 2 units and 4 patients.

Using START triage (see start-triage for the full algorithm): - Patient A (pickup): Breathing 6/min agonal → open airway → does not improve → BLACK (expectant/deceased). Devastating head injury + unequal pupils + agonal breathing. Do not commit a unit to an unsurvivable patient. - Patient B (Civic driver): Breathing present, RR 26, SpO2 88%, perfused, alert → RED (immediate). Chest trauma, hypoxia, shock physiology, trapped. - Patient C (ejection): Not moving, not responding to voice → open airway → assess breathing → triage result depends on respiratory response. If breathing resumes with airway opening → RED. If no breathing after repositioning → BLACK. - Patient D (child): Alert, crying, moving all extremities, no major bleeding → GREEN (minor/delayed).

Resource assignment: - Unit 1: Patient B (critical, trapped, accessible from passenger side) - Unit 4: Patient C (ejection — unknown acuity, assess immediately) - Patient D: assign to a bystander or Fire when they arrive (green tag, monitor) - Patient A: Black tag, do not commit resources

Additional resources needed immediately: - ALS intercept (×2 if possible) - Fire/extrication for Patient B - Medical helicopter for Patient B or C - NM State Police for traffic control (already en route)

Interventions

Patient B (RED — your primary patient): 1. O2 via NRB 15 LPM immediately through passenger window. Target SpO2 ≥94%. 2. Assess for open chest wound — if present, 3-sided occlusive dressing. 3. Spinal motion restriction: manual c-spine from behind headrest through window until Fire can assist with extrication. 4. IV/IO access (ALS scope) — establish en route or during entrapment wait. 5. Hemorrhage control — assess for accessible bleeding while trapped. 6. Coordinate with Fire: rapid vs. standard extrication. She is hemodynamically unstable (pale, diaphoretic, tachycardic) — rapid extrication protocol if further deterioration. 7. Reassess every 2–3 min. Watch for tension pneumo: if SpO2 continues to drop, tracheal deviation develops, or BP crashes → ALS needle decompression needed.

Patient D (GREEN — child): 1. Assign to second EMT or capable bystander after rapid primary assessment. 2. C-spine precautions — significant MOI, young child, cannot reliably report symptoms. 3. Reassess when more resources arrive.

Patient C (ejection — Unit 4 assesses): Assessment and interventions per findings. If RED: ALS + helicopter. If BLACK: tag and move to next patient.

Transport Decision

Patient B: Priority ground transport to SJRMC (Bloomfield is 15 min south) with ALS intercept en route on US-550. Request helicopter to SJRMC pad for possible inter-facility to UNM Level I Trauma. She needs chest surgery.

Patient C (if alive): Helicopter to UNM Albuquerque if hemodynamically unstable. Ejection mechanism = highest mortality MOI.

Patient D: Ground transport to SJRMC with pediatric assessment en route. Green tag patients can decompensate — do not ignore.

Patient A: Remains on scene with Fire/Law enforcement. Medical examiner notification per protocol.

Key Takeaways

What this tests: START triage, multi-patient resource management, chest trauma management, expectant tagging (the hardest decision in EMS), pediatric patient in multi-casualty setting.

Common mistakes: 1. Committing to Patient A — students see the first patient and start working. He has unsurvivable injuries. Tagging him black and moving on saves more lives. This is emotionally hard. It is also correct. 2. Ignoring the child — she looks fine. She's still a patient. Kids compensate and then crash fast. Assign her. 3. Not calling for enough resources early — 4 patients, 2 units, rural highway. Get ALS, helicopter, and fire on the air in the first 60 seconds. 4. Missing the tension pneumo setup — SpO2 88%, chest deformity, tachycardia. Patient B is one more rib fracture away from tension pneumo. Watch for it. 5. Spending too long at scene — extrication + packaging + departure should be coordinated with fire. Your job is medical management, not pulling the door.

NM protocol note: START triage is the NM standard for MCI. Expectant/black tag includes: no breathing after airway repositioning, or unsurvivable injuries with agonal respirations. Do not initiate CPR at an MCI until all salvageable patients are treated and resources allow.

San Juan County context: US-550 between Bloomfield and Cuba is a high-fatality highway corridor — head-on collisions at 65–75 mph are common. Nearest trauma center (SJRMC Farmington) is a Level IV equivalent; UNM is the Level I destination for multi-system trauma. Air transport decision needs to happen early.