When the subject of triage comes up within the Community Emergency Response Team (CERT) scenario, it is clear that we are dealing with a situation where not only are you outnumbered victims to rescuers, but resources are limited and time is of the utmost.

As you steer through that always-dangerous curve headed to work that morning, you are the only witness to a traffic collision. As if in slow motion, you watch the vehicles collide and settle. You stop your car, and in front of you lays the mangled remains of an SUV and a loaded school bus resting on its side.

You’ve already tried to activate EMS by calling 911, but you’re in a dead spot where there’s no wireless signal. Even if you could get through, you know that it can take First Responders at least fifteen minutes to get to your location, and that doesn’t begin until they’re notified.

You’ve grabbed your CERT bag from the trunk of your car. You’ve pulled on a pair of gloves and donned the rest of your PPE. Now you’re facing the scene. Where do you start? You’ve got more victims than you can count from outside the bus.

To whom do you attend first? The ejected SUV passenger bleeding on the road? The screaming children inside the bus? It’s not an easy decision to make. Or is it?

Know What You Are Dealing With

You take a moment to use all of your senses to size up the entire situation. You consider your own safety before taking any action. There’s a safe area just twenty feet from the bus that will serve well to evacuate victims from the scene. There are no power lines or any additional hazards to be concerned about.

To get the full scope of the scenario, you quickly walk around the entire scene. Through the front windows of the bus you see victims. There’s a small fuel leak, but it’s not a hazard yet. As you come around the back of the bus, the emergency door pops open and four dazed but uninjured children slowly emerge. They are scared, but they seem unhurt. You calmly tell them who you are, and you ask them to stick together. They walk over to the designated treatment area huddled in a small group.

The driver of the SUV is complaining of a lot of pain in his left arm and ribs, but otherwise he says he’s okay. You guess he’s got a few broken bones, but you briefly ponder what kind of nightmares he’ll have in the coming months. He agrees to walk up the hill to try to get a signal to call 911, but one of the older boys comes back saying he’ll go instead: the man looks like he hurts too much. He says his mom is a nurse at the hospital so he can call her so the emergency room can get ready. You send the driver over to the where the children are sitting as the boy sprints up the hill and out of sight.

Start Where You Stand

Now you recall your CERT training. You take a deep breath and focus on the S.T.A.R.T. system (Simple Triage And Rapid Treatment) you learned from North Coast CERT. Turning to the bus, you call out loudly, “Emergency Response Team…if you can stand up and walk, come to the sound of my voice!” Eight more children climb around seats and over broken glass to freedom. As you point them toward the others in the designated safe zone, one young girl doesn’t seem to want to go with them.

She’s limping a little, but she assures you it’s just twisted. She says her name is Sarah and that her little brother Charles is in the front of the bus and needs help really bad. She says she took CERT with her mom last year, and she remembers a lot of it. Your thought: she’s hardly even a teenager. Yet, on your request, she agrees to check on the ejected SUV passenger as well as the kids and the SUV driver. Before heading off she tells you that there are no immediate hazards inside the bus other than the broken glass. She’ll come back to help you once she’s completed those two assignments.

Glancing at your watch, less than five minutes have elapsed since you watched this happen, and you have no idea how long it will be before First Responders will arrive. There remains an unknown number of victims in the bus.

Now You’re Revving!

After those precious few first minutes of clarity have evaporated, the enormity of the situation has got your pulse pounding and your adrenaline rushing. How do you remember what to do next when you’re all revved up?

The words then come back to you, clear as day: “When you get revved up, remember ‘R.P.M.’” That’s the key: R.P.M.

• “R” = Respiration
• “P” = Perfusion
• “M” = Mental Status

Armed with these three letters, you turn to the closest victim. Is she breathing? Yes, she’s got good respiration, but she’s looking at you with terror in her eyes. You ask her what her name is, and she answers Fern. Does she know what happened? Good, she has good mental function. Her leg hurts a lot, but with no apparent bleeding she is otherwise well. You take the pink marker from your CERT bag and write a “D” for “Delayed” on her hand. Before letting go, you draw two dots and a smiley face inside and give her a secret wink…for a very brief moment, Fern smiles before remembering how much her leg hurts.

You move forward a few rows to the next child. He’s not moving, and what’s worse is that he’s bleeding from the left temple, and he’s got a gash on his left leg as well. You reposition him on his back and perform the head-tilt/chin-lift maneuver (it just comes back naturally to you after all this time since your training) and within a second he gasps for breath. He is conscious and alert. You press your fingernail into the bed of his and observe the capillary refill rate. It’s longer than two seconds, but considering the bleeding gash on his leg, that’s almost expected. You mark an “I” for “Immediate” on his forehead.

Without saying a word, Sarah grabs some 4×4 gauze pads and a bandage roll from your CERT bag and nods to you to continue. Your adult size gloves seem so huge on her little hands. As you move forward you hear her coaxing him closer to the roof so he could get out of the glass and elevate his legs above his heart to prevent shock. He asks a few questions about what happened, and she answers quickly and quietly. You hear her call him Tyler so clearly that’s not her brother.

It’s only at that moment that you are struck by the strength emitted from such a seemingly “young and innocent” child. Despite the difference in your years and experience, you both seem to know what you need to do. Thinking back to the CERT classroom, you wondered at the time how you would ever remember anything you learned, especially in a crisis. Yet in the present it was coming back as if you had learned it yesterday.

You move on to the last child up front. The image is more gruesome than you’ll be able to forget soon. After two unsuccessful attempts to reposition his airway, you realize the obvious: his body has sustained injuries that you know are beyond your abilities to treat. The pink marker is shaking as it writes the word “DEAD” across his forehead, and without taking the time to respond emotionally, you remove your over-shirt and cover the boy’s body and move on, fully aware that this is Charles.

The bus driver is lying in a crumpled ball in the well of the door. You reposition her airway and ensure she is breathing. Whew. After a perfusion check on her nail bed passes, you see her struggle to return to consciousness. She’s got a lump on her head. You ask her name. She hesitates. You ask what happened and she doesn’t know. You brush her hair aside and tell her that help is on the way. Her forehead gets an “I” due to her decreased mental status.

As you make your way back to the emergency exit, you notice that Sarah has wrapped Tyler’s hoodie around the leg wound tightly so he could hold it in place. She grabs your hand and the both of you crawl out. She says she knows her brother didn’t survive, but instead of joining you to check on the other children, she inches her way back into the bus. The last thing you hear as you step away from the bus is a small giggle from Fern saying that pink is in fact her favorite color too.

Halfway between the bus and the treatment area you pause. The SUV passenger is no longer face down on the pavement, but safely curled on his side with a pink jacket under his head and a black “I” on his forehead. You turn around and look back at the bus. That’s the moment you realize the enormity of what you just accomplished. For a few brief moments you recognize how eerily quiet it has become. The sweat on your freshly ungloved hands feels cold in the morning air. A few moments later the endless silence is pierced by the sound of a distant siren.

A Few Minutes Later

By the time the first EMS unit arrives at scene twenty minutes after the collision, you had already triaged a total of eighteen victims. The decisive action of using voice triage not only left you with fewer victims to deal with, but also provided you with a trained buddy partner.

Medics on scene treat the remaining patients. Two of the Immediates (Tyler and the SUV passenger) and one Delayed patient (the SUV driver), are transported by ambulance to the hospital. The bus driver is evacuated by air ambulance to the inland trauma center. A team of firefighters extricate Fern, and medic teams treat the remainder of the children for mostly cuts and other light injuries. But Sarah’s brother could not be saved, and the Sheriff-Coroner’s office is called in to handle the details.

End Result

Nowadays, whenever you come around that particular curve, you slow down and remember the day you literally saved lives because you knew what to do in that moment. Had you not taken action, several more people could have succumbed to their injuries before responders would have arrived at scene.

As a result of that day, Sarah has remained a close friend of yours—not like a daughter or niece—but as a peer. It’s not easy to talk about the day her brother died. But she thinks it’s really important to keep talking and thinking about it, because more people could have died if you hadn’t stopped to help.

While you’ll never quite understand from where the depth of Sarah’s wisdom comes, it’s obvious that her life continues despite the tragedy. As does yours.