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START Method Makes Triage Fast, Simple

By Dr. Ken Lavelle, MD, NREMT-P

You are settling in for a busy Saturday night in an urban Fire and EMS department. At approximately 4 a.m. you are dispatched to a working fire in an apartment complex with a report of people trapped. The Battalion Chief arrives and reports a three-story apartment building well involved with jumpers down. Multiple other EMS units are also responding. You arrive and have more than 10 victims, some who have jumped from the upper floors and some that have suffered burns or smoke inhalation. What are your first actions?

Once you determine a safe area to operate, one crew member needs to establish command of the EMS branch while another needs to initiate triage. Triage means "to sort" — to figure out which patients need immediate care and which patients can wait. It is a fundamental action that needs to be implemented whenever medical need is larger than medical resources.

There is no perfect triage system, but one of the better methods available to us is the START (Simple Triage and Rapid Transport) method. START was developed in 1983 by the Newport Beach Fire Department and Hoag Hospital in Newport Beach, California. It is designed to identify problems that could cause death to the patient within one hour, typically breathing problems, head injury or significant bleeding.

Whether to use triage tags or not is debatable. While most agencies will use a triage tag of some sort, there have been some EMS leaders that have questioned whether we should deviate from our usual practice just when the situation is becoming more volatile and chaotic. It may be more beneficial to do things as close to normal as possible. Certainly follow local protocol, but understand the weaknesses of both the use and lack of use of the triage tag. It is my opinion that the benefits of a tag outweigh the drawbacks, especially for accountability purposes.

The first step in triage is to clear out the minor injuries and those with low likelihood of death in the immediate future. The best way to do this is to ask in a loud voice (with public address or loudspeaker assistance) for anyone that is injured and needs medical assistance to move to a designated area. These patients are initially tagged as "green" or "minor." While it is possible that these patients may have serious injuries, if they are able to listen, understand you and get up and walk on their own to a different area, the chances of them dying in the next hour is low. As soon as enough medical resources arrive on location, they will need to be re-triaged to look for more serious conditions.

The remaining victims fall into a few categories. They are either:
• Unable to understand your directions; they may not speak English, they may be deaf, or they have an altered mental status affecting their ability to understand
• Unable to move due to injury
• Unconscious
• Dead

To determine which category they fall under, we begin by assessing the respirations of the remaining victims. If they are not breathing we can reposition their airway, but if breathing does not begin spontaneously, the victim is tagged as "deceased." Many EMS providers actually prefer the designation "expectant," which is often used by the military. Initially, if the number of victims largely outnumbers medical staff, it is reasonable to not waste resources on someone in respiratory arrest when other victims may benefit from our actions and be more likely to survive. However if a few minutes later a large number of medical providers arrive on scene, this "black tagged" victim may be able to receive immediate care. This is how the triage process is so dynamic — it depends on resources. If the patient does start breathing after the airway is repositioned, you can place an oral airway, tag them as "immediate" and move on.

If the patient is breathing, and breathing over 30 times per minute, they are tagged "red" or "immediate." If their respiratory rate is fast they may be in shock, or be in respiratory distress.

If they are breathing less than 30 times per minute, the next step is to assess the perfusion or circulation status. This can be done in one of two ways: radial pulse or capillary refill. The problem with capillary refill is that it is largely affected by the environment. A cold night will cause everyone's capillary refill to be delayed, so the presence of a radial pulse can be used instead. The rate does not matter — just its presence or absence of the pulse.

If the radial pulse is absent, the patient is tagged "immediate." We can assume they have one since this patient is breathing, which would not occur for very long if they had no heartbeat at all. Control any external life-threatening bleeding. I prefer to use a commercial tourniquet with a windlass — it can be placed quickly so you can move on to the next victim.

If the radial pulse is present, the last criterion to evaluate is mental status. A patient with normal mental status is tagged as "yellow" or "delayed." These victims often are unable to move due to lower extremity injuries or other conditions that prevented them from moving to the "green" section. If they do have confusion or altered mental status, then they are tagged "immediate," as they may have a head injury or other condition that is causing the abnormal level of consciousness.

The START system ends up triaging the majority of these patients as "red" or "immediate" rather than "yellow." It is understandable, and to some degree desirable to over-triage in order to make sure we do not miss any serious conditions. Remember to keep track of how many of each patient you have triaged so this can be reported back to the EMS branch manager.

As you can see by the above, the amount of equipment that needs to be carried around during triage is minimal — triage tags, oral airways, tourniquets, and a method to count those triaged.

Once you have triaged the patients, treatment can begin on the most serious victims, which will be discussed in the next column. For more information, simply do a Web search for START triage or go to the Newport Beach Fire Department's web site for the support of START triage at www.start-triage.com. At the site, you can order training materials and videos to assist in the training of staff.

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