START Triage

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    START Triage

    As promised, another EMS-related post.

    Imagine yourself the first to arrive on the scene of a bus accident when you’re driving on your next road-trip vacation. Patients (limp, crawling, walking) are strewn about the street next to the over-turned vehicle, and you can see another dozen or so more people inside–some moving, some screaming, others not doing either. What do you do?

    Less likely for one of us, but still possible. Not highly likely for one of our EMS colleagues, but still more so possible. In New York City, EMS responds to a large number of mass casualty incidents, or MCIs. In our city, EMS declares an MCI and creates a leadership structure (filling jobs within a sector called the “medical branch”) for just about every structural fire and large incident. This allows them to practice the mechanics of a complicated incident management system, practice triage, and practice prioritizing transport resources to various hospitals. It doesn’t seem as complicated when you’re the recipient of just a few injuries from a fire scene, or motor vehicle accident, but there is a coordinated response to each of these, with a high degree of sophistication.

    This post will focus on START Triage (Simple Triage And Rapid Treatment), one system used to prioritize patients in an MCI. There are four basic categories. (In NYC, FDNY EMS uses a fifth category, more on that at the end.)

    1. Deceased (black)
    2. Immediate (red)
    3. Delayed (yellow)
    4. Walking Wounded (green)

    When approaching a scene of the mass casualty incident, the first step is to identify the least sick patients and move them to a designated area. Start with “EVERYONE WHO CAN WALK, GET UP AND WALK TO THE SIDE OF THAT FIRE TRUCK!” They are your green-tag, walking wounded patients. They’re called tags, by the way, because you need to actually put a tag on them.

    Next, use the mnemonic RPM for Respiration, Pulse, Mental status to assess patients who cannot hear you, listen to you, and physically get up and walk. It should take no more than 30 seconds to triage a patient. If they are not breathing, reposition their airway once. If they are still not breathing –> black tag, they are deceased. (Yes, they may potentially have a pulse, but not for long. This is a scenario of finding the most salvageable patients among many with your limited resources.)

    Assess their breathing rate (if greater than 30, i.e. they are noticeably tachypneic or in respiratory distress –> red tag) and their pulse rate (if greater than 100, i.e. palpably very fast –> red tag).

    If both of those feel normal, ask them to do something simple for you, like “SHOW ME TWO FINGERS!” If they cannot follow commands –> red tag. If they have normal pulse and respiratory rates, and they can follow your commands –> yellow tag.

    In NYC, FDNY EMS uses a fifth category (follow that link for a good flow chart) to capture patients who may require immediate treatment, but may not be identified as red tags in the START system mainly designed for traumatic injuries. Take for example a person rescued from a fire who has a HR 92, RR 20, and is walking and able to follow your commands, but he’s elderly appearing and clutching his chest with pain. He becomes an orange tag, for urgent transport (i.e. at the discretion of the transport officer, they will be prioritized among the red-tag patients, and before the yellow-tag patients.

    There is some nuance here. Pediatric patients are treated a bit differently with this system, and the incident command system can create some variation to how to prioritize patients (imagine adding the requirement for decontamination if this bus accident also had a Hazardous Materials, or HazMat, component). Now you may have a greater understanding why a patient has the color tag attached to them when they come from a fire scene or larger incident. If you’re the first doctor outside in the ambulance bay triaging patients before they come inside, this is a good system to keep in mind.

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