**Warning – triage can be disturbing. It involves injuries and death.”

What is START Triage?

Triage is the unfortunate job of deciding which patients get treated first if there are too many injuries for resources to handle – also known as a mass casualty incident. If this is unfamiliar to you, you should first read my post on Triage – Who Gets Treated? One method of triage on the scene is called S.T.A.R.T. (Simple Triage And Rapid Treatment). In most cases, only official responders do this. In rare circumstances, such as a natural disaster or a large accident in a rural area, adequate emergency responders are simply not available – thus START triage training.

Triage sounds medical, but the basic assessment isn’t rocket science. Even if you are not a responder or volunteer, this exercise will help you understand their process. Here are links on how to open an airway (BBC Health First Aid Procedures – opening airway) and check a pulse (Learn How to Check Your Pulse) – parts of START triage you should know.

Over 50 People Injured In Train Accident

Over 50 People Injured In Train Accident

Always Be Safe

First and foremost is ensuring scene safety before you triage or help victims. No sense in being a hero if you instead add yourself to the victim count. Always wait for official emergency responders before entering a disaster scene. The only exceptions are 1) official help is unavailable, 2) the scene is clearly stable and safe, AND 3) you have a partner with you at all times, plus someone outside who knows what you are doing. All three are required!

START Triage Process

The goal of START triage is to spend less than a minute per patient, performing rapid assessment, quick lifesaving interventions, and tagging triage level. You gather only enough information to do this, then move on. Don’t waste time finishing an assessment after you’ve determined tag color.

1) Ambulatory patients never need urgent care = tag GREEN. Try to assemble greens quickly in a safe area using verbal instructions. Yell “Anyone who can hear me should move to the parking lot now”! Assign a volunteer to corral green patients together outside the disaster scene.

2) Obviously dead patients = tag BLACK

3) Check for breathing.  If not breathing, open airway. If still not breathing, tag BLACK. If start breathing when airway opened, tag RED.

4) If breathing when found, count breaths (RR = respiratory rate). If over 30/minute, tag RED. If under 30, move on to circulation (pulses and capillary refill – press the finger pad until white, and see how long it takes for color to return).

5). If capillary refill takes over 2 seconds and pulses weak or absent, tag RED. If circulation poor and also bleeding heavily, instruct someone else to apply pressure (or apply a tourniquet if trained). If circulation adequate, move on to mental status.

6) Mental status. If coma, decreased responsiveness, or unable to answer simple questions, tag RED. If confused but able to respond to questions, tag YELLOW.

7) If pass breathing, circulation, and mental status tests, but not walking, they could be either be YELLOW or GREEN. Make your best guess. Cuts with bleeding controlled, small burns, broken arms, etc. are probably GREEN (first aid is adequate initial treatment). Broken legs, severe pain, confusion, larger burns, and breathing symptoms (not bad enough for red tagging) are YELLOW.

Who Wants to be an EMT?

"Victim" at Disaster Simulation. Photo by Vancouver Film School.

“Victim” at Disaster Simulation. Photo by Vancouver Film School.

Feeling brave? Let’s test your triage skills. These are made-up victims from a MRC triage exercise. The scenario is a ruptured gas line and explosion at a large medical clinic. Pretend the emergency responder asked you to do START triage. How would you tag these patients? (My answers follow.)

Victim #1)     School aged boy standing in the middle of the room. Pale, shaking, and crying out loud. No obvious injuries. Doesn’t respond when talked to, but seems alert and aware, and follows your gestures.

Victim #2)     Teenage boy in shorts with blistered reddened skin covering both legs. No evidence of burns above the legs. Alert and talking but has severe pain. No breathing complaints, RR 20. Pulse strong and mildly fast at 110. Good capillary refill. No other injuries.

Victim #3)      Young woman, obviously very pregnant. Complains of shortness of breath. RR 38, shallow, strained. Skin pale, cool and dry, capillary perfusion > 2 seconds. Conscious, alert, but very agitated. Attempts to answer but has trouble understanding.

Victim #4)      Disheveled adult male, poorly groomed. Wandering around without purpose, mumbling. Some scratches and abrasions, but no obvious injury. No breathing difficulties. He tells you his name and where he lives, but speech is bizarre. He thinks terrorists are nearby and will shoot him if he leaves. He admits having a psychiatric history.

Victim #5)      Elderly male in a wheelchair. Complains of severe chest pain, radiating to jaw, with nausea and light-headedness. Alert. RR mildly rapid at 28. Sweaty and pale. Pulse weak, 120. No signs of injury.

Victim #6)      Teen age girl trapped under an overturned piece of furniture.  Only obvious injuries are scrapes, bruises, and a “goose egg” on her forehead. RR 24, pulse 120 and strong, good capillary perfusion. Dazed and confused, unable to help free herself or answer questions, speech garbled.

Victim #7)     Middle aged male. Unconscious. Large areas of red blistered burns on arms, chest, and face, with singed hair on face and head. Horrible burnt flesh smell. Respiration is shallow, irregular and very slow at 4-5/min.

Victim #8)      Healthy appearing senior female on floor with severe leg pain and light-headedness. Alert and able to answer questions. No respiratory complaints, RR 24. Pulse strong and mildly rapid at 120. Leg has deformity and open wound with bone sticking out. Some ongoing bleeding.

Victim #9)    Youngish woman, face down. Large bloody wound on the back of her head, with visible blood leaking through clothes in many spots. When you roll her over, she is limp and completely unresponsive. When you open her eyes, one pupil is large and fixed. Breathing is slow and irregular at 14,   pulse is 60.

Victim #10)   Infant girl about a year old, found under victim #9. Crying loudly, moving arms and legs, has blood on her, but with close examination, no evidence of injury. No breathing distress, RR 28. Squirming too much to find a pulse, but good capillary refill.

Victim #11)   Preschool aged girl, sitting near victims 9 and 10. Crying and holding her arm which is obviously deformed.  Several small cuts. Able to tell you her arm hurts, and wants to know where her mother and sister are. RR 24, pulse 100. No other obvious injury.

Victim #12) Obese late middle-aged male on floor, confused and mumbling. Responds somewhat to shaking, but not making sense. No obvious trauma. Skin is pale and sweaty, and has tremors. RR 30. Pulse 140 but strong. A Med Alert tag on his neck says he has diabetes.

Triage vs Direct admit?Photo by Guian Bolisay

Triage vs Direct admit?
Photo by Guian Bolisay

My answers (with a little medical discussion thrown in for fun):

Victim 1 – Green – doesn’t need urgent medical care. Possible hearing loss from explosion. Might not speak English. Where are his parents?

Victim 2 – Yellow – Passes breathing, circulation, mental status. Has major stage 2 burns, but can probably wait several hours for treatment as long as closely monitored to make sure he remains stable.

Victim 3 – Red – Respiration over 30 and trouble answering.  Type of underlying injury unclear. Could have blast lung or inhalation injury. Could have unrelated illness. Monitor for pregnancy complication or premature delivery.

Victim 4 – Green – walking. No physical injury, but psychotic either from stress or from underlying mental health problems.

Victim 5 – Red – probable heart attack.  START triage  doesn’t work as well for medical problems as it does for injuries. Heart attacks need urgent care, so even if he passed circulation (pulses OK), I would still tag red. On the other hand, if his heart stopped, do not do CPR in this setting.

Victim 6 – Red – unable to answer simple questions.  I would guess closed head injury.

Victim 7 – Attempt to open airway – no appreciable change in breathing. Black. This breathing pattern is a near-death sign. I treat it like someone who is not breathing at all. His lungs probably look like his skin – even with a ventilator, prognosis is dismal.

Victim 8 – Yellow – open leg fracture needs medical attention today, but OK to delay a few hours. Bleeding isn’t enough to affect circulation, so I would not treat it during triage.

Victim 9 – Black – not expected to survive with this level of coma. Description suggests severe open head injury. Typical pupils  for severe brain swelling.

Victim 10 – Green no evidence of injury (shielded by deceased mother). Are you going to leave a baby lying there alone?

Victim 11 – Green – closed arm fractures don’t need urgent medical intervention, just first aid. What should you say to a 4-year-old whose parent is dead?

Victim 12 – Red  – might be low blood sugar instead of injury. If paramedics give glucose, he could improve to yellow.

I have no specific answers on children found without family. How do you balance their need for supervision and care with your need to triage and treat urgent patients? Perhaps ask another volunteer or walking Green to take children outside and stay with them until officials arrive. It’s best to leave discussions to others – for now, just reassure them.

Everyone understands START triage is a rapid first process. You do your best in tough circumstances. If your answers differ from mine, realize even professionals assess patients differently.  START triage guides the initial treatment and transport of patients, but triage should continue every step of the way. Some yellows turn red, some  yellows turn green, and some reds turn black.

Fire Engine from Hillsboro Oregon finishing a call. Photo by Tom Brandt.

Fire Engine from Hillsboro Oregon finishing a call. Photo by Tom Brandt.

Does this give you a different understanding of a disaster scene? Feel free to comment or contact me to discuss the cases.

Stay safe,

Sheila Sund, M.D.

  1. Louis B. Baggett says:

    Good exercise in Triage.

    • disasterdoc says:

      Thank you for reading. I was a little nervous about posting this topic, but I really believe all knowledge is good.

      • Jane says:

        Excellent exercise! It reminds us that you have to remove emotion (those you would want to save) from the triage and focus on those likely to be saved with limited resources! I learned most from # 7 & #9 that I initially rated a red instead of a black. Thank You!

        • disasterdoc says:

          I purposely chose cases that would push emotional buttons, because that’s unfortunately what it would be like. There really will be some blacks that are clearly alive! I am sure from a medical perspective that these “blacks” would not survive even with maximum ICU support – their injuries are too severe. It will be even harder for me when I know they could survive, but I don’t have the resources!

          When we did it as a group exercise, people also fixated on what to do with unaccompanied minors (particularly the baby) who are green. Could you just leave them there and move on? No good answers, even when I posed the question to some first responders I know.

  2. lanie says:

    i found this extremely helpful, I’m studying for my EMT certification test that is coming up very soon and this helped me a great deal to see if i was ready for the triage questions that could be on the test

  3. Cameron says:

    Thanks for posting this. I’m studying for my provincial EMR licensing and found this particularly helpful. Your explanations also added to the ease of reading and understanding. According to your answers I got 9 out of 11 of them correct so I’m also happy about that! I’ll definitely be reading more of your blog.

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