START

(Simple Triage and Rapid

Treatment)
First Responders, Emergency Medical Technicians and Paramedics are trained
to handle emergencies. You know how to quickly assess a patient and intervene.
But even the best emergency provider is easily overwhelmed when there are
multiple patients who all need emergency care.

The START system, developed by Hoag Hospital and the Newport Beach Fire
Department (Newport Beach, CA), helps prepare emergency personnel to quickly
organize their resources to handle multi-casualty emergencies. Using START,
various agencies and individuals assume predetermined roles in managing the
emergency, on-scene personnel quickly evaluate the situation and call in the
appropriate extra resources and assign them specific tasks. Because of the
planning and training that are the core of the START system, agencies and
individuals know what they are expected to do when they arrive at the scene.

The triage portion of START, which is the focus of this training program, relies on
making a rapid assessment (taking less than a minute) of every patient,
determining which of four categories patients should be in, and visibly identifying
the categories for rescuers who will treat the patients.

Triage
The concept of triage is simply a method of quickly identifying victims who have
immediately life-threatening injuries AND who have the best chance of surviving
so that when additional rescuers arrive on scene, they are directed first to those
patients.

Golden hour
The Golden hour refers to a concept that a trauma patient has the best chance
for recovery if he or she can get to Advanced Trauma Life Support within one
hour from the time of the injury. Obviously, those who are most seriously injured
have the least time. When there are multiple victims, the Golden Hour can slip
away because there aren’t enough rescuers for each victim.

START (Simple Triage and Rapid

Treatment)
The START triage system relies on making a rapid assessment (taking less than
a minute) of every patient, determining which of four categories patients should
be in, and visibly identifying the categories for rescuers who will treat the
patients.

If you are the initial START rescuer, you DO NOT stop to do other than the most
basic intervention. If you attempt to treat every patient before completing the
triage, you cannot assess the rest of the patients and identify the top priorities.

Remember that in a serious disaster, it is unlikely that you can save all the
victims. The important thing is to work together with the other rescuers to save as
many patients as you can. START gives you the best chance of doing that.

START
(Simple Triage and Rapid Treatment)
The Tags...
Managing a scene with multiple patients can be frustrating and difficult. These
steps will help you systematically triage and treat each patient. They also will
give you information to help you determine the number and types of additional
rescue personnel, equipment and transport vehicles you need to manage the
crisis.

It is important to recognize that you are not abandoning patients by assigning

them the Delayed or Minor categories. They are being directed to the rescuers or
facilities that have been assigned to handle those patients. The rescuers who are
managing the Minor and Delayed patients will be reassessing them and will re-
assign them to the Immediate category if they deteriorate.

Red - Immediate
When you arrive at an emergency where someone has used the START triage
system, your first priority is to find and treat the IMMEDIATE patients. These
patients are at risk for early death - usually due to shock or a severe head injury.
They should be stabilized and transported as soon as possible.

Yellow - Delayed
Patients who have been categorized as DELAYED are still injured and these
injuries may be serious. They were placed in the DELAYED category because
their respirations were under 30 per minute, capillary refill was under 2 seconds
and they could follow simple commands. But they could deteriorate. They should
be reassessed when possible and those with the most serious injuries or any
who have deteriorated should be top priorities for transport. Also, there may be
vast differences between the conditions of these patients. Consider, for example,
the difference between a patient with a broken leg and one with multiple internal
injuries who is compensating initially. The second patient will need much more
frequent re-assessment.

Green - Minor
Patients with MINOR injuries are still patients. Some of them may be frightened
and in pain. Reassure them as much as you can that they will get help and
transport as soon as the more severely injured patients have been transported.
Any of these patients also could deteriorate if they had more serious injuries than
originally suspected. They should be reassessed when possible.

Navy - Deceased
Those patients determined nonviable should be left in place unless this hampers the
efforts of caring for others

START
(Simple Triage and Rapid Treatment)
The Principle...
The START flowchart is a quick way to learn the system. As you move through
the patient assessment, sequentially evaluate the current status for
RESPIRATIONS, PERFUSION, and MENTAL STATUS (RPM). You either assign
the victim a classification or you move to the next level of the flowchart.
The chart above can be simplified to this...

START Triage
Assess, Treat, (use bystanders)
When you have a color
STOP - TAG - MOVE ON
Move Walking Wounded
NO RESPIRATIONS after head tilt
Breathing but UNCONSCIOUS
Respirations - over 30
D I Perfusion Capillary refill > 2
M E M or NO RADIAL PULSE
I C M Control bleeding
N E E
O A Mental Status Unable to follow simple commands
D
R S D Otherwise
I
E A E
D T L REMEMBER:
E A Respirations - 30
Y Perfusion - 2
E Mental Status - Can Do
D
START
(Simple Triage and Rapid Treatment)
The How To...
Remember this simple formula to guide your START assessment. RPM stands
for

 RESPIRATION
 PERFUSION
 MENTAL STATUS

Sequentially use this assessment system for every patient.

Entering the scene

As always, make sure the scene is safe for you to enter. If it is not, wait until it
has be made safe.

Next, ask those who are not injured or who have only minor injuries to identify
themselves. Tag those with minor injuries as MINOR.

Minor Injuries - Tag MINOR

Ask several uninjured victims to stay close to assist you, direct the others to a
designated spot away from the immediate scene to wait for additional personnel.

Respiration
First, determine if the patient is breathing. If yes, immediately check the
respiration rate.

If not, reposition the patient. If the patient does not start breathing spontaneously,
DO NOT start CPR.

Patient not breathing after repositioning head-

Tag DECEASED
Move on to the next victim.
(Not starting CPR may be the hardest thing you must do at a multiple casualty
scene, but if you perform CPR on one patient, many others may die.)

C-spine injury
You will have to position the airway without manually stabilizing the cervical
spine. This is counter to what you have been taught and may result in worsening
a cervical spine injury. But if you don’t reposition the victim immediately, the
person will die in the field. You won’t have the personnel to carefully stabilize the
C-spine and you can’t afford to let other victims die while you take time to do it
yourself.

If the patient begins breathing spontaneously after repositioning, tag the person
IMMEDIATE and move on. If necessary, ask an uninjured victim to help maintain
the open-airway position.

Patient begins breathing after repositioning

the head - Tag IMMEDIATE
If the victim is breathing when you approach, but has a respiratory rate of more
than 30, tag IMMEDIATE and move on. Don’t take time to formally count the
respirations. If the rate seems too fast, tag the victim IMMEDIATE and move on.

Respiratory rate greater than 30 - Tag

IMMEDIATE
Perfusion
If you can feel a radial pulse, move on to the Mental Status assessment.

If you can’t feel it, tag the patient IMMEDIATE, have an uninjured victim put direct
pressure on any visible, serious bleeding and move on to the next patient.

No Radial Pulse - Tag IMMEDIATE

Next check for capillary refill. If capillary refill is more than 2 seconds, tag the
patient IMMEDIATE, have an uninjured victim put direct pressure on any visible,
serious bleeding and move on to the next patient.

Capillary refill greater than 2 seconds - Tag

IMMEDIATE
If capillary refill is less than 2 seconds, move to MENTAL STATUS.
Mental Status
If the victim is unconscious or can’t follow simple commands, tag them
IMMEDIATE and move on to the next victim.

Unconcious or cannot follow commands - Tag

IMMEDIATE
If the victim can follow simple commands, tag them DELAYED and move on to
the next victim.

Can't follow simple commands - Tag DELAYED

START
(Simple Triage and Rapid Treatment)

Those who are responsible for organizing the operations of a multi-casualty

incident are probably familiar with the Incident Command System (ICS). START
was designed to work within the ICS. While it is not our intent to teach the Multi-
Casualty Branch of the Incident Command system in these few pages, we did
want to give you an overview and share some of our philosophies with you.
Every area has its unique situations, resources and operational procedures that
need to be considered when developing a plan. We hope this will help you to see
what needs to be done to mange a successful multi-casualty incident.

A Management Philosophy
When the first units arrive at a multi-casualty incident, they are certainly going to
be overwhelmed. There is a temptation to set up the management levels of the
organization first, so the operational levels will have supervision when they are
assigned. To do this, most organizations have to use personnel from the first or
second wave of responding resources. This removes them from the triage /
transportation / treatment provider role, creating a delay in getting patients to the
hospital. After 10 to 20 minutes, it’s a sad sight to see many rescuers in ICS
vests, setting up their operations and no one attending to the victims.

Remember that it is not necessary to assign mid-management positions until the

maximum span of control is exceeded. An incident commander can easily handle
5 to 7 direct reporting positions before an Operations Chief or medical group
supervisor is needed. Assigning your first arriving operational units to hands-on
functions as much as possible will speed up your ability to triage, transport and
treat your patients. This is referred to as the bottom up approach to ICS.

If you think about the things that need to be done before you can transport a
patient, it becomes clear where you need to assign your initial resources.

1. Before you can send a patient to a hospital, you must have an ambulance
available and get a destination from an area coordinator.
2. Before you can get a destination, you need to know how many of what
category of patients are loaded in the ambulance.
3. Before you can identify what category a patient is in, they must be tagged
and carried to the ambulance loading area.
4. Before they can be tagged, they must be triaged.

Take It From The Top

Let’s work from the beginning and assign our resources in a sequential order.

For the purpose of focusing on the medical aspects of a multi-casualty incident,

we’ll assume there are no other life threatening factors such as fire, heavy rescue
or hazardous material releases. If there are, of course they must be considered.

Triage
Since nothing much can happen until patients get tagged, it makes sense to
assign the first company to triage. The company officer can assume the role of
triage unit leader, assess the situation and order the necessary resources while
the other members are performing START triage. Something is immediately
happening. The first rescuers on the scene are taking an action that must
precede all others.

How many rescuers need to be assigned to triage? Of course, that depends on

how many patients you have, but keep this in mind. It will take no longer than one
minute to triage each patient, and probably less time. That means two rescuers
will triage two patients per minute. In ten minutes, 20 patients will have been
triaged. The question for you is, how fast can I move these patients to waiting
ambulances and can my triage team stay ahead of the litter bearers? It does little
good to have a lot of patients tagged if there is no one to move, transport or treat
them.

The Movement of Patients

The next major consideration is how to move your patients to either ambulances,
or if none are available, to treatment areas. This will require methods to carry
them (flats, stretchers, backboards) and personnel (litter bearers). Litter bearers
are grouped as Litter Teams and report to the Triage Unit Leader for
assignments. The preferred number of people for a litter team is four, however it
can be done by three in most cases. Plan to assign many of your initial resources
to this function or you will get way behind the curve.

Be sure the equipment you use to carry patients arrives with the personnel.
Having a stash of equipment somewhere that may not arrive until later will have a
devastating effect on the speed of your operation. As the equipment gets used, it
must be replaced. Have a plan that will keep you in carrying devices, such as,
having the ambulance leave backboards to replace the ones they are taking with
patients.

Transportation
Transportation will have to be organized early if you don’t want to end up with a
mess that can’t be straightened out. An ambulance staging and loading area has
to be established and personnel assigned to keep it organized. This function is
managed by the Ground Ambulance Coordinator. The additional staff required
should include someone to manage ambulance staging and another assist with
documentation.

Patient Destination Coordinator

Coordinating patient destination is one of the more complicated functions. In
areas where there are more than one hospital, it’s imperative that we not relocate
the disaster to the closest hospital. A system for the distribution of patients to
area hospitals must be established in advanced and utilized properly by
emergency personnel. The Medical Communications Coordinator performs this
function by notifying the Area Coordinator of the incident and setting the system
into action. Since most systems of this nature take time to get organized,
notification should be given as soon as possible so destinations are available
when the first patient is ready for transport.

Keep Things Moving

Someone needs to direct the litter teams where to go with their patients. This is
the job of the Treatment Dispatch Manager, the traffic cop for the movement of
patients. In the beginning, patients can be moved directly out of triage and into
waiting ambulances, if available. Once the litter teams can move patients faster
than they can be loaded, they will have to go to treatment areas and be sent from
there to loading. It’s the Treatment Dispatch Manager who keeps this organized
and moving.

In Summary
There are whole courses devoted to this subject. It will take a lot of planning,
training, and multi-agency coordination if you want it to go well. Although multi-
casualty incidents are not that frequent, it is well worth the energy to prepare for
them. These principles can be applied on a smaller scale to the more frequent
multiple patient (3-12) incidents. The more these concepts are used in the routine
setting, the better they will be applied to the larger incidents.