Mass Casualty incidents and natural or man made disasters are some of the most physically and emotionally charged and challenging calls that an EMS provider can face. Whether you are a first responder, EMT, AEMT, Paramedic or advanced provider, the fear of what lies ahead coupled with the overwhelming of the immediately available resources can strike fear in the mind of any provider regardless of experience or certification level. Managing the logistics, triage, treatment of injured or affected patients and provision of necessary equipment can often prove to be a daunting task. Primary triage can make or break a mass casualty incident regardless of the root cause. Merriam Webster defines triage as “ the sorting of and allocation of treatment to patients and especially battle and disaster victims according to a system of priorities designed to maximize the number of survivors.”

The START triage method is one proven form of primary triage that is largely accepted by many prehospital EMS systems. START stands for the acronym Simple Triage and Rapid Treatment and involves assessing and sorting patients based on injury severity using a color coded grouping system where green is least injured and black is deceased. In between these two parameters lies the red category and yellow category that groups patients based on three parameters: Respiratory rate, Perfusion status and Mental capacity or level of consciousness. START triage utilizes the process of triaging patients where they are located and based on proximity to the provider. This method minimizes the possibility of missing injured patients or performing a disorganized triage pathway.

Upon initial arrival at a mass casualty incident, the first step in the START triage process is have all patients that can and will ambulate to move to a designated area. This group is often the least injured and is termed as the Green group due to the fact that they often will require less resources that the remaining patients. Green tagged patients can often be treated at the scene or transported for medical evaluation utilizing mass transportation resources and requiring very few EMS personnel to accompany them for medical evaluation.

All remaining patients at the scene will be tagged either yellow, red or black based on the RPM mnemonic. Any patients that are not breathing upon assessment will have their airway opened and if they do not begin to breathe, they are tagged as black or deceased. If they begin to breathe after opening their airway, they are tagged red (or immediate) and we move on to the next patient based on proximity. If the patient is breathing when you arrive at their side, ventilatory rate is assessed. If their breathing rate is over 30/minute they are tagged as red or immediate and we move on to the next patient. If their breathing rate is less than 30/minute then we move on to the Perfusion assessment. If they do not have a palpable radial pulse or capillary refill is more than 2 seconds they are tagged as red or immediate and again we move on to the next patient. Any obvious severe bleeding should be controlled in this patient by bystanders to prevent further deterioration in this patient. The final step in the START triage acronym is the Mental Status evaluation. If the patient cannot follow simple commands or answer simple questions such as what is your name or what day is it today then they are tagged as Red or immediate. If they can answer simple questions or follow simple commands, they can be tagged as Yellow or delayed.

Using the START triage method for patient sorting based on severity of injury provides a method to evaluate a large number of patients in a short period of time therefore allowing resources to be used in the most effective manner. Often the provider is drawn to the most obviously injured or pediatric patient. Using the START triage method and triaging patients as you come to them allows you to rapidly assess and treat large numbers of patients in an organized and proven modality that will benefit the largest number of patients. This can lead to improved outcomes and less physical and emotional stress on the providers.