Tags of Survival: The Start System

From an EMS point of view, the goal of triage is to maximize the number of lives saved, and the best way to do that is to get patients to a medical facility as soon as possible, and in as healthy a medical condition as possible. Obviously, the faster a critically injured patient reaches a surgeon the better his or her chances of survival.

One way to achieve this goal is to take the sickest/most seriously injured patients from the scene first and deliver them to an adequately equipped medical facility immediately. Doing so, though, may mean requiring those less severely injured to wait their turns.

Although any situation that causes an EMT to make difficult choices between patients may – for all practical purposes – be considered triage, in EMS circles that term is commonly reserved for the handling of mass-casualty incidents (MCI). New York City defines MCI as an incident that produces five or more patients and/or requires the use of extraordinary resources.

Simplicity: The Hallmark of Effectiveness

During an MCI some hard but necessary decisions must be made, immediately and on the scene, about which patients receive how much care, and in what order of priority. Without a triage system in place, these decisions would be made capriciously and may be based on the personal opinions of the individual EMS provider.

The hallmark of an effective – i.e., workable – triage system is its simplicity. The criteria established may have to be recalled many months after training, and under pressure. One such system that has been particularly effective is START (Simple Triage And Rapid Treatment), which has been used well both in New York City and in Los Angeles.

During a CPR students are taught to assess three factors: respiration, circulation, and the mental status of the patient. When approaching a patient under theoretically “normal” conditions, the EMTs follow this model from their first interactions with the patient, then return to it again and again as their assessments become more knowledgeable and more detailed.

The START system is based primarily on a rapid assessment of the three factors previously mentioned, the correction/amelioration of specific life-threatening issues, and the need to move on to other patients as rapidly as possible. In practice, the care provider quickly assigns the patient to one of four categories: “deceased,” “immediate,” “delayed,” or “minor.” The resources that are available at the scene of the incident dictate how fast the individuals assigned to each group will receive the medical care they need.

A Quick-Glance Stoplight System

One common tool used by many if not all EMS agencies is the triage tag – i.e., color-coded pieces of paper (or other material) that show at a glance the medical priority of the individuals in each of the four categories listed. Typically, a stop-light pattern is used, with each patient tagged with the appropriate color exposed – green for Minor, yellow for Delayed, red for Immediate, and black for Deceased. The tags tell other providers and medical personnel: (1) that these patients already have been triaged; and (2) what triage category they have been assigned to.

To further expedite matters, all patients who are ambulatory when the START process begins are asked to move to another area; those who can, in fact, proceed to the area designated are given a green tag. The EMTs on the scene then assess those who have not been able to move on their own starting with airway and breathing. Patients who are not breathing after two immediate treatments are pinned with black tags.

The EMT receives additional quick information about a victim’s status by squeezing the nail bed of the patient and timing the return of color – which, under many circumstances, is a fairly reliable indicator of the patient’s circulatory system. Patients who have an abnormal or slow return of color are pinned with red tags. If a patient cannot follow a simple direction – e.g., “open your eyes” – he or she also is given a red tag. All other patients are given yellow tags. At this point, the EMT(s) will go back and re-triage all those in the walking-wounded (green tag) area to ascertain if there are patients in that area who require more attention.

Triage is, in short, an essential component both of EMT training and of MCI operations. Without an effective triage system in place patients could suffer and die needlessly. The most important characteristics of an effective triage system are clarity, simplicity, and thorough training. Without all three, the survival of patients/victims will depend on the personal skills, background, and training of the individual EMT, or worse on their personality and emotions.

Links for Additional Information:
START Program:  http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=137373#B2
START  (in the NYC REMSCO Protocol Book):  http://www.nycremsco.org/apendices.asp?intCategoryID=6&intArticleID=62
REMSCO:  http://www.nycremsco.org/default.asp
CPR Programs:  (AHA) http://www.americanheart.org/presenter.jhtml?identifier=3011764
Triage tags: 

Joseph Cahill
Joseph Cahill

Joseph Cahill is the director of medicolegal investigations for the Massachusetts Office of the Chief Medical Examiner. He previously served as exercise and training coordinator for the Massachusetts Department of Public Health and as emergency planner in the Westchester County (N.Y.) Office of Emergency Management. He also served for five years as citywide advanced life support (ALS) coordinator for the FDNY – Bureau of EMS. Before that, he was the department’s Division 6 ALS coordinator, covering the South Bronx and Harlem. He also served on the faculty of the Westchester County Community College’s paramedic program and has been a frequent guest lecturer for the U.S. Secret Service, the FDNY EMS Academy, and Montefiore Hospital.



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