I’ve studied and taught mass casualty incident (MCI) care and response for 40 years and have found that students often get confused when tasked with memorizing rarely used triage processes or algorithms.
They easily grasp and master the difference between BLS and ALS, because they use these concepts daily. However, they often stumble when at the scene of a mass casualtyor active shooter incident, where they’re tasked with rapidly determining the category of seriously or mortally wounded patients.
When I train students, I explain how to perform triage as a simple modification of the daily BLS/ALS decision-making process.
I show them how to integrate these modifications with the simple triage and rapid treatment (START) approach to triage, the most commonly used triage system, which was developed in 1983 by staff of Hoag Hospital and from the Newport Beach (Calif.) Fire Department.1,2
Teaching START Triage
START is a simple adaptation of the daily clinical assessment of patients and uses just a few key assessment categories. When I explain each category to students, I break it down and show each priority area and its individual components. Students understand and accept it.
However, if I start with an algorithm from a textbook or online source, they often get confused. It gets even more confusing when students from different agencies, counties and states are in the same class.
Depending on where they were trained and what textbook they used, the algorithm is displayed differently.
Some triage tags include a variety of miscellaeous information, including everything from hazmat and terrorism to salivation, lacrimation, urination, defecation, GI distress, emesis and miosis. Some tags include small stickers with numbers, bar codes, personal evidence tags, areas to list medications and specifics on IV insertion.
In addition to this, systems add in the popular and accurate JumpSTART algorithm for children, which uses slight triage nuances.
Others adopt modified START adult versions, without retraining their personnel when new revisions are made.
This occurred in 1996 when the presence of a radial pulse was substituted for capillary refill, with a report of improved accuracy, especially in cold temperature.3 These revisions, combined on some charts, unintentionally complicate the thought process.
No wonder responders get confused. The large number of variations in systems and tags further complicate a simple process, and may inadvertently add seconds to patient processing time.
These different tags and processes ask responders to check off multiple boxes and fill in information when, in reality, there’s very little time to do so at an MCI.
The SACCO triage system uses a formula and computer-based system that requires responders to use a scorecard, laptop or tablet to calculate a patient’s triage score range. The tags are then used to attach the calculated score range to the victim—rather than a color-coded tag.
Patients are then grouped by score ranges, and patient transport priorities are set through the rule-based protocol. Scene managers have to check on bed availablity at each hospital before assigning patients for transport. It’s a system that’s well-thought-out, tested and accurate.
However, the challenge with this approach is that it takes time to achieve that level of accuracy—about 40 seconds per patient just to calculate their score.4
There’s limited time for algorithm recall and chart calculation when people are dying from wounds inflicted by an AK-47, a massive truck or an improvised explosive device full of nails. Responders must look, act, and move on—often as they’re still in harm’s way.
THE ‘blast’ approach
Although it hasn’t been validated by studies, my method of teaching triage mixes practice with practicality in a way that allows responders to easily understand it.1,3,5,6
BLS-Logistics-ALS-Situational Triage (BLAST) is based on our everyday clinical assessment of BLS and ALS patients, and factors in the important aspects of logistics and resources available at the time of an incident, and the specific (often dangerous, fast-moving and complex) situations that confront us today.
BLAST includes most START triage parameters (with a few nuances or deviations) but has personnel think the same way they classify patients 99% of the time (using most of their BLS and ALS classifications) to expedite, organize, triage, treat and distribute a large volume of patients.
The ‘75/25 Rule’
Approximately 75% of the patient volume at an MCI requires BLS care. This is a group that can be placed in a school bus with some EMS personnel, a kit and a radio, and be transported to a more distant hospital. These patients have minor injuries and fit the definition of green/low priority.
Of the remaining 25% of patients, approximately three-quarters of them are patients of concern—but not critical. In most cases, these patients fit the category of yellow/delayed. We’re concerned about them; we treat them and monitor them closely, applying direct pressure, wound clot dressing, immobilization and transportation—but they aren’t going to die in the next 20 minutes.
The remaining 25% of our patients, approximately 10% of all patients, are truly critical. They have conditions and deranged or deteriorating vital signs that, if left untreated, will result in death in 20 minutes or less unless care is administered.
I call these critical patients ALS “prime” patients. These include arterial bleeds; uncontrolled hemorrhage; severe respiratory distress; respirations < 10 or > 30; adult patients with pulses > 100; patients with pale, clammy skin; bilateral femur fractures; and those with poor vascular circulation.
These patients get a red tag, need immediate, intensive, constant care, and should leave an MCI scene before most others, if possible.
The START triage system classifies patients as red/immediate if the patient fits one of the following three criteria: 1) A respiratory rate that’s > 30 per minute; 2) Radial pulse is absent, or capillary refill is > 2 seconds; and 3) Patient is unable to follow simple commands.
With the BLAST approach, I also teach that all ALS prime patients with the following symptoms should be tagged red, treated and transported to a hospital capable of administering care within 20 minutes:
>>All unconscious patients;
>>Burns with airway/respiratory involvement;
>>Open chest or abdominal wounds (regardless of size or depth);
>>Uncorrectable airway/respiratory problems;
>>Uncontrollable external hemorrhage;
>>Pneumothorax, tension pneumothorax, hemothorax or hemopneumothorax;
>>Shock (including signs of significant depletion of blood volume);
>>Emotionally uncontrollable patients (that need to be removed from the scene to maintain safety and control);
>>Complex medical problems (e.g., impending cardiac arrest, chest pain and pregnant patients traumatized to any extent);
>>Fracture of one or both femurs; and
>>Fractured extremity with pulse absent (even when manipulated).
With the START triage system, patients who can’t walk, are perfusing adequately and can obey commands, are tagged as yellow/delayed.
In the BLAST approach, I teach that all regular ALS patients (i.e., not the 10% ALS prime patients) fit this category. Although we’re concerned about them decompensating or getting worse over time, they can survive if assessed, treated and sent to a definitive care facility within 60 minutes of first EMS contact.
This also includes some patients who, under normal EMS contact, might be treated as high-priority patients and, in some cases, transported or flown to a trauma or specialty center, such as:
>>Patients with burns not affecting the airway;
>>Conscious patients with head injuries;
>>Chest pain patients not presenting with ectopy or dyspnea;
>>Patients with spinal injuries or paralysis (with no dyspnea); and
>>Patients with moderate blood loss, but signs of shock are not present.
Green/Low Priority Patients
Under the START triage system, patients who can walk are to be classified as green and sent to secondary triage. Beware of classifying patients who can walk as low priority; you can get fooled easily, particularly if you don’t do a rapid assessment and take a set of vitals on them.
For example, when President Reagan was shot in 1981, and was initially assessed by the Secret Service, none of the red START criteria applied to him. However, after he walked into George Washington University Trauma Center on his own two feet, he was spitting up bloody, frothy sputum and had almost no blood pressure due to an open chest wound.6
At the first World Trade Center bombing in 1993, a patient ran out of the underground garage and past incoming EMS personnel. This patient had internal organs displaced and torn by the shock waves of the massive, contained blast, and ended up dying.
With the START triage system, both patients would fit in the green/low priority category because they were walking on their own.
With BLAST, I teach that BLS patients are green/low priority if they’re assessed and you feel they can survive for at least 90 minutes before they reach a hospital or other care facility. This includes minor injuries, minor fractures and walking wounded (i.e., minor injuries and no red or yellow indications/conditions).
The START triage system advocates that patients who are apneic should be tagged black and not be treated and transported in an aggressive ALS manner.
However, my experience has been that if a patient stops breathing or loses their pulse in front of you—and you have adequate ALS and transport resources—they often survive if you tag them as red/immediate and quicly give them to a crew to treat and transport.
Many severely wounded and/or apneic patients at recent mass shootings and terrorist attacks fit into this category, and were treated and survived.
With the BLAST approach, if care and transport resources are scarce and you’re confronted with many patients who are mortally wounded but who still have vital signs, I advocate tagging them as green/low priority patients, place them in a separate area near the green/delayed patient collection and treatment area, and only treat them if resources become available.
I recommend black-tagging individuals who are clearly deceased on scene, or who you don’t feel could survive for more than 10 minutes after you triage them—even if they’re sent to a hospital immediately. This includes:
>>Mortally wounded multi-system trauma patients. If you have adequate ALS and transport resources on scene, I advocate that you work to resuscitate them;
>>Agonal respirations (unless you have abundant ALS or transport resources on scene or arriving shortly);
>>Pulses and respirations are absent during your first contact with them; or
>>Patient is decapitated.
It’s worth noting that both press secretary James Brady and congresswoman Gabrielle Gifford each had agonal breathing after sustaining a gunshot wound to the brain—and both survived because they were triaged, treated and transported early.
I teach the BLAST triage approach to students in just 30 minutes. It’s easy to remember because, in addition to the three key START parameters for red/immediate patients, it allows personnel to use the same clinical assessment of BLS and ALS patients that they use daily, and factors in the important aspects of logistics and resources available at the time of an incident.
Triage isn’t a once-and-done process. There are several opportunities to re-triage a patient at a scene after they are initially tagged. This includes: 1) When they’re moved onto a lifting and moving device; 2) When they’re placed in a specific priority treatment area; 3) When sub-triage occurs in a priotization area to prioritize patients for transfer to the transportation area; and 4) When they’re sent to the transportation and loading area.
1. Benson M, Koenig KL, Schultz CH. Disaster triage: START, then SAVE—A new method of dynamic triage for victims of a catastrophic earthquake. Prehosp Disaster Med. 1996;11(2):117–124.
2. Newport Beach Fire Department. (n.d.) START: Simple triage and rapid treatment. START Support Services. Retrieved Feb. 28, 2018, from www.start-triage.com.
4. Sacco WJ, Navin DM, Fiedler KE, et al. Precise formulation and evidence-based application of resource-constrained triage. Acad Emerg Med. 2005;12(8):759–770.
5. Garner A, Lee A, Harrison K, et al. Comparative analysis of multiple-casualty incident triage algorithms. Ann Emerg Med. 2001;38(5):541–548.