Mass Casualty Triage Using START Method

Before triaging any patients, ensure the incident scene is safe. Do not enter an unsafe area. Position yourself in a location where you can visually assess all casualties quickly. If working alone, establish a mental map of the area and identify hazards (fire, chemicals, unstable structures). Position downwind and uphill from hazards. Designate physical treatment zones: Immediate (Red), Delayed (Yellow), Minimal (Green), and Expectant (Black). Move patients to these zones as you assess them, or mark them clearly if movement risks additional injury. This spatial organization prevents losing track of patients and aids communication if others arrive.

Do not attempt triage in an unsafe environment. Your safety is the prerequisite to helping anyone.

The entire START assessment takes approximately 30 seconds per patient. Approach and perform RPM assessment:

Respirations (R): Is the patient breathing? Count breaths for 6 seconds and multiply by 10 to estimate rate. Normal is 10-30 breaths per minute. If not breathing, open the airway using head-tilt chin-lift. Re-check. If still no breathing after airway positioning, the patient is Expectant (Black tag).

Perfusion (P): Check for a radial pulse at the wrist. If no pulse, classify as Immediate (Red). If pulse present, assess capillary refill: press a fingernail or palm until pale, release, and count seconds until color returns. Normal is <2 seconds. If >2 seconds, classify as Immediate (Red).

Mental Status (M): Ask a simple question ("What is your name?" or "Can you hear me?") or give a command ("Squeeze my hand"). If the patient is confused, not following commands, or unresponsive, classify as Immediate (Red). If alert and oriented, determine Delayed vs. Minimal based on visible injuries.

Use colored tape, paint, ribbon, or cloth to tag each patient visibly:

RED (Immediate): Breathing >30/min or <10/min (after airway opening), altered mental status, no radial pulse, capillary refill >2 sec. These patients die without immediate intervention. Examples: severe airway compromise, uncontrolled bleeding, shock, severe head trauma with altered consciousness, chest/abdominal penetrating injury.

YELLOW (Delayed): Breathing 10-30/min, normal perfusion, alert and oriented, but with significant injuries. These patients survive hours before treatment becomes critical. Examples: fractures with stable vital signs, moderate wounds, chest/abdominal injury without shock, burns <20%.

GREEN (Minimal): Alert and oriented, normal breathing, normal perfusion, able to walk or follow commands, minor injuries only. These patients can defer treatment. Examples: minor lacerations, small fractures, contusions, minor burns.

BLACK (Expectant): Non-breathing after airway positioning, no pulse, or injuries incompatible with survival (massive head trauma, truncation, severe burns >50% with airway involvement). These patients will not survive with available resources.

Treatment order depends on what supplies and personnel you have:

With minimal resources (one person, few supplies): Treat Red (Immediate) patients only. Stabilize with tourniquet, airway positioning, or pressure dressing. Once stable or beyond help, move to the next Red patient. Yellow and Green patients must wait or self-care.

With moderate resources: Red patients are priority 1. High-acuity Yellow (e.g., chest/abdominal injury with stable vitals) are priority 2. Assign responders: one per Red patient, one for critical Yellow, one for Green organization.

Transportation order: Red > High-risk Yellow > Stable Yellow > Green. Transport Red patients as soon as they are stabilized. Do not delay transport waiting for more patients to triage if advanced care is available elsewhere.

Retriage regularly: A Yellow patient can deteriorate to Red. A Green can deteriorate. Check patients every 10-15 minutes if they are waiting. If resources improve (more personnel, supplies, transport), reclassify Expectant patients as Immediate if appropriate.

Classifying someone as Expectant (Black tag) is morally and emotionally demanding. This is a resource allocation decision, not a judgment of human worth. In true mass casualty scenarios, some patients cannot be saved with available resources. You are maximizing total survivors by directing limited supplies and time to patients with chance of survival.

For yourself: Expect moral distress, guilt, or psychological injury. These reactions are normal. Plan to debrief with others after the incident. Remind yourself: "I made the best decision with the information and resources available. I saved lives by being systematic."

For the patient: Do not abandon Expectant patients. Sit with them when able. Provide comfort: keep warm, manage pain with any available medication, hold their hand, speak calmly. Assume they can hear even if unresponsive. Explain what is happening.

For family: Briefly explain: "The injuries are beyond what I can reverse with what I have available. I am focusing treatment on patients with better chances of survival. I will stay with your loved one." Allow goodbyes and presence if time permits.

Reclassification: If more resources, supplies, or personnel arrive, reassess Black-tagged patients and reclassify as appropriate. Keep records of all tagged patients.

Expectant classification is based on available resources NOW, not medical certainty. Conditions change. Reassess if circumstances improve. Provide human presence and comfort care to all Expectant patients—they are not abandoned.