____ VIDEO _____
[A disaster scene can be trying for the most sophisticated rescue team.
START helps rescuers know where they are needed most.]

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.

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[Paramedic gives his take on Immediate category within SMART]

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.

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[Firefighter shares hints on rapidly triaging patients.]

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.

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.

Check with your local protocols about whether patients marked DECEASED should be moved. Some systems don't want patients moved until a coroner is on scene, unless they are interfering with rescue attempts.

The mnemonic RPM will help you categorize each patient.

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. 

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.

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[START triage rescuer quickly checks respirations to determine if they are too fast.]

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

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.

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.

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

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[START triage rescuer quickly checks perfusion status.]

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.

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.   

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.

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[START triage rescuer quickly checks mental status.]

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

Overview