Start TriageEdit

Start Triage refers to the immediate sorting of victims in the first moments after a disaster or mass casualty incident, with the aim of directing scarce medical resources to those most likely to benefit. The best-known framework for this work is the Simple Triage and Rapid Treatment (START) method, which field responders use to quickly categorize patients and initiate life-saving actions. Responders move through the crowd, quickly assessing breathing, responsiveness, and circulation, and then assign color-coded tags that indicate priority for treatment: red for immediate, yellow for delayed, green for minor, and black for deceased or expectant. The overarching purpose is clear: maximize lives saved in chaotic, resource-constrained settings, while keeping responders able to perform critical tasks. For more on the general concept of triage, see triage.

In practice, Start Triage functions as the opening act in a larger system of disaster response. It is designed to be fast, repeatable, and teachable, so that a broad mix of responders—firefighters, EMTs, police, and sometimes volunteers—can apply it under stress. The method emphasizes rapid, rule-based decisions rather than lengthy clinical assessments at the scene. Its enduring appeal is pragmatic: when minutes matter and ambulances are scarce, a clear protocol helps avoid paralysis and reduces the risk of treating a large number of people who are unlikely to survive given current conditions. See mass casualty incident for a broader discussion of events where Start Triage is typically deployed, and incident command system for how on-scene leadership coordinates triage with hospital surge plans.

Overview and origins

Triage as a concept predates modern emergency medicine, but START was crystallized in the late 20th century as a practical, scalable approach for urban emergencies. By simplifying assessment into three quick checks—breathing status, ability to follow commands, and perfusion—the system can be applied by personnel with varying levels of medical training. The four-color scheme (red, yellow, green, black) translates quickly into action, guiding which patients receive rapid life-saving interventions, which can wait, and which are unlikely to benefit from treatment in the moment. See START triage for a formal description of the protocol, and respiration/perfusion basics for the physiological criteria that underlie the judgments on scene.

START is part of a family of triage approaches that adapt to different settings. Pediatric versions, such as JumpSTART, modify the criteria to account for children, while other systems like SALT (Sort, Assess, Lifesaving, Treatment) broaden the framework for certain environments or jurisdictions. See JumpSTART and SALT triage for related methods. The on-the-ground practice is shaped by local disaster plans, hospital readiness, and the availability of ambulances and medical supplies. See disaster preparedness for a broader look at how communities prepare for such events.

Principles and protocols

Breathing check: If a patient is not breathing after an initial airway opening, responders reset ventilatory status; if still not breathing, the patient is categorized as black unless there is a clear chance of revival with rapid intervention.
Perfusion check: A radial pulse or other perfusion sign helps distinguish red from yellow when mental status is intact.
Mental status: The ability to follow simple commands helps differentiate those who can be treated quickly from those who need more time or may be unlikely to benefit in the scene.
Color tags and treatment order: Red (immediate), Yellow (delayed), Green (minor), Black (deceased/expectant). The color code is intended to be a fast, repeatable signal for line-of- duty and hospital staff, not a final medical prognosis.
Re-triage and reassessment: As conditions change or resources free up, patients may be re-categorized. This dynamic aspect is central to effective Start Triage and to integration with hospital surge plans. See retriage for related practice.
Training and doctrine: Start Triage relies on regular drills, standardized tags, and coordination with on-scene leadership and hospital systems. See training and disaster response drills for related topics.

The START framework sits within a broader ethical and clinical conversation about how to allocate scarce life-saving interventions. Proponents argue that in mass casualty situations, the best available evidence, quick decision-making, and transparent criteria produce the most good for the most people under pressure. Critics focus on potential biases, the risk of misclassifying patients, and the tension between utilitarian aims and individual rights. For a deeper ethical discussion, see medical ethics and utilitarianism.

Implementation in practice

Training and credentials: Responders train in a standardized process to perform rapid scene assessment, mark victims with color tags, and initiate priority interventions such as hemorrhage control or airway management where feasible. See emergency medical services for the broader system that supports field triage.
On-scene flow: Start Triage feeds into incident command on the ground. Triage decisions influence how patients are moved toward treatment zones, how quickly ambulances depart, and how hospitals prepare for incoming patients. See incident command system and triage tags for related concepts.
Hospital coordination: Triage at the scene is complemented by hospital triage and surge planning, so that emergency departments can expand capacity, allocate operating rooms, and prioritize critical care when resources are stretched. See hospital surge capacity and emergency department.
Community and volunteers: Civilian responders, CERT teams, and private partners can contribute to the initial surge of triage activity, with formal training ensuring consistent application of the protocol. See volunteer responder and CERT for related topics.

Ethics and debates

In debates about Start Triage, the central questions are how to balance speed and fairness, and how to justify the allocation of life-saving resources under extreme scarcity. A pragmatic defense rests on several points:

Maximizing lives saved: With limited ambulances, hospital beds, and staff, a rule-based approach helps ensure those most likely to benefit are prioritized first. The framework is designed to be transparent and repeatable, reducing ad hoc decisions under pressure. See utilitarianism for the philosophical base some cite in justifying this approach.
Limiting bias: While no triage system is perfectly unbiased, START relies on simple, observable criteria to minimize subjective judgments. Critics may still worry about systemic biases that affect outcomes, but proponents argue that structured protocols reduce chaos and improve overall survival.
Fairness in catastrophe: Some critics emphasize that any triage system will affect vulnerable groups—elderly, disabled, or chronically ill individuals. Proponents counter that the alternative—no triage or arbitrary decision-making—would likely yield worse outcomes for everyone. The discussion touches on deeper questions of equity, risk, and the social contract in crisis moments, which are explored in medical ethics and philosophy of disaster ethics.
Role of government and private action: A practical perspective stresses resilience built through local control, volunteer networks, and private philanthropy alongside public emergency services. This combination is argued to deliver rapid response and flexible resources without excessive centralization. See philanthropy and public policy for related debates.

The critiques of this approach often come from advocates who call for broader social protections or more expansive government preparedness. From a practical standpoint, supporters argue that Start Triage is a necessary instrument for preserving social order and saving as many lives as possible when front-line resources are overwhelmed. See health policy for related policy discussions.

Contemporary developments and training

Pediatric considerations: Specialized variants like JumpSTART adapt the core principles for children, acknowledging different physiology and survival probabilities. See JumpSTART for details.
Data and after-action reviews: Modern responses increasingly incorporate after-action analyses to refine triage criteria, update training, and improve interoperability among agencies. See after-action review.
Integration with technology: Digital tagging, geolocation, and hospital capacity dashboards are being explored to streamline triage decisions and hospital readiness during large events. See health information technology for related topics.
Global adoption and variations: Different countries or regions may adapt START or adopt alternative triage frameworks, reflecting local medical practice, civil-murence policies, and disaster preparedness priorities. See international disaster response for broader context.