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Life Lines Articles - Disaster First Aid

Triage For Disaster:
What it is - Why it is - How it is
by Victoria Chames, EMT, EDT

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What it is: All forms of triage are systems for identifying and sorting levels of severity of injury or illness. Every hospital Emergency Room has a limited number of beds and medical staffing so there is always a Triage Nurse to greet you at the door, so that those at risk for worsening or death can be prioritized and be treated first, while those whose condition is assessed to be minor, moderate, or non-life-threatening, are sent to the waiting room to wait for their turn.

Disaster mass-casualty Rapid Triage, though based on the same principle, is different in a number of ways. Most importantly, it must be faster (because there are so many injured at once, and because seconds or minutes may make the critical difference) and it must be simpler, so that it can be done by almost anyone, without medical knowledge or professional training.

S.T.A.R.T. multi-casualty triage was created in 1983 by the Emergency staff of Hoag Memorial Hospital and Newport Beach Fire Department, Newport Beach California. It is the system used by most professional medical, rescue, and emergency personnel to make the best use of limited medical resources when the number of injured needing care vastly exceeds the amount of personnel and resources available. The goal is to "Do the most good for the most people." When performed in line with recognized standards of practice, in most countries triage is recognized and sanctioned by law.

“Our goal is to maximize the number (of people) who will survive the incident. Some patients will live no matter what medical care they receive, and some will die regardless of the care they receive. Others will die UNLESS they receive medical care immediately (but have a good chance of survival if they do).

We Don’t want to utilize valuable resources on people who are certain to die, nor on people who will survive without medical care. Our goal is to identify those who will survive the event with immediate care, and to get it for them as soon as possible.”

–from the article "Prehospital Triage” by Matthew R. Streger, BA, NREMT-P, EMS Magazine-The Journal of Emergency Care, Rescue, and Transportation.

The critical tasks of S.T.A.R.T. (which stands for simple triage and rapid treatment/or transport) are: (1) to sort injured persons based on probable needs for immediate care, (2) to give brief essential life saving interventions, and (3) to recognize futility. In this way, a small number of emergency workers and helpers can determine and act upon those persons and conditions which will benefit most from the expenditure of the limited resources available.

The origin of triage in general goes back to the time of Napoleon, but the type of triage we will discuss here, S.T.A.R.T. triage, was developed in Orange County California in the early 1980's. Considered the Gold Standard of field and multi-casualty triage, S.T.A.R.T. is now practiced all over the world.

Why it is: Some injuries require immediate medical care, but some hospitals in the disaster area will be overrun or may be shut down by damage. Serious trauma may require surgery within one hour of the injury, which has been called "the Golden Hour." Since surgeons can only treat one person at a time even when there are many more, some of the injured will have to be sent to a more distant hospital. So it becomes critical to identify "which is which" early. Also very important about S.T.A.R.T. triage - each injured person, while being triaged, is also minimally treated with life-saving procedures (such as opening blocked airways, controlling bleeding, positioning for airway safety, and treating for incipient shock).

"A system is needed to determine the severity of each patient quickly and accurately. It should be easy to learn, simple to remember (especially under stress) not require any diagnostic skills, and should allow the triage (caregiver) to immediately stabilize any basic life-threats encountered. The system most widely recognized and used is the S.T.A.R.T. System.


–from the article "Prehospital Triage” by Matthew R. Streger, BA, NREMT-P, EMS Magazine-The Journal of Emergency Care, Rescue, and Transportation.

How it is: S.T.A.R.T. triage is a fast, compact, and very specific system for identifying and marking (or "tagging" because a color-coded tag is often used) the injured into four groups or levels of priority. As each one is triaged (which takes from 10 to 30 seconds) they are given specific, brief, essential treatments as needed, and tagged with their severity level for future reference. The Triager moves from person to person until all are looked at quickly and given these critical first-action treatments. More care will be given later, after rapid triage is done and professional help, if needed, has been requested.

Disaster triage could be described as "choosing the best of the worst" because we are giving first priority to those who will actually benefit from it most - the ones who have a good chance to survive and recover IF they get help soon. We don't give first priority to the ones with minor injuries, because waiting will not change their outcome. We do not give it to the moderate injuries, because waiting will not change their outcome. We do not give it to the deceased, because waiting will not change their outcome. We give first priority to those where it makes the critical difference, and S.T.A.R.T. triage identifies those for us. We do not have to decide ourselves.

Between 75% to 85% of fatalities occur within the first 20 minutes of the event, usually before EMS (911 emergency response) can arrive."

In the chaos and confusion of a disaster, a simple plan like this WORKS, and has been proven in actual practice to save about 40% more lives since its inception more than 25 years ago. That's why it's used by Medical Rescue and Public Safety agencies in the U.S. and many countries worldwide. The Disaster Rapid Triage you learn and use in Disaster First Aid© is the same system they use, adapted and simplified for citizens and non-professional volunteers. The average person may not have the same equipment professional rescuers carry, but s/he does have everything that's needed to do Rapid Triage and save lives in those critical first minutes and hours while waiting for help to come. Time is the essence; this is the time when the most lives are either saved or lost.

Both Rapid Triage and Disaster First Aid are designed and intended for large, multi-casualty events. They are intended for situations where massive emergency makes normal 911 Emergency and Rescue Services unavailable or seriously delayed. They are NOT a substitute for professional medical care at any time when that is available.

Helping in a disaster even with the S.T.A.R.T. formula may seem stressful, especially for civilians and volunteers, who of course are not experienced in triage. It's important to understand that you are not making any decisions about the fate or outcome of any injured person, you are simply applying the time-tested and proven formula which makes the decisions for them.

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