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Who survives a disaster? How understanding the START classification system can save lives!
When faced with a mass casualty incident (MCI), first responders are challenged to quickly and efficiently screen and triage the injured. Simple Staging and Rapid Treatment (START) is one such screening method that has been widely used in the United States since its development in 1983 at Hoag Hospital and the Newport Beach Fire Department in California.
Filter categories
First responders using the START approach classify each casualty into one of four categories based on the severity of their injuries:
Death/Expectation (Black)
Immediately (red)
Delay (yellow)
Walking injury/minor injury (green)
The colors correspond to the filter labels that indicate the status of each casualty. Although not all agencies use physical tags, it is usually necessary to move injured people who can walk on their own to a specific area at the scene. Next, the non-viables will be evaluated. The only medical intervention before the victim was declared dead was an attempt to open an airway. If the victim is still unable to breathe after the attempt, they are classified as dead and marked in black. Casualties are classified as candidates for immediate treatment if they are breathing and have:
Respiratory rate exceeds 30 breaths per minute;
Absence of radial artery pulse or capillary regurgitation for more than 2 seconds;
Unable to follow simple instructions.
All other patients were classified as having delayed treatment.
Treatment and evacuation
Once all casualties have been assessed, first responders use the START triage to prioritize treatment or evacuation. The most basic approach is to transport the injured according to a fixed priority order: first transport the immediate category injured, then the delayed category, and then the walking category injured. More detailed secondary screening systems, such as the SAVE system, may also be used in this setting, where START triage is critical in determining the order in which injured persons should undergo secondary screening.
It is important to note that the START system does not provide guidance for resource allocation. Its triage algorithm does not depend on the number of casualties or the amount of available resources, so the way treatment and evacuation are implemented may vary significantly between different institutions.
Modifications of START and similar systems
Many institutions have modified START or developed similar screening systems. One of the early modifications was to use the radial pulse instead of capillary return to triage casualties for immediate treatment. The New York Fire Department uses a modified version of START that adds an orange "emergency" classification, which is between immediate and delayed.
Modifications for Pediatric Patients
The use of START has also been modified for pediatric patients and is called JumpSTART. This modification makes some simple adjustments for the adult version. The most important adjustment is to change the "normal" breathing rate: because children usually breathe faster than adults, JumpSTART classifies children according to their breathing rate, and only when the child's breathing rate is less than 15 or greater than 45 per minute , it is marked for immediate treatment. If the child is not breathing but has a pulse, the emergency personnel will give five breaths. If breathing is restored, it will be marked as "immediate". If not, it will be marked as "dead." Determining the difference between children and adults can be determined by a quick examination of underarm hair development in boys and breast development in girls.
Similar filtering systems
In addition, there are other screening systems such as Triage Sieve, Pediatric Triage Tape and CareFlite Triage, which also use four or five screening categories including red, yellow, green and black.
Restrictive
However, START also has its limitations. To date, there are no relevant criteria to measure the appropriateness of any screening system in mass casualties. While START's strength lies in its simplicity, this also becomes a major limitation. As the field of emergency medicine has evolved, experts have come to realize that the screening process should be more sophisticated and take into account resource limitations and capabilities to determine how to prioritize the injured.
In critical situations like this, are we prepared to respond to emergencies and effectively use these screening systems to save lives?
