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When life hangs on a thread: How does START classification determine life and death?
In emergencies, especially mass casualty incidents, how to quickly and effectively triage a patient's condition can be the difference between life and death. Simple Triage and Rapid Treatment (START) is a staging method used by first responders 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.
The START method is designed to assist first responders in quickly triaging victims and treating them effectively based on the severity of their injuries.
In this system, first responders assess victims and classify them into four categories:
- Dead/Expectation (Black Label)
- Instant (red label)
- Delay (yellow label)
- Walking injured/minor injury (green label)
These color tags help first responders quickly identify each victim's condition, even in some facilities where physical tags are not required if patients can be physically sorted into different areas. First responders will first ask victims who are able to move to a specific area to identify patients who are able to move freely. For patients who are unable to move on their own, a more comprehensive evaluation is performed.
On the premise that breathing is confirmed, the patient will be further classified only after attempts are made to open the airway.
If a patient cannot breathe despite efforts to open an airway, they are marked dead and given a black label. After this, first responders will focus on other patients. Those who are still breathing will be classified as immediate or delayed, depending on their condition:
- Respiration rate greater than 30 breaths per minute
- Missing radiographic pulse or capillary filling for more than 2 seconds
- Unable to follow simple instructions
All other patients are marked as delayed.
Treatment and Evacuation
After all patients have been evaluated, emergency personnel will prioritize treatment or evacuation based on START classification. The most basic approach is to transport according to a fixed priority order: immediate patients first, followed by delayed patients, and finally patients with minor injuries.
The power of the START system lies in its simplicity, but this is also one of its limitations, because patients are prioritized without regard to the number of available resources.
Some agencies have not yet fully relied on START for resource allocation, which has created significant differences in the execution of treatment and evacuation between agencies.
START and its variants
Over time, several institutions have modified the START method and even developed similar systems. An early modification was to use radiographic pulses instead of capillary filling to determine immediate patient classification. The New York City Fire Department uses a modified version of START that adds an orange "emergency" label, whose severity ranges between immediate and delayed.
For children's grading, START also has a specially modified version called JumpSTART. In this version, children's "normal" breathing rates are adjusted to reflect differences between them and adults.
The main change to JumpSTART is that breath rates less than 15 or greater than 45 will be marked as immediate.
In addition, children who are not breathing but still have a heartbeat will be given five artificial respirations. If they resume spontaneous breathing, they will be marked as immediate; if they are no longer breathing, they will be marked as deceased.
Limitations and Challenges
Although the START method has been widely adopted by many agencies in the first responder field, there are no consistent evaluation criteria for judging the appropriateness of any given system in responding to a mass casualty incident. Like many other grading systems, START suffered from implementation issues, such as over-grading.
While START's simplicity is its main advantage in this process, many experts have agreed that the tiering system should be more complex, applying resource constraints and capacity to facilitate patient prioritization.
Today, the hierarchical method in emergency medical treatment is receiving more and more attention. When faced with the increasing challenges of various disasters, how will START evolve and adapt to future challenges?
