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Triage--trying to sort it out.

Every day on the news, we hear about accidents, natural disasters, terrorist attacks and other incidents that may produce a large number of casualties. When this happens, health professionals are called to the scene and they have to treat the casualties based upon the priority their injuries or illnesses demands. This sorting is done following a predetermined protocol. What do we call this process? It's called triage. Whether it is in the field or in the medical office, triage is nothing more than an organized method of screening patients based upon the severity of their illness.

In the medical office, triage frequently starts with an automated answering device phone message. How many times when you call a clinic have you heard, "if this is an emergency, please hang up and dial 911"? What did that automated device just do? It allowed the patient to triage themselves. It lets the patient determine just how bad their condition is. If the patient believes he/she truly has an emergency, they should call 911; if not, they can hold on and they can make an appointment. The phone message and the patient have already started the triage process.

When patients are calling for an appointment, many clinics implement a protocol book to help decide when the patient needs to be seen. Specially trained medical assistants ask the patient to explain his/her chief complaint. The MA finds that chief complaint within the triage protocol book and then begins to ask the patient a series of questions designed to sort patients with similar conditions into various categories. When the response from the patient is "No," the MA goes to the next question on the list and continues until the answer is "Yes." At that point, the MA can move across the grid and find the appropriate response to give to the patient, whether he or she should come go to the emergency room, be seen in the clinic ASAP, get an appointment within the next 24 hours, or within the next several days, etc. Sometimes the response from the protocol book is to provide the patient with physician approved homecare instructions. The MA has now "triaged" the patient based on his/her chief complaint and using the protocols, determined the patient condition and need for care based upon a set of preapproved criteria.

In those offices that do not use a screening or triage protocol book, generally the individual answering the phone has been provided some specialized training in order to sort the patient appropriately based upon need over the phone, and determined when the patient needs to be seen. Regardless of which method is used, it takes time to learn how to appropriately triage patients in our everyday jobs. The bottom-line, it is a very complicated process.

Field triage is no less complicated. Triage started in the Napoleonic wars and was used to sort casualties among the soldiers for the first time based solely upon the severity of their injuries. Over the years the processes were refined. In the Civil War, both Southern and Northern army surgeons developed processes to triage and treat patients based upon the severity of their injuries; as a result many lives were saved. This process of sorting casualties, whether in wartime or peacetime, has undergone a number of changes over the years. The most common form of triage for many years used by both the civilian and military emergency services and/or medical personnel was what many referred to as NATO or Military triage.

NATO triage sorts casualties into four categories: minimal, immediate, delayed, and expectant. For each category, there is a specific list of injuries qualifying casualty to be placed into this category. Immediate patients are categorized by conditions such as difficulty breathing, chest pain, severe external bleeding, head injury, open wounds to the chest and abdomen, shock, second-degree and third-degree burns to the neck and face and others. These are the patients whom they felt would not live more than 60 minutes without definitive care. There are also similar lists for delayed patients who could wait more than an hour for treatment without fear of too much deterioration; and minimal who had minor injuries that were not life-threatening. As you can imagine, this particular type of triage took an extensive amount of training for individuals who were to perform these duties in the field. Because this form of triage is also dependent upon all patients being brought to one area to be sorted, it is slow and cumbersome, sometimes taking precious minutes away that could be used to save the victim's life in the evaluation and decision making process..


Time and circumstances have now changed the way we think of triage and how it should be done. In "Mass Casualty Triage: an evaluation of the science and refinement of a national guideline" (EB Lerner, DC Cone, et al) was one of the first studies to actually look at triage and casualty management, to determine the effectiveness of triage methods. Sponsored by The Centers for Disease Control, this group and others looked at the limited amount of data available and developed a system called SALT. SALTstands for Sort, Assess, Lifesaving measures, and Treat/Transport. (David Cone, 2009) (EB Learner, 2011)

The basic idea was to quickly sort the patients to those with minor injuries, those with more serious injuries who could respond to rescuers, then those who could not respond. Rescuers would call for all who could walk to come to a specific area outside the danger zone of the incident, such as to the ambulance or fire truck. These were the minimal category patients. Armed with colored tape or color coded triage tags, the rescuers would then systematically go to those who were unable to respond, initiate lifesaving measures, i.e., open the airway or stop major external hemorrhage, tag the individual as immediate or expectant depending on the response to opening the airway, then move to the next patient and so on. Once everyone was sorted, they were then transported to the appropriate treatment area. The result of a practical exercise with multiple casualties was rescuers were able to assess and treat the casualties in 5 to 55 seconds per patient. This model set the stage for other methods of triage to develop. (Cone, Serra, Burns, et al, 2009)

One triage model that has been accepted by more than a few communities, because of its simplicity and the speed with which casualties are sorted, is START (Sort, Treat And Rapid Transport). This system was developed by Hoag Hospital and Newport Beach, CA, Fire Department in 1983 (Buncombe County EMS, 2008). Their goal was to develop a triage system that was fast (evaluate patients in under 30 seconds) and effective (perform swift emergency lifesaving care, i.e., open airway or control major hemorrhage) yet be easy to remember. Many believe that START or Jump START (Pediatric Triage system based on START) does exactly that.

Training to perform this is minimal. Basic first aid (control of external hemorrhage), opening airways and assessing respiration, evaluating pulse or profusion, determining if the victim can follow simple commands. The mnemonic is pretty simple: "30-2-Can Do". There are many similarities to SALT. Sorting is done by immediate identification of walking wounded to having those who can walk come to a given area for evaluation and treatment. Everyone else is assessed by the rescue team. Members of the team start where they are at and begin an organized sweep of the area for casualties.

The flow chart to the right explains the process.

There is also a separate triage for pediatric patients as well which can be found with a simple Internet search for "Jump Start Triage."

Is either SALT or START the answer? It's hard to say. According to Bob Loftus, Member-EMS Advisory Panel at American Heart Association, Continuing Education Coordination Board for EMS (CECBEMS) National EMS Museum Foundation, National EMS Educator (NEMSEC) and CEO of EMT Chief and Associates, "What the EMS community is looking for is simply a national standard that is easy to perform with minimal training, providing the best possible outcome for the victims. There are too many different methods and the EMS field needs to settle on one standard for the nation."

What can AMT members do? Stay current in CPR and First Aid. Contact local Fire Department or Community Disaster Planners and find which triage method is in use in the local community. Get trained in that form of triage and be ready to use these skills whenever an accident or disaster hits. Someday, you may be the most qualified individual at the scene and if you're going to save lives, you need to put those skills to work. People's lives can depend on what you do when an emergency arises. Be ready to START where you are.



Buncombe County EMS. (2008). START Simple Triage and Rapid Treatment. Retrieved July 24, 2012, from BCEMS Web Employee Website:

David Cone, M. J.-P.-P. (2009). Pilot test of the SALT Mass Casualty Triage System. Prehospital Emergency Care(Vol 13, No 4), 536-540.

EB Learner, D. C. (2011, June 5). Mass casualty triage: an evaluation of the science and refinement of a national guideline. Disaster Med Public Health Prep, 129-137.

* Christopher D. Williams, CMSgt, USAF (Ret), IDMT, BSHS, AHI, RMA, President, AMT Ohio State Socity
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Author:Williams, Christopher D.
Publication:AMT Events
Date:Jun 1, 2013
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