START Triage with RPM

By Demetrius A. Kastros

Without question, the mass casualty incident (MCI) environment is a chaotic scene. Quickly establishing a level of organization is essential. Simple triage and rapid treatment (START) with respiration, profusion, and mental status assessment (RPM) as the diagnostic component remains a primary and effective tool in the mass casualty incident (MCI) environment.

By now, we understand the need for triage in the MCI environment. Sorting patients into categories for Immediate, Delayed, or Minor treatment saves lives and provides an effective structure to the initial, chaotic stages of a MCI. Local definitions vary, but a MCI is simply defined as an emergency situation in which the number of injured persons will quickly overwhelm the normally available fire/EMS system.

The goal of triage is to quickly identify those victims likely to die within the first 60 minutes of the incident if they do not receive proper medical care. START provides an established, well tested method to identify victims who have serious respiratory issues, profuse bleeding, head injuries, and/or are in shock. These are the “killers” to which many trauma victims succumb in the first 60 minutes of an incident.

START provides a simple, effective method that the first-arriving fire/EMS personnel can initiate to organize the emergency scene. Phase one is “Start Where You Stand.” Victims should be initially triaged based on four factors, which follow:

  • Their ability to walk and follow simple commands.
  • Their respirations.
  • Their circulatory system profusion.
  • Their mental status.

The first emergency responder to enter the MCI environment gives a clear, audible instruction to those injured: “Anyone who can hear me and can walk, please get up and come to me now.” Those victims that can follow this simple direction are immediately categorized as “Minor.” Because these victims are able to move, understand simple directions, and do not appear to have life-threatening injuries, classifying them as Minor is warranted. Apply a triage tag to these Minor victims and direct them to assemble and wait nearby. This allows for a subsequent reassessment and provides a personnel pool for you to use in assisting, as directed, more severely injured victims.

IMPORTANT TIP:  Most triage tags have strings attached with two loose ends. When stocking your emergency medical services (EMS) bags in the morning—long before the incident—tie these ends of string together on each tag. This provides an easy, rapid method to apply your triage tags by simply looping and running the tag through the loop. Immediately apply the triage tag to the victim’s wrist or ankle as you first kneel next to them. After a quick assessment, tear off the colored labels to show the appropriate categorization. This approach saves valuable time on scene by avoiding the clumsy task of attempting to tie the triage strings together while assessing a patient and wearing rubber gloves.


(1)                                                         (2)                                                                 (3)           

In the above series of photos, a common triage tag is shown with the string ends untied. Photo 2 shows the tag with the ends tied together. Photo 3 shows how the tag easily slips through the loop created by tying the string ends together, allowing the rescuer to easily and quickly attach the tag to the patient.


Once the walking Minor injury victims have cleared the area, begin assessing the remaining victims. Initiate “Start Where You Stand” by first assessing the victim closest to you. A complete assessment should take no more than 30 seconds. RPM is a simple effective diagnostic tool for the triage environment. Assessing the victim’s respirations, circulatory system profusion, and mental status makes for easy triage. A simple to remember mnemonic is “30-2-Can Do.” If the victim’s respirations are more than 30, if capillary refill takes more than two seconds, or the victim cannot follow simple commands, they are categorized as “Immediate.” As soon as they fail one test, categorize them immediate and proceed to the next patient. Further assessment is not necessary. If they pass all three with respirations less than 30, proper capillary refill measures less than two seconds, and can follow simple commands and/or answer easy questions (i.e., date, time, and location), categorize them as “Delayed” and proceed to the next patient.

If you cannot assess capillary refill because of nail polish, check for the radial pulse. If present, profusion is adequate; if absent, tag the victim Immediate and move to the next patient.

IMPORTANT TIP:  In the MCI environment, cardiopulmonary resuscitation (CPR) is not typically performed on victims in cardiac arrest. When encountering a patient who appears to have no respirations, properly position his airway and assess for breathing for 10 seconds (look, listen, and feel). If respirations are absent after 10 seconds, reposition the head and repeat the assessment. If respirations return, use a bystander or person initially tagged Minor to hold open the airway. Tag the victim as Immediate and move to the next patient. If respirations remain absent after two assessments, tag the victim “Deceased” and proceed to the next patient. Doing CPR in the MCI trauma environment is rarely effective and delays rescuers from assessing and treating savable patients.

During the initial triage process, the rescuer should only pause to treat life-threatening conditions such as compromised airways, severe bleeding, and shock. The victims categorized as Minor can assist with those more severely injured by providing direct pressure on a wound, holding an airway in the open position for an unconscious victim, or elevating the legs of a shock victim and covering him with a coat or other immediately available suitable material.

By Starting Where You Stand and systematically assessing patients, the initial rescuer begins to bring organization to the chaotic MCI scene. Subsequently arriving rescuers can quickly determine which patients still need assessment by checking the nearest, untagged victim. Once all patients are tagged, the victims can be moved to the medical treatment/transport areas for further treatment, assessment, and transport to a medical facility starting with those tagged Immediate. The process of patient movement is clearly established by the triaging of the patients. When triage is complete, rescuers entering the MCI zone systematically package and transport victims, starting with the first patient they encounter who is tagged Immediate.

A victim with the triage tag “looped” and secured onto her ankle. Colored markers on the tag can now be removed to indicate the proper designation of Immediate, Delayed, Minor, or Deceased.


IMPORTANT TIP:  When removing the colored tabs from the triage tags to show the appropriate categorization, keep the removed portions. These will give you a reference point to quickly and accurately identify the number of patients in each triage category. It is important to reassess those victims initially assessed as Minor or Delayed. Serious head and internal injuries are often progressive and may not be apparent in the initial assessment process.

After the triage process is complete, where to begin more advanced treatment varies by jurisdiction. If the MCI environment is safe, I prefer to initiate at least some treatments when necessary prior to moving the victims such as C-spine immobilization, controlling bleeding, and splints. Scene safety is paramount, so the decision on where and how much treatment to provide post-triage will be determined by not only safety but available resources.

Establishing a medical treatment area in a safe zone is a common step in the MCI process. In the treatment area, patients can be reassessed and receive necessary care as the transport and treatment managers coordinate treatment and movement of the victims to appropriate medical facilities. Tarps colored red, yellow, and green corresponding to Immediate, Delayed, and Minor patients are a great help in organizing the flow of patients in the treatment area.

Long experience—domestically and in the wars in Afghanistan and Iraq—shows us that getting seriously injured victims to the proper medical facility within 60 minutes of injury gives those patients a 95-percent chance of survival. This time period is commonly referred to as the “Golden Hour.” The START system allows the initially arriving fire/EMS personnel to quickly bring organization to the chaotic MCI scene. This initial approach will allow for subsequently arriving personnel to quickly integrate into the emergency and allow for the formation of an incident command system which will effectively move patients to the life-saving care they need.


Demetrius A. Kastros is a 42-year fire service veteran and a semiretired shift battalion chief from the Milpitas (CA) Fire Department. In 1974, he was among the first group of firefighters in the State of California to be certified as an emergency medical Technician (EMT). Kastros has a college degree in fire science and is a state certified chief officer and master instructor. He continues to work in fire service-related activities. He is the lead instructor for the City of Monterey (CA) Community Emergency Response Team program. He has been published previously in digital editions of Fire Engineering.

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