Talk:Simple triage and rapid treatment

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I am an Undergraduate Student at the University of Virginia majoring in the Electrical Engineering Field with a minor in Engineering Business. I am currently working with a professor, whose research is in First Responders, researching the ethical aspects of obtaining medical information from patients and having it be applied to everyday life as well as during emergency crisis for my thesis. Sweetdid15

Instructive section

This was at triage. It can probably be killed outright (this kind of "howto" doesn't really belong in an encyclopaedia), but maybe someone can salvage something?

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Only perform triage for two or more injured persons. For a single injury, always perform first aid!

Some form of marking is very helpful to ration care. If you have triage tags—the right solution—immediately available, use them. If you have a marker or lipstick on your person, mark foreheads with "D" for deceased, "I" for Immediate, "DEL" for Delayed or "M" for "minor injuries." Unmarked or untagged persons should be considered unevaluated. If you cannot mark or tag, proceed anyway.

Triage 1: Loudly and authoritatively ask the group to get up and walk to a safe area that you designate. Do not ask them to walk to the sound of your voice. Designate a particular close area. Anyone who can walk does not need immediate life-saving help in a mass casualty situation. However, people can change categories, and the walking wounded are usually the largest category of victim. A person in shock, for example, might start an incident able to walk, and then faint in the walking-wounded area.

Those with minor injuries are your human resources to perform first aid. You will tell them what to do.

If you have not called for help, point at a particular person, and forcefully ask them to call for help. Make eye-contact, and get them to promise to do it. Ask them to call for help using the local emergency telephone number (9-1-1 throughout the United States and most of Canada, 1-1-2 throughout most of the European Union [but 9-9-9 in the UK and 18 in France], 101 in Israel and 000 for Australia).

Triage 2: On each remaining person, check RPM—Respiration, Perfusion, and Mental state. For each person, follow this procedure:

Triage 2R: If a person is not breathing, adjust their head and clear their airway. If that does not restore their breathing, they are beyond your ability to help. Tag them as DECEASED. Do not start CPR as several other persons may die while you are trying to save just one.

If a person is breathing, check the rate. If it is more than twice as fast as yours—more than 30 inhale/exhale cycles per minute—they are entering shock. Mark them IMMEDIATE; have a person with minor injuries lay them down, elevate their feet, and warm them with a blanket or jacket. As soon as you have instructed the walking-wounded care-giver, move on.

Triage 2P: If a person is breathing, but less than 30 cycles per minute, check their perfusion (blood circulation) by pressing and releasing a fingernail, or the ball of a finger, and seeing if it turns pink within two seconds. Use the ball of the finger if they have nail polish. If it's dark, use your flashlight, if you have one on your person. If it's dark and you have no flashlight, you may check for a pulse at their neck. If they are not perfused, tag them as IMMEDIATE.

Checking the fingernail is both faster and more reliable than checking the pulse, if the light permits, and this means you are less likely to mismark a person as "IMMEDIATE."

Triage 2M: If they are breathing and perfused, check their mental state. Ask them their name, and what happened. If they cannot reply, or say something unrelated, ask again, and tell them that you are testing to see if they are mentally confused. If they are confused, it may indicate a brain injury, which is beyond your ability to help. Tag them as "I" or IMMEDIATE for immediate transportation.

If the person is not confused, mark them DELAYED to indicate that they are stable and their transportation to the hospital may be delayed.

Now quickly check the person for bleeding. If a large wound is arterial bleeding, determine the first aid method of treating it, and ask the victim (if they are rational) or a particular person ("YOU, yes YOU...", not "Somebody") with MINOR injuries to perform the care.

Now, go back and repeat the process for the next person. Using this process, a trained responder can evaluate most injuries in less than thirty seconds. Remember, do not give care yourself. Give the care-giving tasks to walking wounded on the scene, so you can be free to evaluate other people.

Triage 3: Evaluate the IMMEDIATE injuries to prescribe first aid. Deputize people with MINOR injuries and bystanders to perform first aid operations, by telling them what to do for each person. There are almost always enough people to perform the needed first aid when given instruction.

Triage 4: Evaluate the DELAYED injuries to prescribe first aid. Recruit the victim to self-treat, or people with MINOR injuries to perform the first aid operations, by telling them what to do for each person.

Triage 5: Train one of the persons with MINOR injuries to watch the other MINOR injuries for signs of shock. As time permits, examine the victim, including the MINOR injury patients for shock. Look for very rapid breathing, more than twice as rapid as yours, and confirm by touching their skin. If they are clammy or cold, or the breathing is sufficiently rapid, they are entering shock. Have them sit down. If they are sitting, have them lay down. If they are lying down and you have no reason to suspect spine injury, have them raise their legs. The object is to raise the blood pressure to their inner organs to prevent oxygen starvation of major tissues, which is one way that shock kills. If possible, try to keep shock victims dry and warm to reduce their need for oxygen. If you have oxygen, and know how to administer it, do so. As you have time, tag walking wounded as "WALKING" and upgrade shock victims to "IMMEDIATE".

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Academic reference

I have not been able to find an academic reference for START. Only recent papers compare it with other triage systems. Does anyone know a good ref. JFW | T@lk 15:31, 8 July 2007 (UTC)

Cap Refill

Hey, cap refill is a horrible sign, and shouldn't be part of START, could someone please cite a source for checking cap refill? From my experience, and as per the Red Cross First Responder Instructor Manual, page 201, a radial pulse is the correct assessment. purpleidea (talk) 05:48, 17 February 2008 (UTC)

...for pulse, but not for blood pressure. Doing regular blood pressure measurements takes too long for the purpose of STaRT, so cap refill is OK as a first guess - when used with brain (CAVE: cold fingers, colored nails, ...). —Preceding unsigned comment added by 84.152.47.115 (talk) 22:31, 1 May 2009 (UTC)

Radial pulse also gives a rough estimate of blood pressure: if present, systolic BP is higher than 80 mmHg (see Blood pressure). This might make cap refill redundant. At least, this is what I was taught as a Red Cross volunteer. Anzate (talk) 21:38, 24 June 2009 (UTC)

When I took the CERT training in 2008, they taught us to use the "blanch test." Sure, a radial pulse is a good measurement, but it's not always easy to find, especially for people with little experience. However, anyone can tell if the nail color is returning within two seconds.

*Septegram*Talk*Contributions* 05:06, 24 February 2010 (UTC)

Edit

I removed the following from the section on pediatric START:

However the only Evidence based method for the triage of children is the Smart Tape. As the Smart Tape gives the rescuer a tool to do the job it allows them to be much more objective, vital when dealing with sick and injured children. The pocket sized tape is tough enough to cope with the worst environments.

This reads completely like an advertisement, and the link to which it referred (http://www.tsgassociates.co.uk/English/Civilian/products/smart_tape.htm) is not an article showing this tool is "evidence-based" but rather to the company's website.

*Septegram*Talk*Contributions* 04:53, 24 February 2010 (UTC)

References

Imbalance in discussion of limitations

The addition of the "START Limitations" section with numerous citations to works authored by Sacco et al. presents a serious point of view problem and reads like a criticism section (See: WP:CSECTION and WP:UNDUE). While the editor presents arguments that are supported by published sources in the medical literature, the section spends way too much space discussing what triage "should" or "should not" be; I have removed these sections as they neither describe START nor describe a criticism of START. As it is, the addition of this criticism section without additional cleanup and citations of the main part of the article presents a biased point of view: nearly all medical citations presented are in the criticisms section and nearly all of these are by Sacco et al., which could erroneously suggest that there is a consensus in the medical community around Sacco et al., that START is not valid as a triage mechanism.

I think there is a place for the limitations of START to be discussed in this article, but the current limitations section is too long, covers too many tangential subjects, and deviates from NPOV by relying too much on one set of studies. I am going to work a bit on improving the main article by adding academic citations, and I would like to solicit feedback on how to incorporate the limitations. If I do not receive any feedback on this talk page, I will continue to cut back on the limitations section.

Wetrat (talk) 15:04, 12 April 2013 (UTC)

Feedback RE: Imbalance in discussion of limitations

Thank you for reviewing this. I agree that this section could be shortened and that a NPOV is needed for this article. However, I don’t think the Limitations section is the problem. Let’s consider what existed prior to this section, the importance of this subject, the nature of the Sacco et al. research, and consensus that does exist.

The article begins by claiming that START effectively and efficiently evaluates MCI victims. It then states that START Delayeds can wait up to 1 hour, while Immediates should be treated immediately, and that START has worked well for many years. What are the bases of these claims, and where are the medical citations? A NPOV?

On this page, reviewers have commented on not finding an academic reference for START, assessment problems using cap refill and now a lack of medical citations for other article sections. Where is the START research (from high quality medical sources)? How does START effectively and efficiently evaluate MCI victims, and where is the evaluation? How has it worked well? How were categories designed, evaluated and tested? What evidence was gathered or used to support and validate START’s categorical definitions? How precise and useful are these categories?

In 2005, Dr. David Cone, a Senior Associate Editor of Academic Emergency Medicine, wrote a commentary on the initial Sacco et al. research (Sacco), stating he was surprised that so little research existed validating or even evaluating triage systems, that START was probably the most commonly used system in the United States, and that there had been almost no scientific evaluation of START. That was almost eight years ago! Besides Sacco, who else has rigorously evaluated and tested the START methodology and categories using quantitative methods and evidence?

Triage literature identifies assessments, prioritizations and resource allocations elements and goals. If START is a commonly used system for MCI preparedness and response, shouldn’t this article address how exactly and well does START assess, prioritize and allocate resources, and perform against its goal on concrete bases?

The START goal is “to do the greatest good for the greatest number.” What exactly does this mean and how is it accomplished? An expert panel assembled by the AHRQ found that the goal of mass casualty response should be to maximize the number of lives saved. Is this what the START goal means? How does START do this? This is not a tangent; the START goal should be important and needs to be explained (I think the De-facto START goal is to provide some structure and to organize the scene, which have been important contributions).

The AHRQ expert panel also found that resource allocation and triage protocol needed to change in order to accomplish the goal of maximizing the number of lives saved as the incident size grows. Where does START even address resources or incident size, much less provide any (objective) methodology to optimize resource allocation and maximize the number of lives saved? After 9/11 and recent events, isn’t this relevant and important? There was no mention previously of how START orders patients within its categories and allocates resources.

Sacco shouldn’t be marginalized because of the lack of other efforts to evaluate and test START. They evaluated START methodology and its categories using applied mathematics and evidence from a large trauma database. Using measures that met or exceeded (statistically) existing trauma measures, they quantified survival probability ranges within START categories. Using statistics 101 lessons, they explained and demonstrated dangers of using a worst Immediate first protocol.

Sacco presented their research to key (NAEMSP) stakeholder groups beginning in 2002. Sacco papers and studies began to be published in 2005 in prominent peer review medical journals, citing START limitations, and also in EMS trade journals. A close reading of Sacco reveals abundance of independent participation and review.

Sacco has been multi-faceted. In addition to papers on blunt trauma, penetrating trauma, military applications including blast overpressure-like injuries, Sacco also introduced industrial engineering approaches to various triage exercises that test and evaluate prioritization (ordering), resource allocation, and process, as well as tagging accuracy. Their initial results of tabletops, published in a 36 page 2004 report to the Pennsylvania Department of Health that is posted on the Sacco Triage website, indicated “profound inconsistencies” in ordering and tagging patients.

Sacco published results of a parallel triage exercise in The Journal of Trauma where the EMS agency had used START for twelve years. START performed poorly, despite mandated pre-exercise training, and EMS falsely believed after the exercise that START had performed well, until exercise data was analyzed. Sacco stated that these studies are predictable because START ordering is subjective within and based upon flawed categories, and poor results have been replicated in numerous other states.

These exercises demonstrated that START was not reproducible and was not compatible with interoperability, and tagging accuracy was a red herring. Triage has been deemed a critical skill for MCI preparedness and response. Shouldn’t triage systems be compatible with the National Incident Management System (NIMS)? If not, let’s state this and the reasons for exclusion. The Sacco Triage website indicates working with FEMA subject matter experts in 2007 to develop an evaluation and testing program of NIMS compatibilities and operational effectiveness for triage.

There have been MCI studies that have evaluated START’s performance in Madrid and Glendale, and demonstrate poor patient assessment and significant overtriage. Patterns from responses after terrorist attacks around the world corroborate this. The NAEMSP/SALT work group identified issues with START in its attempts to propose a national protocol and identify criteria for a proposed national guideline. These issues include no differentiation of patients placed in large categories with varying injury severities, that resources must be considered, problems with assessment using cap refill, and potential for poor patient outcome with worst Immediate first triage and overtriage. These citations were provided in Limitations.

Why are there no other explicit evaluations of START process and categories? Is this not important? Why are established best practices in engineering and management science not applicable to medicine and allocating its resources? I think Steven Brill’s Bitter Pill investigation of healthcare costs enters into this. Stating that the Sacco peer reviewed and published START limitations and conclusions about ranges and overlaps of survival probabilities for START categories may be so, when there were no such qualifications in the published original research, and a dearth of evidence-based response, would appear to be unscientific, disingenuous and agenda-based.

START’s Limitations was motivated by the lack of a NPOV that existed previously and unsubstantiated claims that are at odds with medical citations that do exist. This section adds to the NPOV and quality of this article rather than detracts from it. — Preceding unsigned comment added by Critthink (talk • contribs) 16:09, 20 April 2013 (UTC)

I agree that the article should not say that START "effectively" evaluates and treats MCI victims. That being said, the whole article is bad, as it reads like an instruction manual. In fact, I have suggested rewriting the article, including limitations in the main text. However, almost all of the rest of what you are talking about needs to be in the talk page for triage, not in the page on START, because it deals with the question of what triage "should" accomplish and how different methods compare to one another. I agree that OR/MS should be applied in healthcare, but that has nothing to do with the encyclopedia entry on START. Most of your response misses the point as it is simply a defense of Sacco, the validity of whose work I never questioned! I only said that your presentation of the criticisms would erroneously lead a reader to believe that the medical community has formed a consensus around Sacco's point of view and against START; this has not happened and many people use START. Most of your criticisms are not even specific to START but apply to most color-coded triage systems. As far as I know, overtriage (for example) is not a START-specific phenomenon.

Let me outline my thoughts more carefully. Someone looking for an encyclopedia entry on START is most likely looking for: 1. What is START? 2. How does START work? 3. Who uses START and for what purpose? 4. What other things are related to START (which can be mostly covered by linking to triage)? In the discussion of (1) it can be stated that while START is a system for sorting patients into four color coded groups, which are given fixed priorities, it primarily a classification mechanism and not a tool for supporting resource allocation decisions. In the discussion of (2) it can be emphasized that START does not assign priorities within classes (but without claim to whether this makes it "invalid"). In the discussion of (3) it can be noted that some folks have found START to be inadequate for various reasons, which has motivated additional triage standards and attempts to refine or redefine triage (link to triage). Wetrat (talk) 20:55, 20 April 2013 (UTC)

Article rewrite on 4/21/2013

After getting only one feedback, I went ahead and rewrote the article using reliable secondary sources. Most of the rewrite involved bringing down to size what didn't actually relate to START or was only tangentially related to START. I have included brief mentions of related methods and brief limitations, but 80% of what was in the article before probably belongs in triage.

As it is the article is fairly short and descriptive. Before adding to it,

• please ask yourself whether what you are planning to add belongs in this page (i.e., is actually part of an encyclopedic article on what is START triage); see WP:coatrack.
• please use secondary sources; see WP:MEDREV.

Wetrat (talk) 23:16, 21 April 2013 (UTC)