Triage system sorts injuries quickly

Two trains collided in Chatsworth.

The death toll would reach 25. More than five times that were injured.

Peering through a home's chain-link fence, first responders saw fire licking twisted metal.

Soon they brought order to the chaos with color-coded tarps: red for the most severely injured, yellow for the moderately injured and green for the least injured.

The story, however, starts 30 years ago, some 80 miles to the south, in Newport Beach, where the Fire Department and Hoag Hospital staff developed a system of sorting patients based on who needed care most. They called it START: Simple Triage and Rapid Treatment.


Simple beginning

In 1983, Newport Beach firefighters conducted a drill involving high school students with fake injuries simulating a mass casualty bus accident.

Firefighters invited Hoag staff to participate and make suggestions on improving their response, according to Dr. Greg Super, Hoag's medical director of emergency services at the time.

What started as an afternoon's excursion became several months' worth of work and collaboration between the department and hospital, according to Costa Mesa interim Fire Chief Tom Arnold.

"It was a collaboration that married their world of medicine and our world of the application of that medicine," said Arnold, then a Newport fire captain.

The responses to multiple-victim disasters before START were impractical, requiring paramedics to make diagnosis while in the field, said Super, one of START's developers.

Sometimes emergency crews treated the first people they found, neglecting those who urgently needed care but were out of sight.

"It was pretty chaotic, and that's when this thing came around," said Dr. Carl Schultz, UC Irvine's director of disaster medical services.

In analyzing other incidents, including a plane crash in the Everglades, the collapse of a balcony onto a dance floor in the Midwest and a subway fire in London, the team gained a better understanding of what's known as mass-casualty incidents.

"What we learned was in those kinds of situations, about a third of the people affected were dead on the scene and about a third of the people didn't have any significant injuries," Super said.

With START, rescuers first ask those who can walk to go to a designated area, which enables a quick assessment of the severity of injuries. If victims are able to move and obey commands, they are likely not in dire need of care.

Rescuers can then go to the more critically injured, checking pulses and breathing and assessing them for head injuries. Each person is then assigned a color: green, yellow, red or black — the latter for the dead or dying.

A veteran rescuer can evaluate someone in as little as 15 to 20 seconds, Schultz said.

Some START protocols are counterintuitive. For instance, rescuers don't stabilize the necks of those who are not breathing before clearing the airway.

But that's OK, Schultz said, because the "odds are overwhelming" that someone would not have a ceverical vertibrae — or neck area — fracture.

By the mid-1990s, START had become standard across the U.S., later spreading to Canada, Australia and Europe, Super said.

"This triage algorithm isn't the only one, but almost anybody in the first world … anybody that has a triage system, knows about START," Schultz said. "Some have borrowed from it. It's definitely a worldwide distribution."

It remained a standard for about two decades and is still used in some form worldwide. With technological advances, other systems have since emerged.

Fire personnel and medical experts attribute START's longevity to its simplicity.

"It's a fairly stress-free method," Schultz said. "It's so simple [that] even if you're under a lot of stress, you can do it right."

Newport Beach Fire Capt. Ed Wick said the system makes it easier to prioritize patients.

"It takes all the emotions out of things, and it really comes down to who has the vital signs that are the worst," said Wick.


Practical use

In one of its earliest uses, START was employed after an SUV flipped, spilling high school students onto the road after a school event.

"It's ideal," said Wick, who was among those who responded. "Even if it was my child, I would want the START system being used in a major incident, because it does the most good for the greatest number of people."

In 2002, when an 87-year-old drove her Volvo into a crowd at the Balboa Island ferry pier, first responders used START to sort the 13 people injured.

"That one really came into play because if you think of the island, it's such limited access to get on and off," said Newport Beach Fire Capt. Jeff Boyles, who worked that day. "It was difficult to get ambulances so we really had to assess and triage."

Schultz said although other systems have since emerged, only START has faced data-driven testing, which showed a 90% accuracy in assessing patients, according to his research.

"This is an example of how if it doesn't exist, and if it needs to improve, we will invent it," Arnold said.

In the 2008 Chatsworth train wreck, START was crucial to assessing patients, according to Gregory Reynar, the Los Angeles Fire Department's assistant chief in the EMS, or emergency medical services, division. The system remains an important part of LAFD's responses to emergencies, and all LAFD personnel are trained in START.

Because of the size of LAFD's coverage area, START is something it uses regularly, Reynar said.

"That's something we use every day … that's something we rely on," Reynar said.

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