START Over

When an 80-year-old steam pipe ruptured beneath a busy Manhattan intersection in July 2007, it scalded those above with 400ºF steam and blew a plume of mud and debris 40 stories high. It hurt 45 people but killed just one: 51-year-old Lois Baumerich, who’d been working a block away and suffered a cardiac arrest while fleeing.

In her death Baumerich illustrated a problem with traditional methods of triaging patients in mass-casualty events.

“The only true black tag that would have occurred on that scene was this woman who walked up to an ambulance with chest pain,” recalls John Freese, MD, who until recently served as the Fire Department of New York’s chief medical director and now oversees its quality assurance and prehospital research. “The fact that she walked up made her a green-tag. And yet 30 seconds later she collapsed in cardiac arrest.”

Later in that same event, as hospital personnel decontaminated yellow-tagged victims with sundry knee and ankle injuries, they found among them a young girl having an asthma attack and her mother, also asthmatic, who’d been tagged yellow because her respiratory rate was just 12. “Her respiratory rate was 12,” notes Freese, “because she couldn’t possibly exhale any more quickly—she was just that tight.” She ended up getting epi during decontamination.

All of these patients were categorized appropriately under the START triage system. And that’s a weakness with START.

“We see these patients whose physiology or symptoms say, ‘I’m really sick,’” says Freese. “And providers, if they truly follow START, will group those patients in with others who can wait hours if not days for care, when these patients probably can’t.

“You don’t want a person with active chest pain walking over with the green tags and us missing an opportunity to save them.”

With plenty of transport resources, FDNY hasn’t seen any bad outcomes due to delayed care for those who confound traditional triage. But seeing such potential across multiple MCIs spurred the department’s top docs, led by Chief Medical Officer David Prezant, MD, to begin weighing modifications to START that could better catch those who might fall through its cracks.

They saw the biggest of those groups as 1) pediatrics and 2) those like Baumerich, with true medical and traumatic emergencies that might not be identified by START criteria.

In short, as Freese explained at the EMS State of the Sciences Conference in February, START asks six simple questions:

• Can a patient walk away?

• If not, are they breathing?

• If not, what if you open their airway?

• How fast are they breathing?

• Do they have a radial pulse?

• Can they follow commands?

This effectively separates ambulatory patients and the dead and dying, and it distinguishes the most critically injured and ill based on physiological criteria. What it can miss is serious patients who can walk, medical emergencies among the injured, and problems with peds.

To remedy that, FDNY instituted three changes:

1. Infants are automatically tagged red. (This isn’t a huge change; their respiratory rates usually place them in that category anyway.)

2. Children who aren’t breathing after their airways are opened get five rescue breaths. If they’re still not breathing, they’re black-tagged. Adding the rescue breaths is intended to help providers in mass-casualty situations call a death and move on, rather than spending time trying to resuscitate a dead child for emotional reasons.

“The decision to black-tag a child may be the most difficult decision EMS providers face,” says Freese. “So what we often see is that those patients are still resuscitated, even though they’re black. We wanted a way, when we’re faced with more children than we can deal with, to save the children who can be saved, and yet let our providers know they’ve done everything possible for any particular child when making the hard decision to move on.

“Since most salvageable children are respiratory-induced cardiac arrests, the five breaths are an effort to catch those early respiratory arrests, reverse them and restore some spontaneous breathing. Patients who don’t respond to that we’ll be able to recognize as beyond our ability to help.”

3. Patients who meet green or yellow criteria but are felt by providers to be sicker or more injured can be given a newly created orange tag to indicate a level of urgency between yellow and red. “It’s a way to let personnel use their experience and knowledge without having to uptriage to red,” says Freese. Orange tags are mandatory for those with ongoing dyspnea or chest pain.

There haven’t been a lot of orange patients in the year-plus since the category was created, but it has been appropriately used with occasional multipatient events. With continued use, it, and the whole modified START protocol, should become a sharper tool for FDNY’s next major incident.

“We still want a simple process any EMT or paramedic can perform rapidly in the field,” says Freese, “and yet something that picks up on what we perceive to be the deficiencies of START. I think right now we have a better method, but part of our job will be to prove that.”