There were also suggestions that additional colors were needed to refine the prioritization. Colors such as orange, “really red” and yellow-green were suggested in a tongue-in-cheek manner. One firefighter in Region C characterized the dilemma of prioritizing tagged victims as “There are reds, and there are reds!”
Participants said they expected variations in the selection of top 10s, but most were shocked at the level of inconsistency.
Other Factors—Participants said they considered other factors beyond their protocols during actual triage situations. Participants said field triage is based on the experience of the triage and transport officers at the scene, but they acknowledged that such officers would often triage differently. One paramedic even said that if he were asked to repeat the exercise the next day, he would expect a different result.
Additional factors consistently mentioned as influencing triage decisions included:
- Type of trauma
- Age of victim
- Number of transport and treatment resources available
- Type and proximity of treatment facilities
- Access/egress characteristics (i.e., processing capacity) of scene
- Potential that victim will survive
- Cycle time of ambulances to the scene
- Weather (for helicopter transport)
Participants acknowledged that considering such factors further complicates field triage decision-making, and expressed doubt that any protocol could be so inclusive as to encompass all of them.
START and START-like protocols lead to strikingly inconsistent results. The tagging of victims is widely variable. This seems due to two primary factors:
1) Emergency responders cannot be expected to remember the precise START decision tree when it is rarely used (most often in annual exercises). They must instead utilize the flowchart-type START protocol.
2) Emergency responders openly acknowledge a lack of confidence in the protocol and rely on their experience and best judgment in making triage decisions. They realize this requires them to “play God,” so to speak, and for many it’s one of the most emotionally challenging aspects of their job.
The inconsistency in setting priorities within START and START-like protocols is extensive, but not surprising. Such protocols offer no explicit guidance to differentiate priority within the categories of immediate and delayed, and categories can contain wide variations in severity. A victim might be red-tagged due to a high respiratory rate, yet have a normal pulse and mental status, while another red-tagged patient with a high respiratory rate might also have significantly abnormal pulse and mental status. This leads to survival rates for red-tagged victims that range as high as 97%.7 This surely indicates that immediate-need victims aren’t being as accurately identified as the protocol intends.
Further, the protocol does not account for resources. Study participants openly acknowledged that their strategies in the tabletop exercise would be different if resources were more constrained or more abundant.
As well, START protocols are not scalable. The best strategy for a 20-victim incident is not the same as for a 200- or 2,000-victim incident, yet the protocols provide no guidance or adjustment. Emergency responders try to adjust on their own.
Every group of participants was asked what the goal in a mass-casualty event should be, and every group said to “save as many lives as possible.” The goal of START is “to do the greatest good for the greatest number.” This goal is not explicit and cannot be measured.
The ramifications of these inconsistencies are significant. They may cost lives. Imprecise and subjective START and START-like triage protocols unnecessarily burden emergency responders with making life-and-death decisions under impossible circumstances. The tag color is the only tool at their disposal, yet they consider the availability and timing of resources, the patient’s prognosis and many other factors as they try to save as many lives as possible.
The wide use of color-coded tagging gives a false sense of interoperability. While it is true that many EMS regions use color-coded tags, not only did this study uncover profound differences from one region to the next, but the level of inconsistency within regions makes the strategy almost random, and interoperability a complete misnomer.