Skill guide · Medical Care

Understanding START Triage

The decision logic behind sorting multiple injured people by severity, not a replacement for practicing it on simulated patients. This is a Stage 3 self-sufficiency skill from the Medical Care chapter and its addendum, and the decision tree itself is genuinely teachable in text, the same way a checklist is, even though becoming fast and automatic at it takes real practice.

Download this guide as PDF

This is for multiple casualties, not one injured person

START (Simple Triage And Rapid Treatment) exists to solve one specific problem: more injured people than you can treat at once, so you have to decide who gets help first. If you're dealing with a single injured person, don't triage them, just help them; see the first aid basics guide for that.

The four categories

TagMeaningWhat it signals
Green (Minor) Walking wounded Can wait; treat everyone else first
Yellow (Delayed) Serious but stable Needs care, but survivable if it waits
Red (Immediate) Life-threatening, treatable Highest priority; treat or evacuate first
Black (Deceased/Expectant) Not breathing, even after airway repositioning Beyond what first aid can change

The decision sequence, in order

START is built to tag each person in about 30 seconds, by walking through the same five questions in the same order every time. Once you've assigned a tag, move to the next person; you're sorting quickly, not treating yet.

  1. Call for anyone who can walk to move to one spot. Everyone who gets up and walks there on their own is tagged Green. Someone able to hear you, understand the instruction, and walk is very unlikely to die in the next hour; that's the entire logic behind checking this first, before anything else.
  2. For everyone who didn't get up, check breathing. If they're not breathing, reposition the airway (tilt the head back, lift the chin) the same way you would before rescue breaths. Still not breathing after that? Tag Black. If breathing starts once the airway is open, tag Red immediately and move on; don't stay to treat yet.
  3. If they were already breathing on their own, check the rate. Faster than about 30 breaths a minute (roughly one breath every two seconds) suggests shock or respiratory distress; tag Red. Slower than that, continue to the next check.
  4. Check perfusion: a radial pulse (at the wrist) or capillary refill. Press a fingernail until it goes pale, then release; longer than about 2 seconds to return to normal color, or no radial pulse at all, means poor circulation; tag Red. A normal pulse and quick refill means continue.
  5. Check mental status: can they follow a simple command? "Squeeze my hand" or "open your eyes" is enough. Can't follow it, or too altered to respond meaningfully? Tag Red. Can follow it? Tag Yellow.

Five questions, and every person ends up tagged Green, Yellow, Red, or Black by the time you're done with them. Move to the next person immediately after tagging; treatment happens in tag order once everyone's sorted, not as you go.

Why this specific order

Each question is placed to catch the deadliest, most reversible problems first: an unrepositioned airway or a rapid respiratory rate kills faster than almost anything else a bystander can actually fix in the field, so those come before circulation and mental status, which still matter but progress more slowly. The order isn't arbitrary; it's sorted by how fast each problem kills and how quickly it can be caught.

How to actually mark the tag on a person

Sorting someone into a category only helps the next responder if the tag is physically visible on them, not just decided in your head. Commercial triage tags (color-coded cardstock with a tear-off strip matching the category) are the real, purpose-built tool, and worth keeping in a CERT kit or car if you've taken the training. Without one, colored surveyor's tape or ribbon, tied around a wrist or ankle, works as a real substitute, keep a roll each of red, yellow, and green on hand for exactly this. As a last resort with literally nothing else available, writing the color directly on the person's forehead or a piece of exposed skin with a permanent marker communicates the same information; legible and visible matters more than which of these three methods you use.

Children need a different version of this: JumpSTART

Everything above is the adult protocol, and applying it to a child can cause a real, serious error in exactly the wrong direction. The starting sequence and tag colors are the same, but three things change for a pediatric patient: if a child isn't breathing but still has a pulse, give 5 rescue breaths before tagging Black, not immediately, since children go into respiratory arrest well before cardiac arrest and often start breathing again with a little help, a step adult START doesn't include at all. The respiratory-rate cutoff for Red also moves, roughly under 15 or over 45 breaths a minute for a child, not the adult 30, since a rate that's dangerously abnormal in an adult is normal for a young child. And the mental-status check swaps "follow a command" for the AVPU scale (Alert, responds to Voice, responds to Pain, Unresponsive): alert or voice-responsive is Yellow, pain-responsive or unresponsive is Red. This variant is called JumpSTART; if CERT or another course offers it, learn both, not just the adult version, especially since a real mass-casualty scene rarely sorts itself into adults-only.

Retriage: tags aren't permanent

A mass-casualty scene keeps changing after the first pass. Someone tagged Yellow can deteriorate to Red while you're working through everyone else; someone tagged Red who gets a few minutes of care can sometimes be safely reclassified. Re-check tags periodically rather than treating the first sort as final, especially for anyone tagged Yellow.

What this doesn't replace

Reading this sequence is not the same as being fast and automatic at it under real stress, with real people, in a chaotic scene. CERT (Community Emergency Response Team) training is free in nearly every Wasatch Front city, run through the local fire department, and includes hands-on practice running START on simulated patients, exactly the repetition that turns a five-step list into instinct. This guide is the "what" and "why"; CERT is where the "fast and correct under pressure" part actually gets built.

Where to find it: search "[your city] CERT training." Salt Lake City, South Salt Lake, West Valley City, American Fork, and most Wasatch Front cities run their own free programs.

Sources