You are on page 1of 7



Reprinted with permission of The Gold Cross and Leonard Publications


After reading this article the EMT will be able to:

• describe the circumstances of an MCS;

• understand how an MCS differs from a standard EMS call;

• review START, the method for triage;

• list the components of RPM and how they are used in triage;

• understand the need for CISM after an MCS.


You are at home watching television when your program is interrupted by a

special report. An anxious-sounding reporter stands at the edge of a wide marsh
where a jumbo jet carrying hundreds of passengers has crashed a short time
ago. As she describes the disaster the TV camera scans the area. You see a
flash of EMS reflective vests and helmets as rescuers scramble through the mud
and smoke searching for victims. As spectators, we watch the special report, say
a few silent words of encouragement to our EMS colleagues, and breathe a sigh
of relief that the incident did not occur in our coverage area.

But underlying our relief is the unquiet certainty that sooner or later, we will be
responding to a similar disaster. In this state, it’s only a question of time.

New Jersey is highly susceptible to mass casualty incidents; no community in

this state is immune. With its huge network of congested highways, crowded
airspace and hundreds of daily trains, disasters will inevitably occur. Many
squads have already had considerable experience in dealing with disasters.

Any event which occurs suddenly and creates large numbers of victims in a
localized area is called a mass casualty situation (MCS), or mass casualty
incident (MCI). An MCS may be caused by an event such as an act of terrorism
or an airline crash. In these events, the number of victims outnumbers the initial
number of rescuers. Because of that inequity, an MCS overwhelms the standard
emergency resources of the area including police, fire, rescue, EMS, and
hospitals. The military calls this a "resource scarce environment." Local agencies
are forced to quickly request assistance from other municipalities as well as state
and federal government agencies.

Can an MCS happen in your hometown? Absolutely. And when it does, the
citizens will rely on your squad to respond quickly and efficiently.

In this article, we will examine triage, or how EMTs initially manage victims in an
MCS. We will not discuss treatment beyond what is required in those first 60
seconds of decision-making.

Do You Know What to Do?

There are a number of triage methods that you can use. In the heat of the
moment, however, it is often difficult to remember what you learned.

An MCS is considerably different from the standard medical or trauma call.

Those routine calls allow us sufficient time and ample resources to provide care
to a single patient and his family. Often we are assisted by first responding police
officers and/or fire fighters, and for patients with life threatening conditions, ALS
responds. There is safety in numbers and we can do everything possible for this
one patient.

In the MCS, however, we are out-numbered. We must shift our focus from doing
everything possible for every victim to doing the greatest good for the greatest
number of people. This means that we may have to make decisions that
challenge our work ethics and life values. For example, under normal
circumstances a victim in cardiopulmonary arrest would have received CPR. In
an MCS, he will be black-tagged and triaged as dead. In effect, we are put in the
uncomfortable position of determining who will live and who will die.

METTAG: Color Code the Victims

As the triage officer, your initial role is to direct the organization of

victims/patients. (Note: A "victim" becomes a "patient" once triaged.)

In New Jersey, the METTAG serves as a standard communications’ tool for

triage. This tag identifies the medical treatment and transportation priority of MCS
patients, and communicates this information to those performing these jobs. It is
physically affixed to patients once they have been evaluated and assigned a

The METTAG is a rigid card with four highly-visible, color-coded, perforated tabs
at its bottom edge. (See figure 1.) Each color code corresponds to a priority
number and symbol. For example, red is one of the colored tabs. On the red tab
is a Roman numeral one (I) and a symbol of a rabbit. In this article, we will refer
strictly to the color system to keep things simple.
• Green is the lowest priority and is used for walking wounded or patients who
may not need to go to the hospital. Patients in this category may have minor
musculoskeletal or soft tissue injures. They can wait for treatment and/or
transport until all other patients have been removed from the scene.

• Moving up the tag, yellow is the next category and is used for patients who
definitely need to go to a hospital, but not immediately. These patients have
injuries that are serious but not life-threatening, such as burns without airway
problems, major or multiple bone or joint injuries, and back injuries without spinal
cord damage. These patients will be treated and transported after the critical (or
red-tagged) patients have been taken to trauma centers or hospitals.

• The highest priority is red, and it is used for critically-injured patients with
treatable life-threatening injuries or illnesses. This might include airway and
breathing difficulties, decreased mental status, and uncontrolled bleeding. These
patients will be treated and transported from the scene first.

• The final category is black and it is used for dead and unsalvageable patients
such as someone in cardiac arrest. These victims will be removed from the
scene, but only after all of the living/salvageable patients.

After assessing a patient’s needs, you place the METTAG over his head (around
the neck) and tear off the perforated tag(s) at the bottom. The color left at the
very bottom is the patient’s triage identification.

A word here about cervical spine immobilization:

Cervical immobilization is a problem in an MCS. In all standard EMS calls, c-

spine immobilization is a top priority in trauma. But in an MCS, you are initially
faced with too few personnel to maintain standard treatment protocols. The truth
of the matter is that applying collars and holding manual c-spine immobilization is
just too labor intensive.

The result: Remember the circumstances; do the best you can with the
manpower and equipment available. The patient will ultimately receive proper
immobilization in the treatment phase of the MCS operation.


METTAGs in hand, you now begin the tremendous responsibility of organizing

the chaos. Simple Triage And Rapid Treatment, or START, is a triage system
that was developed in California in the early 1980s. (See figure 2.) It is simple
and fast, requiring less than sixty seconds for each patient. It does not require
any special assessment or diagnostic tools. EMTs do not need a blood pressure
cuff, a stethoscope or even a penlight. The system provides for rapid life saving
stabilization such as airway control and bleeding control, but excludes CPR.
A word here about cardiopulmonary resuscitation: CPR is not performed in these
situations because two or three rescuers would be required to treat a single
patient whose probability of survival (in the chaos) is zero-to-none. On the other
hand, those same two or three rescuers could play an important role in treating
five, ten, or maybe even more patients.

How to Start

The first (and easiest) thing you must do is separate the walking wounded from
the other victims with more severe injuries. This can be done by shouting slowly
and clearly or using a bullhorn. Designate an area for walking wounded and
instruct anyone who can walk to get up and move to that area. (Note: Some
victims may be unwilling to leave their friends or family members who are ill or
injured; permit them to stay as they can help you with managing the patient.) The
theory here is that if a person can walk, he does not need immediate medical
care. Green-tagged patients will not be ignored. Rather, they will be further
assessed and treated when all of the red and yellow patients have been treated
and/or transported and resources become available to take care of them.

All of the patients in this area are considered to be "green tags." Later you will
return to the "green" area and "officially" tag them but only after you have triaged
the red and yellow victims. With this green group in a separate (safe) location,
you are well on the way to being organized.

Evaluating the Remaining Victims

The next step is to triage the remaining victims. By evaluating respiration,

perfusion and mental status, you sort and separate them into three categories
which give the greatest priority to those victims who are most critically injured,
and have the greatest chance of survival. Let’s quickly review our color-coded

• Red Tag: those victims whose injuries are life-threatening and must be
immediately treated and transported.

• Yellow Tag: those whose injuries will allow for delayed treatment and transport.

• Black Tag: those who are dead or unsalvageable.

How do we make that determination? RPM.

R = Respirations

The first assessment is for presence and rate of respiration (RPM). Is the victim
breathing? If there is no respiratory effort, reposition his head and reassess. If
there is still no respiratory effort, the victim is considered "dead/non-
salvageable." Apply a black tag and move on to the next victim.

What if he is breathing? Assess the rate. If the rate is above 30 breaths-per-

minute, the patient is critical and requires immediate care. (Remember from your
EMT-B class that a respiratory rate above 30 and below eight breaths-per-minute
(BPM) is not adequate to meet the body’s needs and may quickly progress to
cellular death.) As triage officer, however, you do not stop to ventilate this
patient! He is given a red tag and you move on to the next victim. You do not
need to complete any other components of the START assessment on this

If the patient requires simple airway maintenance (e.g. manual head positioning),
you will need to assign someone to this task. If no emergency service personnel
are available, remember that you have a pool of human resources in the green
tag area. If no one there is available, you will need to improvise by placing
something under the patient’s head/neck to keep the airway open. It should also
be noted here that airway maintenance might need to be done without standard
cervical spine precautions.

If the respiratory rate is less than 30 breaths-per-minute, move on to the next part
of the assessment process.

P = Perfusion

The next step is to assess for Perfusion (RPM). As you may remember from your
EMT-B course or core refresher, perfusion is the circulation of blood within an
organ or tissue in adequate amounts to meet the cells’ current needs. If the body
lacks adequate perfusion or circulation, cells, tissues, and organs will die.

How do we assess perfusion in victims at an MCS? Check for the presence of

radial pulses. However, note that we are not concerned with a pulse rate at this
time. If the patient has no radial pulses, he is critical and in immediate need of
care. You apply a red tag to the patient and move on to the next patient.

If there are no radial pulses, there is no need to check for carotid pulses. Why
not? If the patient does not have a carotid pulse, then he will also have no
respiratory effort, and therefore, would have been triaged as dead/non-
salvageable in the previous step. Recall also that the presence of a radial pulse
correlates to a systolic blood pressure of at least 80 to 90 mmHg. If radial pulses
are present, move onto the next assessment.

There is one other assessment-finding related to perfusion status which must be

mentioned here: severe bleeding. Uncontrolled bleeding is potentially life
threatening and must be treated when found. Again, you may have to improvise
by using the cleanest piece of cloth around which may not be sterile.
Do not forget your human resources available in the green area. Delegate
someone to maintain direct pressure on the wound and move on to the next
victim. Your job remains triage.

M = Mentation

The third and final assessment is for Mentation (RPM) or mental status. A patient
who is either unconscious, or conscious but unable to follow directions, is critical
and requires immediate care. You will apply a red tag to this patient and move on
to the next victim. If the patient has a normal level of consciousness and can
follow directions, he is not in immediate need of care and is triaged as yellow.

As soon as a patient meets any one of the criteria for triage as critical/immediate,
you should apply a red tag, delegate someone to provide rapid treatment (e.g.
maintain an airway or control bleeding), stop any further assessment and move
on to the next victim.

Any patient who makes it through all three assessments, without any findings
that would result in triaging as critical/immediate, is given a yellow tag. No triage
system is 100% fail safe. It is, however, reasonable to assume, that a patient
who cannot walk, but is maintaining his own airway, breathing at a rate less than
30 breaths-per-minute, perfusing radial pulses, has no sign of uncontrolled
bleeding and follows commands, is in need of medical attention at the hospital,
but can wait until all of the critical/immediate (red tags) are removed from the

Secondary Triage

Let’s quickly review how START integrates with the METTAG system.

• Anyone who gets up and walks to the designated area is given a green tag
(may not even require hospital care).

• Anyone who is not breathing is given a black tag (dead/non-salvageable).

• Anyone who fails one of the RPM assessments is given a red tag

• Anyone who cannot walk but passes all of the assessments is given a yellow
tag (delayed).

START is a very versatile tool. Once you have sufficient personnel and your
patients are separated into different locations, you can retriage patients still using
START. All EMTs know that injuries may progress from bad to worse.
(Occasionally they improve.) Therefore, patients may need to be recategorized,
and then moved to another triage location. START may be used repeatedly for
patients on scene.

Psychological Aftermath

For EMS Personnel

Mass casualty situations are different from the normal medical or trauma call in
every aspect. There may be tens or hundred of patients. As an EMT, you are
personally overwhelmed. Your ethics are challenged as you must determine the
order in which patients will receive care. You will be required to ration who gets
that care, and in some cases who will not, simply because there are not enough

Often we will be unable to manage our patients the way we learned in EMT
class. We may have to maintain an airway without taking c-spine precautions, or
control bleeding with non-sterile supplies. We may have to direct others with no
medical experience to perform life saving maneuvers.

An MCS is a highly stressful event, charged with devastating circumstances. The

psychological toll taken on EMS and rescue personnel may not be easy. I
encourage anyone involved in an MCS to take advantage of New Jersey’s
Critical Incident Stress Management (CISM) teams. They may be reached by
calling LIFECOM at (609) 394-3600. Be prepared to give your name, a return
telephone number, incident nature and the agencies involved. LIFECOM will
contact the CISM team coordinator, who will return your call within thirty minutes.

Remember: Your initial role in triage is to sort the patients and prioritize their
treatment and transportation, thus bringing organization to chaos. You are now
equipped with a rapid, easy-to-learn tool which requires no special assessment
or diagnostic equipment, and provides for rapid life-saving stabilization.

Practice START drills at least once a year. It’s that simple.

Andrew Harris, BS, MICP, is the EMS coordinator at Somerset Medical Center
and an associate member of the Morganville First Aid and Rescue Squad. He
has been active in EMS in NJ for 16 years.