12.3 Scenario Practice for Professional Issues

Disaster Triage: START and JumpSTART

When casualties overwhelm resources, individual ESI triage is replaced by mass-casualty triage, where the goal shifts from doing everything for one patient to doing the greatest good for the greatest number. The dominant U.S. field system is START — Simple Triage And Rapid Treatment — which sorts adults in under 60 seconds using RPM: Respirations, Perfusion, Mental status.

The START flow:

1. Ambulatory? Anyone who can walk to a designated area is tagged GREEN (minor).
2. Respirations — none after opening the airway = BLACK (expectant/deceased); over 30/min = RED (immediate).
3. Perfusion — radial pulse absent or capillary refill over 2 seconds = RED.
4. Mental status — cannot follow simple commands = RED; otherwise = YELLOW (delayed).

JumpSTART for Children

JumpSTART is the pediatric adaptation (roughly infancy to age 8, or anyone who looks like a child) and reflects a crucial physiologic truth: children most often arrest from respiratory causes, not cardiac ones. So JumpSTART adds a rescue step START lacks.

The key differences:

• The respiratory rate window is 15-45/min (outside that range = RED), versus the adult cutoff of 30.
• If a child is apneic but has a palpable pulse, the rescuer gives 5 rescue breaths. If breathing resumes, tag RED; if the child remains apneic, tag BLACK. An apneic, pulseless child is tagged BLACK.
• Mental status uses the AVPU scale: a child who is "P" (responds only to pain) or "U" (unresponsive) is tagged RED.

This 5-breath trial is the single most-tested JumpSTART distinction: you never tag a pulse-positive apneic child expectant without first attempting rescue breaths, because a brief intervention may convert a salvageable child.

Reading the Scenario and the Triage Mindset Shift

The hardest mental adjustment in a mass-casualty incident is abandoning the one-patient mindset. In daily ED practice you give an arrested patient full resuscitation; in a multi-casualty event with limited resources, that same patient may be tagged expectant so that several salvageable patients can be saved instead. The CEN tests whether you can make this utilitarian shift — the greatest good for the greatest number — rather than defaulting to maximal care for the first critical patient you reach.

During secondary triage, after the rapid first sort, patients are reassessed and may move categories as their condition or available resources change; triage is dynamic, not a single labeling event. When a scenario gives you a victim's respiratory rate, pulse or capillary refill, and ability to follow commands, work the RPM sequence in order and assign the color the algorithm dictates — do not let a dramatic-sounding injury override the objective criteria.

A patient with an obviously deformed femur who is walking, breathing normally, perfusing, and following commands is still tagged green, because the algorithm measures physiologic threat to life, not the visual severity of the wound.

Forensic Evidence and Family Presence

The emergency nurse is frequently the first link in the chain of custody. When caring for victims of violence, gunshot, stabbing, sexual assault, or suspicious death:

• Do not cut through bullet holes, stab defects, or existing tears in clothing; cut around them so the defect is preserved for the crime lab.
• Remove each clothing item and place it in a separate paper bag (paper breathes; plastic traps moisture and degrades biological evidence). Air-dry wet items first.
• Place a paper barrier between stained areas, label, date, and sign each bag, and never leave evidence unattended — every transfer is logged so the chain of custody is unbroken.
• Document objectively, using the patient's direct quotes in quotation marks, and avoid words like "alleged" that imply judgment.

Family presence during resuscitation (FPDR) is endorsed by the Emergency Nurses Association when a trained staff facilitator stays with the family to explain events and support them. Research shows witnessing the team's effort can ease grief and reduce complicated bereavement, and a family member may be asked to step out at any point.

End-of-life duties also include early referral of every imminent death to the Organ Procurement Organization (OPO). Federal Conditions of Participation require timely referral so the OPO can assess suitability; the OPO representative, never the bedside nurse, approaches the family about donation — this separation (the "decoupling" of the death notification from the donation request) protects the family and improves consent. If the patient is on a state donor registry, that registration is first-person consent and legally authorizes donation.

Diagnosis of brain death — irreversible loss of whole-brain function — is a clinical determination made before donation discussions, and it is distinct from withdrawal of care. The emergency nurse's role is to identify the potential donor, refer promptly, and provide physiologic support, not to raise donation directly with the grieving family. Donation after circulatory death is also possible when a patient is not brain-dead but death is imminent and the family decides to withdraw support, so the OPO is notified for every imminent death, not only brain-death cases.