3.5 Multiple Patients and Triage

When one patient becomes many

The EMR test plan includes investigating the scene to determine the potential number of patients. When the number or severity of patients exceeds what the responders on scene can treat at once, the call becomes a multiple-casualty incident (MCI) and the EMR's job shifts from treating to triage — rapidly sorting patients so limited care and transport go where they do the most good. The hardest mindset shift the exam tests is this: the first patient you find is not automatically the most critical, and a screaming patient is often less sick than a silent one. You count and sort before you commit to anyone.

During triage the only treatments performed are the few that take seconds and save lives without stopping the count: opening an airway (positioning) and controlling massive bleeding (direct pressure or a tourniquet, often delegated to a bystander). You do not stop to do a full assessment or CPR on one patient while others remain unsorted.

START triage: RPM and '30-2-Can Do'

The most widely taught adult system is START — Simple Triage and Rapid Treatment. Each patient is sorted in under 30 seconds using RPM: Respirations, Perfusion, Mental status, captured by the mnemonic 30-2-Can Do.

1. Ambulatory first. Announce loudly for anyone who can walk to get up and move to a designated area. Everyone who walks is tagged GREEN (Minor). This clears the walking wounded so you can focus on the rest.
2. Respirations (the '30'). Assess breathing in remaining patients. If a patient is not breathing, open the airway by positioning. If breathing does not start, tag BLACK (Expectant/Deceased). If breathing starts only after positioning, tag RED (Immediate). If breathing is present but the rate is over 30 per minute, tag RED. If 30 or under, move to perfusion.
3. Perfusion (the '2'). Check capillary refill (or a radial pulse). Capillary refill over 2 seconds, or an absent radial pulse, means poor perfusion — tag RED. Control any major bleeding now. If perfusion is adequate, move to mental status.
4. Mental status (the 'Can Do'). Ask the patient to follow a simple command ("squeeze my hand," "open your eyes"). If the patient cannot follow commands, tag RED. If the patient can follow commands and passed respirations and perfusion, tag YELLOW (Delayed).

JumpSTART for children

JumpSTART is the pediatric adaptation, used from infancy to about age 8 (or any patient who appears to be a child). Its key difference reflects that children usually arrest from respiratory failure: an apneic child who still has a palpable peripheral pulse receives 5 rescue breaths before any tag. If breathing returns, tag RED; if the child stays apneic, tag BLACK. Children able to walk are GREEN.

The respiratory thresholds differ from adults — a rate under 15 or over 45 per minute is RED — and mental status is assessed with AVPU (Alert, Verbal, Pain, Unresponsive): an age-inappropriate response to pain, posturing, or unresponsiveness is RED.

Keep the picture simple on exam day: GREEN walks, RED is an immediate life threat, YELLOW waits, BLACK is not breathing after a simple airway maneuver. Re-triage as resources arrive, because patients deteriorate and a YELLOW can become a RED.

After the sort: treatment areas and re-triage

Triage is only the first pass. As more responders arrive, patients are moved to treatment areas organized by category — typically an Immediate (red) area, a Delayed (yellow) area, and a Minor (green) area — so the most critical patients receive care and transport first. The EMR's role in a developing MCI is to keep sorting, control catastrophic bleeding and airways during the sort, and report the count of each category to command so transport and additional units can be matched to need.

Patients are re-triaged continuously, because a Delayed patient whose breathing worsens or who loses a radial pulse becomes Immediate and must be re-tagged and moved up in priority.

A frequent exam trap is the responder who finds a critical patient first and begins full treatment while ten other patients go unassessed. In an MCI, that is the wrong instinct: completing the triage sweep so that every Immediate patient is identified does more total good than perfect care for one. The shift from "do everything for this patient" to "do the most good for the most patients" is the defining mental change of an MCI, and the exam tests whether you can make it.

Specific takeaways:

• Switch from treating to triaging when patients outnumber responders.
• START sorts by RPM in under 30 seconds: 30-2-Can Do.
• The only triage treatments are airway positioning and bleeding control.
• JumpSTART gives apneic children with a pulse 5 rescue breaths; RR under 15 or over 45 is RED.
• Re-triage continually as the scene and patients change.