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Trainer’s Corner: Mass casualty incident triage

Mass casualty incident triage

December 11, 2007  By Ed Brouwer

edbrouwerThe goal of this month’s column is to increase the fire fighter’s ability to triage, treat and transport patients arising from a multiple patient or mass casualty incident. The initial actions of the first arriving officer shall be directed toward scene size-up, requesting appropriate resources and initial organization of the scene.  The first arriving company officer at a multiple patient incident will assume command and give an on-scene report, which will answer the questions: what do I have, what action will I take, and what resources do I need?

The type of situation and the approximate number and condition of patients should be communicated to your dispatch centre as soon as possible. Command should rapidly survey the scene to identify any hazards or safety concerns and establish a safe zone for crews to operate.

This can be accomplished through proper defensive rig positioning, use of flashing lights and the placement of flares or reflectors. Additional traffic control should be requested from law enforcement through dispatch. Command should immediately request additional assistance if the need is indicated. Initial reports should indicate the scale of the incident to allow dispatch to notify other agencies.

Triage will be initiated early in an incident, especially when the number of patients and/or the severity of their injuries exceed the capabilities of the on-scene personnel to provide effective extrication, treatment and transportation. Once triage is complete, a Triage Report should be radioed to dispatch.


ICS terminology: The word “sector” refers to a geographical or functional assignment that is equivalent to a division or a group or both. When their assigned function has been completed, they are available for reassignment (IFSTA IV Edition).  The ICS system no longer uses the word sector, it uses the word “group.” Possible groups at a Multi Casualty Incident may include Triage Groups, Treatment Groups, Transport Groups and Safety Groups.

The first arriving company officer needs to quickly determine the most effective means to treat patients. In incidents with few patients, it may be more effective to treat patients “in place.” At incidents with a greater number of patients, a treatment area should be established.

Once the Triage Group has identified and sorted all patients, Command should be contacted and given a “Triage Report.” This includes the number of patients and their condition. A Triage Report may sound like: “Command – Triage.”  “Go ahead, Triage.” “Triage has been completed. We have two  immediates, three delayed and four minor.”

Command uses the triage report to call for additional resources or to scale back the response, and relays this information to dispatch.

A triage report becomes the triage benchmark, similar to the way an “All Clear” signifies the completion of a “search and rescue” at a fire incident. This means that all patients have been triaged and are ready for transfer to treatment or transportation group based on the severity of injury. Some incidents may require patients to be extricated from the scene to the patient treatment area before triage has been performed. This may be due to safety considerations such as a building collapse, hazardous materials release, or the nature of the incident such as a bus collision or train wreck.

Under these circumstances, a Triage Group Officer performs triage at the entrance to the treatment area. In many situations, patients are often discovered and identified as the incident proceeds. When this occurs, the Triage Officer or Treatment Officer can relay a “triage update” to Command.

When all immediate patients have been transported, the Transportation Group should notify Command that all critically injured patients have been transported from the scene. This should be relayed by Command to dispatch.   An “All immediates transported” declaration also serves to lower the stress of field personnel by notifying them that all critical patients are gone; they can now focus on treating the delayed and minor patients.

Multiple patient incidents are rare, but when they do occur we as fire fighters must be ready to effectively deal with them.  In order to do that we in the Canadian Fire Services should have a national standard to follow.  The following is a description of START – Simple Triage And Rapid Treatment.

START was developed by the Newport Beach (Calif.) Fire and Marine Department to quickly identify and sort patients during a multiple patient incident. START quickly distinguishes between critically ill victims and the less-severely injured.

Following a specific algorithm, a First Responder quickly assesses the ABCs – Airway, Breathing, Circulation – and LOC (level of consciousness) to categorize a patient’s condition. With START, a triage team of two can assess an average of one patient every 30 seconds.

At an incident with 40 casualties, two triage teams will take approximately 10 minutes to accurately triage patients using the START process. The only treatment rendered by the triage team is to open a patient’s airway by head/tilt neck lift or by insertion of an OPA, or to apply direct pressure to stop an obvious bleed or by elevating the extremities.

START was used successfully during the Trade Center and Oklahoma City bombings. Foreign countries including France, Saudi Arabia and Israel have also adopted START.

The three items that are checked when using START are: RPM — Respiration, Pulse & Mental Status.
There are four classifications that patients are put in: immediate (red), delayed (yellow), minor (green) and dead/dying (black).
•    Immediate (red) patients are those whose RPM is altered.
•    Patients who are unable to follow instructions to evacuate the scene, but whose RPM is intact are categorized delayed (yellow). This is the most common category. It also includes patients who have a significant mechanism of injury, but whose RPM is intact.
•    Minor (green) patients are those at large incidents who were able to leave the impact area on the instruction of EMS personnel. They are the “walking wounded” and should be tagged later. Note: Minor patients should not be confused with “paediatric” patients.
•    The dead/dying (black) are those who cannot breath after the airway is opened and are mortally wounded.  The patients will probably die despite the best resuscitation efforts. It is often a difficult decision to leave a dying patient, especially if it is a child. But remember resources are often wasted here on unsalvageable victims.

The three medical treatments rendered when performing START triage are: open an airway or insert an OPA, stop any visible bleeding and elevate the extremities for shock.

Triage priorities: Your initial goal during triage is to find immediate patients.  Your efforts should focus on locating all immediate patients, getting them treated and transporting them as soon as possible.  Once immediate patients have been treated and transported, reassess all delayed patients and upgrade any to “immediate-by-mechanism,” depending on their injury, age, medical history, etc.

When performing the triage function, regardless of incident size, don’t get distracted, move quickly and focus your attention on immediate patients. Those are the real lives you’ll save. The goal is to stay focused on red.

Start where you stand and walk either clockwise or counter clockwise. As you approach, identify the uninjured or “walking wounded.”  Move them out of danger or use them to control bleeding, maintain an airway and proceed to the victims that cannot move.

Triage assessment:
Step 1. Respiration (breathing)
A. None, open airway, still no breathing, tag deceased.
B. Respiration’s greater than 30/min. or less than 10/min. tag immediate.
C. Respiration between 10-30 per minute. Go on to Step 2.

Step 2. Perfusion check (radial pulse) or use a capillary blanch test
A. Squeeze nail bed, palm of hand or pad of finger.
B. If colour regains in greater than two seconds, tag immediate.
C. If the colour returns in less than two seconds go onto Step 3 – Mental status.
D. In poor lighting, attempt to find the radial pulse. If radial pulse is present proceed to Step 3.

Step 3. Mental status
A. Altered mental status is the inability to follow simple commands, tag immediate.
B. Able to follow simple commands, tag delayed.
C. Example of simple commands: “can you squeeze my hands?” “Can you open and close your eyes?”
D. All steps have been passed for patient to be tagged (delayed).

Rapid treatment
Ventilation: Open airway, clear obstructions or blood from airway; no heroics i.e. mouth to mouth.
Circulation: Apply a quick bandage. The “walking wounding” can assist. Raise legs to return blood to the heart. Note: If victim is unconscious mark as immediate.

MCIs involving more than 25 patients
A review was conducted on how fire departments around the country manage their major medical incidents (or drills). Based on these interviews and discussions, the following suggestions may improve response to mass casualty incidents.  Create the position of an ambulance co-ordinator within the Transportation Group. This person is assigned to directly oversee patient assignment to rescues. (In larger incidents, significant delays have occurred as critical patients awaited transport while available ambulances waited in ambulance staging.)  ALS personnel should remain on scene, usually in “Treatment,” to render advanced life support care to patients awaiting transport.

When incidents involve more than 50 casualties, Transportation Group should initially direct patients away from the nearest hospital or trauma centre until they can be checked for availability. Why? Because research indicates that in past large disasters, over three-quarters of the patients are sent to the nearest hospital or trauma centre. This quickly overloads those facilities. Don’t relocate the disaster to the nearest hospital.

In his book “Responding to the Mass Casualty Incident: A Guide for EMS Personnel,” Alexander Butman indicates that several pitfalls can hamper our effectiveness at multiple patient incidents. 

They are: failure to alert hospitals quickly; failure to perform any triage at all; lack of focus on critical patients resulting in slow stabilization and movement of patients; rendering time-consuming care on scene; and sending too many patients too quickly to nearby hospitals.

In addition, there are other mistakes often made which have been identified in his research on disaster response: improper use of personnel; patients not uniformly distributed to hospitals; lack of strong, visible Command; lack of preparation or training; failure to adapt to circumstances; and poor communication.  We need to prepare for the worst if we expect to do our best. In order to help you practice the START system I have prepared several scenarios for you, just drop me a line at  A scanned copy of the START Triage Card is also available.

Until next time, stay safe and be sure to train like their lives depends on it, because they do.

Ed Brouwer is the Fire Chief/Training Officer for Canwest Fire and a member of the Osoyoos Fire Department. The 18-year veteran of the fire service is also a Fire Warden with Ministry of Forests, a First Responder III instructor/evaluator, Local Assistant to the Fire Commissioner and a fire service motivational speaker and chaplain. E-mail .

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