Triage: Allocating Care When Resources Are Limited

Imagine 50 patients arrive in 10 minutes and you have supplies for 20. Who do you help first? Triage (from the French trier, "to sort") is the system emergency responders use to answer that question. Its governing principle is not "treat the sickest first" — it is maximize the number of lives saved given the resources and time available. That distinction is everything. The most widely used field protocol is START (Simple Triage and Rapid Treatment). It works in four steps: Step 1 — Walk: Direct all patients who can stand and walk independently to move to a designated safe area. They are tagged GREEN immediately and removed from further assessment. Only non-ambulatory patients proceed to the three-sign evaluation below. Step 2 — Respirations: Is the patient breathing? If not, one airway-repositioning attempt is made. Still no breath after repositioning = BLACK tag. Breathing rate above 30 per minute = RED tag. Step 3 — Perfusion: Check capillary refill time (press a fingernail and count seconds until color returns). Refill longer than 2 seconds = RED tag. Note: In the field, responders sometimes check for a radial pulse as a practical alternative when capillary refill is difficult to assess (gloved hands, low light, cold temperatures), but capillary refill time is the original START criterion. Step 4 — Mental Status: Ask the patient to follow a simple command ("squeeze my hand," "open your eyes"). Cannot follow commands = RED tag. The four color categories: - RED (Immediate): Life-threatening but survivable with prompt intervention. Treat first. - YELLOW (Delayed): Serious injury, stable for now. Treat after Reds. - GREEN (Minor): Walking wounded — identified at Step 1. Can wait; may self-treat. - BLACK (Deceased): In classic START, Black means only one thing: the patient is not breathing after a single airway-repositioning attempt. (Some military and newer civilian protocols — such as SALT triage — extend Black to include living patients with unsurvivable injuries; that sub-category is called "Expectant." Classic START does not include that sub-category.) The Black tag reflects a difficult reality: the one-repositioning limit means no further individual rescue attempt is made, freeing all resources to save others who can survive. This is a utilitarian trade-off — population benefit over individual rescue when genuine scarcity exists. Medical ethics recognizes it as legitimate under those conditions, but it requires training, accountability, and reassessment as conditions change. Key insight: triage is not a final verdict. Categories are reassigned as resources arrive or a patient's status changes. A Yellow patient who deteriorates becomes Red. A system that never reassesses is a broken system. Hint: For each non-ambulatory patient, work through the steps in order. Note: START only flags two breathing findings — absent breathing (BLACK) and rate above 30 (RED). A low but present respiratory rate is not itself a RED criterion; the perfusion and mental status checks then determine the tag for that patient. START's mental status criterion is inability to follow simple commands — not confusion, inability to state a name, or other verbal tests. Apply the first finding that places the patient in RED or BLACK; if none do, decide between YELLOW (serious but stable) and GREEN (minor).