Red Is Not Always Red: Rethinking Priority in Mass Casualty Triage
Introduction: Misunderstanding the Mission
Triage is not about who looks the worst—it’s about who can be saved. Yet in the civilian EMS sector, triage is often misunderstood and misapplied, especially during mass casualty incidents (MCIs). At its core, triage is a battlefield decision-making process designed to sort patients based on survivability, not sentiment. The goal is not to save everyone, but to save as many as possible with the resources available. Unfortunately, civilian models often miss this fundamental point, defaulting instead to an emotional and counterproductive practice: prioritizing “Red” patients above all else.
In the chaos of an MCI, civilian responders frequently overcommit time, attention, and resources to the most visually critical patients—those tagged Red—believing they require immediate and exhaustive intervention. This fixation may feel morally correct in the moment, but in practice, it undermines the entire mission. It delays treatment for Yellow or Green patients who are highly salvageable, and it drains operational capacity. It also ignores a critical truth: not all Reds stay Red, and not all Reds need everything.
Red Patient Fixation: The Civilian Blind Spot
Civilian responders often focus too heavily on the most graphic injuries, assuming “Red” patients need prolonged attention. While well-meaning, this mindset undermines the purpose of triage: to save the most lives with the least resources. A rapid blood sweep—completed in under a minute—can control massive hemorrhage with a high-and-tight tourniquet and help quickly estimate total casualty count. It's a fast, high-impact tactic for both treatment and situational awareness.
Spending four minutes on one critical patient can mean four others go untreated. Military triage is fluid—patients are reassessed constantly. A Red-tagged casualty with bleeding controlled may be downgraded to Yellow, freeing up time and resources. Civilian systems often fail to reassess, treating triage tags as fixed. This results in resource misallocation and delayed care for other treatable patients. In mass casualty incidents, fixation kills time—and time kills patients. Treat, reassess, and move.
Tourniquets Change Everything
The most common and most fixable life-threatening injury in MCIs is hemorrhage. And the most effective way to manage extremity bleeding is a tourniquet. Despite this well-established fact, many civilian providers fail to recognize the game-changing effect of tourniquet application in triage.
Military medics are trained to perform rapid blood sweeps and apply tourniquets within seconds of identifying massive hemorrhage. Once applied, the patient’s risk of imminent death drops drastically. They are then reassessed and re-tagged, often from Red to Yellow. This process frees up medics to move on to the next critical patient, rather than lingering with someone whose primary threat has been addressed.
Civilian responders must embrace the same principle: treat and move on. Applying a tourniquet isn’t the end of care, but it does buy time and change prioritization. EMS must be trained to reassess triage categories constantly, not just once. Triage isn’t a static checklist—it’s a dynamic, ongoing evaluation process.
Resource Misallocation in the Field
The core mission of triage is to maximize survivability with limited resources. That means allocating personnel, supplies, and transport assets where they will have the greatest impact. When Red patients are over-prioritized, and reassessments are ignored, the result is a cascade of operational problems:
Ambulance delays: Red-tagged patients are often rushed to the front of the evacuation line—even when their condition has stabilized. Meanwhile, Yellow patients with serious but manageable injuries wait too long and may deteriorate.
Responder bottlenecks: Too many providers become occupied with a single Red patient, leaving large gaps in coverage for the rest of the scene.
Treatment site congestion: CCPs and staging areas become cluttered with low-priority or stabilized patients still classified as Red, confusing the chain of evacuation and disrupting command oversight.
To combat this, EMS and incident commanders must adopt a military triage mindset. That means distributing resources based on potential outcome, not just severity. It also means understanding when a patient no longer qualifies as a Red and moving them out of the urgent category.
Adopting Military Triage Principles
Military triage emphasizes rapid assessment, immediate intervention, and constant reassessment. In the field, medics are taught to apply life-saving care within seconds—stop the bleeding, open the airway, relieve tension pneumothorax—and move on. It’s not about providing every intervention; it’s about providing the right intervention at the right time.
This approach can and should be integrated into civilian mass casualty response. For this to happen, several changes must occur:
Update training standards to emphasize dynamic triage and reassessment.
Incorporate tourniquet reassessment into field SOPs and triage protocols.
Shift the mindset from “treat the worst first” to “treat the most salvageable efficiently.”
Empower MRTs (Medical Rescue Teams) to use color reassignment as an active part of triage and care.
Educate incident command staff to base transport decisions on updated tags, not initial impressions.
By applying these changes, civilian EMS can drastically reduce the number of preventable deaths that occur due to misallocated effort and misunderstanding of triage priorities.
Building the Next-Level Civilian Triage System
The civilian sector must recognize that Red does not mean exclusive. Red means urgent—until it’s not. The true value in triage comes from identifying who will benefit most from limited resources, not who looks the worst. That means using tools like tourniquets, airway adjuncts, and bleeding control as triage reset buttons—applying them quickly and then moving on to the next patient.
Civilian EMS also needs to build a culture of rapid reassessment. Triage tags should not be treated as a one-time designation. As the scene unfolds and patients respond to treatment (or deteriorate), their category must be updated. This requires not just training, but cultural buy-in. Responders must be comfortable changing a Red tag to Yellow without feeling they are downgrading care or failing their duty.
Agencies must also revise MCI protocols to account for dynamic movement between triage categories. Transport decisions, resource deployment, and patient handoff must reflect real-time status, not first impressions. This adaptability is what saves lives in the middle of chaos.
Conclusion: Fix the Mindset, Save More Lives
The misunderstanding of triage in the civilian world is not just procedural—it’s cultural. It’s rooted in the desire to help, the instinct to prioritize those who look the worst, and the fear of doing too little. But triage isn’t about doing everything for everyone. It’s about doing the most for the most with the least.
Red does not always mean red. A patient in extremis can become stable in seconds with the right intervention. If we continue to treat triage as a rigid system based on appearances rather than potential outcomes, we will continue to lose lives that could have been saved.
It’s time for civilian EMS to adopt the lessons that military medics have learned through hard experience: reassess constantly, apply treatment that changes prognosis, and move on. Triage is not a finish line—it’s a dynamic process of making the best possible decisions under the worst possible conditions. The sooner we fix the mindset, the more lives we’ll save.
