Introduction: Bridging the Divide in Mass Casualty Triage

Triage—the act of sorting patients based on urgency—has always been the cornerstone of effective mass casualty incident (MCI) response. Yet as threats evolve, so must our systems. The current divide between civilian and military triage approaches poses a significant challenge in unified response. Civilian systems like START (Simple Triage and Rapid Treatment) and JumpSTART (for pediatric patients) are often applied in isolation without recognizing their military origins or operational strengths. If we are to do the greatest good for the greatest number, we must stop viewing these systems as separate and instead merge them into one cohesive, mission-ready triage framework.

Civilian Missteps: Overemphasis on “Red” and Resource Drain

In civilian mass casualty settings, there is a common but problematic tendency to prioritize "Red" patients—the most critical—at the expense of overall operational flow. Reds consume vast amounts of resources, time, and personnel. This "Red fixation" often leads to treatment delays for patients who are far more salvageable with less effort—namely, those in the Yellow category.

Moreover, not all "Red" patients are truly red in nature. A patient with a catastrophic extremity hemorrhage may initially appear Red, but the rapid application of a tourniquet can quickly convert them to Yellow. Civilian providers, often trained in slower, more detailed assessment models, may not recognize this opportunity and misallocate both time and care.

Meanwhile, Green-tagged patients—the walking wounded—are frequently neglected, when in reality they can be swiftly moved to a holding area to clear space and reduce confusion.

The Real Problem: We Don’t Practice Triage Like We Should

One of the most critical failures in modern MCI preparedness is that civilian EMS agencies do not regularly practice triage in accordance with the National Incident Management System (NIMS). The NIMS structure exists to create a standardized, scalable approach to incident response. However, EMS often treats it as a theoretical exercise—one reserved for disaster drills or large-scale simulations.

In contrast, fire services are the gold standard when it comes to practicing the NIMS process. Fire departments apply NIMS command structures on every single call—regardless of scale. From house fires to motor vehicle accidents, they treat each incident as an opportunity to reinforce command, communication, and operational hierarchy.

This consistent application ensures that when a large-scale MCI does occur, the process is muscle memory—not a last-minute adaptation. EMS must adopt a similar approach. Triage and incident command are not skills to be activated during chaos—they must be practiced in the calm.

The reason EMS doesn't practice this process consistently is because larger EMS systems are often overworked and overwhelmed by call volume, leaving little time or capacity to train on low-frequency, high-impact operations like triage and incident command.

Civilian Triage: Sorting or Searching?

Another major shortfall in the civilian model is the failure to adopt rapid sorting techniques. Civilian providers too often enter an MCI scene and begin "searching" for Reds rather than rapidly sorting all casualties based on urgency. This leads to tunnel vision, where a single critical patient becomes the sole focus of care while dozens of others—many with survivable injuries—are delayed or missed entirely.

What civilian systems must adopt is a quick color-sorting model—the hallmark of military triage. In combat environments, the military immediately executes Rapid Blood Sweeps to identify and control massive hemorrhage. Casualties are assessed rapidly, life-threatening bleeds are treated in seconds, and patients are immediately tagged with a triage color.

Only after this initial life-saving step is completed does the secondary assessment begin—most commonly using the MARCH algorithm (Massive Hemorrhage, Airway, Respiration, Circulation, Hypothermia/Head Injury).

Rapid Identification of Greens and CCP Movement

The most efficient step upon arrival is the quick identification and clearing of Green (minor) casualties. This is typically done with a simple auditory command:
“If you can hear my voice, get up and move to [designated location] now.”

This simple directive accomplishes two things:

• It clears the scene of ambulatory patients, reducing chaos and clutter.

• It narrows the provider's focus to those truly in need of urgent intervention.

Once all massive hemorrhages have been addressed via blood sweeps and tourniquets, secondary arriving teams must prioritize the movement of Yellows and stabilized Reds to the Casualty Collection Point (CCP). It is here that the more thorough MARCH assessment should be performed, allowing for reassessment, tagging updates, and preparation for evacuation or transport.

Why We Must Combine START and JumpSTART into a Unified Model

START and JumpSTART are not just complementary; they are inseparable tools in a comprehensive triage strategy. START offers a rapid RPM (Respirations, Perfusion, Mental Status) approach for adults, while JumpSTART modifies the same for pediatric physiology and neurological baselines. When applied together, they create a seamless triage solution for mass casualties spanning all ages.

Combining both into a single, standardized operating procedure ensures that Medical Response Teams (MRTs) are equipped to handle the full spectrum of casualties, regardless of age or mechanism of injury. This merger promotes consistency, speeds decision-making, and eliminates confusion when transitioning from one patient to another—especially in chaotic, mixed-age environments such as schools, public events, or family-oriented venues.

Simplicity, Speed, and Structure

START and JumpSTART succeed because they are designed for efficiency under pressure. Both systems rely on simple assessments, require minimal equipment, and allow providers to make triage decisions in under 60 seconds per casualty. This operational simplicity ensures:

• Speed of treatment: Providers can quickly intervene on Yellow-level injuries.

• Rapid identification of non-salvageable casualties: Prevents resource waste on Black tags.

• Streamlined evacuation: Clear priorities support fast transport.

Most importantly, the systems allow for consistency across responding agencies. Whether it’s EMS, fire, police, or tactical teams—everyone speaks the same triage language. This unified communication significantly improves patient outcomes and system coordination.

Merging Military Triage into Civilian Chaos: Application in the CSR Framework

The Chaos, Stabilization, Recovery (CSR) framework offers a practical model for integrating triage into a high-threat environment. During the Chaos Phase—the first 10–15 minutes when scene security, situational awareness, and life-saving interventions converge—military-style triage becomes essential.

MRTs operating within or adjacent to the hot zone must triage patients in place. Using START and JumpSTART, these providers can immediately assess, tag, and apply rapid interventions (tourniquets, airway adjuncts, needle decompressions) with minimal delay. Once tagged, patients can be moved by transport or law enforcement to Casualty Collection Points (CCPs), where stabilization begins.

By triaging early and accurately, MRTs support more effective deployment of limited assets, reduce unnecessary duplication of care, and lay the groundwork for the Recovery Phase, where hospitals and long-term systems take over.

Triage Tags as Tactical Tools

Modern triage tags are more than colored labels—they're tactical tools that support accountability and tracking in complex operations. A unified START/JumpSTART system benefits from standardized tagging that incorporates:

• Color codes for rapid recognition

• Barcodes and numbers for patient tracking

• Fields for key interventions like tourniquets or airway placement

Civilian agencies must embrace the concept of “Tag where they fall.” No patient should be moved without triage and tag documentation. This prevents double assessment, preserves the continuity of care, and strengthens inter-agency coordination.

Pediatric Considerations: Why JumpSTART Must Be Part of Every Response

Civilian MCI response often lacks pediatric expertise. This omission is unacceptable. In mass shootings or disasters involving schools, families, or public venues, pediatric patients are a given.

JumpSTART provides a scalable, easy-to-apply model for rapid triage of children. It adjusts for normal age-specific vitals and uses the AVPU (Alert, Voice, Pain, Unresponsive) scale for neurological status. Without this tool, responders risk over- or under-triaging children, potentially leading to preventable death or misallocated care.

Incorporating JumpSTART is not optional—it is a critical component of ethical and effective triage.

Conclusion: Integration is a Moral Imperative

The time has come to abandon the siloed view of triage systems. START and JumpSTART should not be seen as separate “civilian” or “military” tools but rather as interoperable components of a singular, dynamic MCI triage system. The failure to merge these models results in fragmented responses, wasted resources, and, ultimately, preventable deaths.

And more importantly, we must acknowledge this truth: we don’t fail at triage because it’s hard—we fail because we don’t train for it. Fire departments practice the NIMS process on every call, embedding it into their operational culture. EMS must follow that example. Triage, command structure, and communication protocols must be part of daily operational practice, not just theoretical planning.

When seconds count and lives hang in the balance, responders must:

• Treat the treatable—Don’t get stuck on every Red.

• Move the Green—Clear the field and reduce confusion.

• Reassess early—Tourniquets save lives and change tags.

• Sort fast, tag fast—Practice rapid sorting, not patient fixation.

• Train like Fire—Every call is an opportunity to practice command.

If we do not train this unified system daily, we will not rise to the occasion—we will fall to the level of our (disjointed) training. Merging START and JumpSTART into a unified operational model is not just a best practice. It is the standard we must demand—before the next siren sounds.