02 - Simplicity of the System?

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Introduction:

As imperfect as START may be, it was designed to be simple enough for anyone to use with limited practice. Be it a seasoned paramedic or a new CERT member, the familiar mnemonics of RPM, 30-2-Can Do and Start Where You Stand have been ingrained in our training. The designers of START knew that the mental stress of an MCI required as few decision points as possible to ensure neither subjectivity or complexity would effect the ability of a responder to apply the algorithm. The Working Group suggests their algorithm is simple but due to the number of variables and decision points inherent within it, one may ponder if it is simply too complex to recall in a high-stress environment.

Where’s the mnemonic?:

There is no START-like phrase that one can fall back on for quick recall of the SALT process. As insignificant as this may sound, these memory aids prove vital to the human condition. Like DECAPBTLS and RECEO, we need acronyms to recall a process.

Sort-Assess-Lsi-Treat/Transport does not tells us how to do it. If compared to RPM, SALT’s mnemonic would be BOHNM.


In an ironic desperate attempt to create a mnemonic for SALT, the city of Dayton, OH (One of the few cities that has adopted SALT) uses this:

C – Follows Commands

R – No Respiratory Distress

A – No (uncontrolled) Arterial bleeding

P – Peripheral Pulse Present


Driven by Assumptions:

In an effort to homogenize what the Working Group felt were the best concepts picked from dozens of triage systems coupled with data they derived from often-flawed published articles, SALT evolved into a lengthy Life-Saving-Intervention-based multi-tiered decision process that varies based off resources. If there were empirical data to support SALT’s additional layers of complexity there might be reason to embrace them but to force a new and more difficult process on responders that are already trained on something that works should be a consideration that is not taken lightly.


A 5th Category?:

The concept of resource-dependent categorization is nothing new. START considered and rejected it and the SACCO Triage Method (STM) and MASS professed it. ‘Seems simple enough, if resources are scarce you place the ‘red-reds’ into a category equivalent to palliative. The problem is that resources change quickly in an MCI, especially at the onset. This results in one triage member triaging differently than those behind him that are aware of new resources. This turns triage into a subjective, inconsistent process. Moreover, what exactly does a MedComm do with a count of ‘Greys’? Is a precious trauma bed made available “just in case”? Now subjectivity has made its way into bed availability and transport.

S.A.L.T. Categorization Criteria. (Verbatim from the SALT documentation)


Patients are categorized as MINIMAL if they are able to follow commands OR make purposeful movements, AND they have peripheral pulse, AND they are not in respiratory distress, AND they do not have a life-threatening external hemorrhage, AND their injuries are considered minor. This includes patients that cannot walk.


Patients are categorized DECEASED if they cannot breathe.


Patients are categorized as IMMEDIATE if they are unable to follow commands OR make purposeful movements, OR they do not have a peripheral pulse, OR they are in obvious respiratory distress, OR they have a life-threatening external hemorrhage; provided their injuries are likely to be survivable given available resources.


Patients are categorized as EXPECTANT if they are unable to follow commands OR make purposeful movements OR they do not have a peripheral pulse, OR they are in obvious respiratory distress, OR they have a life-threatening external hemorrhage, AND they are unlikely to survive given the available resources.

 

Patients are categorized as DELAYED if they are able to follow commands OR make purposeful movements, AND they have peripheral pulse, AND they are not in respiratory distress, AND they do not have a life-threatening external hemorrhage, AND they have injuries that are not considered minor.

S.T.A.R.T Categorization Criteria.


Patients are categorized GREEN if they can walk.


Patients are categorized BLACK if they cannot breathe.


Patients are categorized RED if they fail the RPM test.


All others are categorized YELLOW.






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A Look at Both Systems - SALT vs START ComparisonS.A.L.T.S.T.A.R.T.

Decisions Take Time:

SALT does not place a priority on rapidly obtaining a patient count. This affords it the luxury of time - allowing a responder to engage in a more complex granular decision tree process. START’s emphasis is obtaining a rapid size-up and utilizes half as many decision points to derive at an answer. START’s deliberate omission of the Expectant category removes a layer of variable subjectivity, again expediting the rate at which patient transport can begin.


Keep it Simple Stupid:

There will always be a fine line between the greater good and defining the role of how triage personnel are best used. Triage is, and should be, ready to evolve as data dictates. This has not yet occurred. The evidence simply does not exist to warrant a change to a more complex system at this point in time.

If it ain’t broke don’t fix it, and if you are going to fix it do it with something better than what we have now.