Technical Gray

Safety Techniques in
Agroindustry
Professor: Dalton Henrique Alves dos Santos

Daniel Diovani Café

What is the START Method?
Get to know the important screening technique of
multiple victims used in the service
Pre-Hospital
Before answering what the START method is, it is necessary to present
some concepts that allow the insertion of the technique in a context.

The pre-hospital care has particularities that interfere with the assistance provided.
This environment is often considered inadequate, lacking lighting, watered.
through the rain, with extreme heat and even the possibility of new incidents.

Therefore, the action of the team of qualified professionals must be quick, but
guided by appropriate and scientifically grounded conduct. The interventions
we can define life or death, the temporary or permanent sequel and even
a dependent or productive life. Therefore, they should be carried out quickly and
calm, ensuring the safety of the team and the victim(s).

The Pre-Hospital Care provided to a single victim has well-established principles.

different from the performance provided in Multiple Victim Incidents (MVI). In
first case, all resources must be made available in an attempt to save life or
to avoid sequelae in the individual. The second, on the other hand, requires the attempt to save
the largest number of possible victims. Then the need arises to define
priorities through screening.

Accident simulation in the APH – Pre-Hospital Care course at IESPE

It is important to make it clear that in both cases the professionals need to
adequate training to define and execute customer service techniques. For the
Interested parties, there are many training courses (APH, BLS, ACLS, PALS...) and
postgraduate studies in the area.
Victim triage
The word triage, according to the Michaelis dictionary, has a French etymology and
means 'to select, the act of choosing'. It consists of a classification process.
the victims by severity, with the aim of treating them maximizing the survivors
and reducing the sequelae. There are historical records from the year 1800 about the first
applications of triage on the battlefields of Napoleon Bonaparte, in an attempt
to treat the soldiers who could return to the front line. The high number
of soldiers was almost synonymous with victory.

Currently, with the emergence of terrorist attacks and natural disasters, the
pre-hospital care has triage as an indispensable tool, since
that an incident with multiple victims presents resources in proportion
incompatible for the service and transportation of all involved in the incident. In other words,
if the available resources (human, infrastructure, materials, transport) are
scarce, there is a need to carry out a screening in order to classify and
categorize the victims according to severity, using the logic 'greater chance'
of survival.

The Ministry of Health defines the implementation of screening in cases as a recommendation.

of events with more than five victims. The best triage method is the one that is
of the team's knowledge and applied correctly. The START method, for
being simple and objective is the most widely used screening method around the world.

Considering that the environment is secure, the scenario has already been assessed and
isolated by the first team that arrived at the site of the incident and the information already
were forwarded so that the regulation center can call for reinforcements and support
necessary, now we can return to the beginning of the reasoning: "What is the method
START? We already know the context in which we can need it, now let's
learn how to use it.

The START method

The creation of the START method dates back to 1983 when paramedic firefighters from
Newport Beach and the medical team at Hoag Memorial Hospital (USA) proposed
a simplified victim triage process and rapid treatment (Simple Triage
and Rapid Treatment – START). Therefore, this method of victim triage does not
forecasts the medical diagnosis and, yes, the classification of injured people
based on the needs for care and chance of survival.

How should the START method be used?

This method uses the mnemonic '30-2-can do' to triage victims of a
incident, in which "30" evaluates the respiratory capacity in one minute, "2" the
peripheral perfusion quality in 2 seconds and "can do" the level of
awareness of this victim to follow the commands of the rescuers.

This initial assessment lasts approximately 30 seconds and should not exceed
60 seconds. Therefore, it is quick and does not require medical equipment.
specialized.

Remember that START is a dynamic and continuous process. Thus, the victims
must be assessed, classified, and re-evaluated constantly until the
definitive treatment in a trauma center should be done, as an initial classification
pode ser alterada à medida que decorre o tempo após o trauma (as lesões ocultas
they appear.

Below is the flowchart suggested by Hoag Hospital and the Fire Department
from Newport Beach, published in the 8th edition of PHTLS/NAEMT:
How is the categorization of triaged victims?
In the START method, the victims are classified by the severity of their condition and each
category uses a color for easy identification at the time of evacuation and
transport of the scene.

Immediate (red color): victims with serious injuries, but with a chance of
survival. They have high priority for service, removal from the scene and
transport. Example: Chest trauma with unstable thorax.
Can wait (yellow color): victims with moderate injuries. Can wait.
a time on the scene until definitive treatment. Example: fractured limbs.
Light (green color): victims with minor injuries, who can walk and assist
other more weakened victims. These victims are the ones that usually cause some
problems, as they are wandering, scared and in pain. Investment should be made
psychological support and guidance so as not to overload the tertiary service of
health. Example: diffuse abrasions on the body.
Dead (gray or black color): victims who do not respond to simple procedures,
such as airway obstruction and critical injuries that indicate imminent death.
Example: patient in cardiac arrest, exposure of brain mass.
Categorization can be facilitated by the use of cards in red, yellow, and green colors.
and black (gray). These instruments are placed on each victim according to the
gravity.

After categorizing the victims, what should be done?

The victims must be directed to the priority areas, which have the
same colors defined according to the categorization of the victims (red,
yellow, green, and gray). The pre-hospital service usually delineates these areas.
with tarps laid out on the ground, in a safe area, so that the second one can be carried out
part of the screening, confirming the categorization and starting the treatment of the team
medical for later transport.

Accident simulation with multiple victims conducted by VIABAHIA in Jequié

When do these victims have access to definitive treatment?

The continuity of pre-hospital service and definitive treatment occurs intra-
hospital. In order for the injured to have access to this service, a
evacuation triage.

The severe and moderate victims (red and yellow) are referred to, in this
sequence, by the vehicles to the hospital.

Mild victims (green) can go on their own, being advised to seek

units of lesser complexity.

And finally, the expectant victims (ashes) can be removed if necessary.

still, after the evacuation of all the others.
Accident simulation conducted by SAMU in Ribeirão Preto
Who can classify the victims according to the START method?
It is important to have knowledge and specialized training for the application of this.
method, since the number of victims in an austerity environment requires
calmness, logistics and leadership. Decision-making and critical-reflective thinking
about the state of the victims are the biggest challenges for this professional, once
it will be your responsibility to identify the victims in critical condition
and with low chances of survival. Ongoing training and education are the
indicated path to achieve linear and systematic service.

Are there other screening methods?

Yes! The other methods of victim triage in the pre-hospital setting use logic.
described for the START with some adjustments for the local reality.

M.A.S.S. (move, assess, sort, send): move, assess, classify and send.
SALT (sorting, assessing, life-saving, treatment, transport): classify,
assess, intervene to save lives, treat/transport.
Manchester Protocol: risk classification used in the intra-
hospital, "aims to ensure that medical attention occurs in accordance with
the response time determined by the patient's clinical severity, besides
being an important tool for the safe management of patient flows
when demand exceeds response capacity
Important points for consideration:
The establishment of protocols facilitates the implementation of interventions in any
situation. This reflection is more evident in extremely stressful situations.
like IMV. The protocols serve to guide the care, remembering that the
Adaptations are appropriate, as long as they are applied coherently.
Realistic scenario simulations are very effective, especially when
carried out with different segments such as Fire Department, SAMU (Mobile Emergency Care Service)
Mobile Emergency Care, Civil Defense, Federal Highway Police,
Traffic agents, energy companies, among others. Despite all the
institutions presenting the same purpose which is to assist the victim, each one
has its own service process and the union of all is refined each
service. Therefore, with each simulation, the service becomes more focused in favor of
of the lives of those involved.
Another important aspect is an Incident Command System (ICS), in which
All professionals involved in a disaster scene must be aligned.
with the flowcharts for assisting victims and understanding the agreement between the
professional categories and hospitals that will receive the victims. Regarding the
hospitals, it is worth noting that not always the closest to the disaster will be able to
receive a high number of victims.

Conclusion
The IMV is a chaotic event that has victims screaming, people crying, blood,
mutilations, several people calling for help and rescuers needing to decide
who will be the first to be rescued, who will be the most serious, who
they will be ignored in the first instance. These are very difficult decisions to
It is very complicated to leave a 5-year-old child in line.
cardiopulmonary resuscitation (CPR) without assistance because there are dozens of victims
needing your work. How good would it be if each victim had their own team
exclusive. Unfortunately, this is synonymous with utopia.

Considering this is true, it is worth highlighting the importance of respecting the categories.
defined by the START method and meet them as prescribed. A child in
PCR is classified as gray code and should be expectant until it has resource.
enough to meet everyone. Probably this child will increase the number
of deaths from the incident, but your conduct as a rescuer will make so many
other victims survive. Complex decisions! So we need to be cold?
Negativo! Precisamos estar preparados tecnicamente. Basta respeitar o princípio
IMV's basic principle: to save as many victims as possible.