START Triage in 60 Seconds: The 30-2-Can Do Mnemonic

You’re first on scene. Multiple patients. Somebody’s screaming, somebody’s not moving, and three people are walking toward you asking what to do. You need to sort this. Fast.

START — Simple Triage and Rapid Treatment — has been the dominant mass casualty triage system in North America since 1983. It was developed by staff at Hoag Hospital and the Newport Beach Fire Department with one design goal: categorize any patient in 60 seconds or less.

The system is simple enough to teach in an hour and perform under extreme stress. But “simple” doesn’t mean “automatic.” Under the cognitive load of a real MCI, even well-trained providers freeze, second-guess, or start treating instead of triaging.

That’s where the 30-2-Can Do memory tool comes in. It compresses the entire START algorithm into three numbers and a question that you can run on autopilot.

The Algorithm: Walk → Breathe → Perfuse → Think

START assesses four things in sequence. Each either assigns a category or advances to the next check.

Step 0: The Walking Filter

Before you touch anyone, stand up and project your voice:

“If you can hear me and you can walk, move to [that area] NOW.”

Everyone who walks is GREEN (Minor). Don’t reassess. Don’t second-guess. Someone with a broken arm who walks under their own power? GREEN. You’ve just cleared 30-40% of your patients in five seconds.

Now you move to the non-walkers. This is where 30-2-Can Do kicks in.

Step 1: Respirations → 30

Is the patient breathing?

No → Reposition the airway (head-tilt/chin-lift). If they breathe → RED. If not → BLACK.
Yes, rate greater than 30/min → RED.
Yes, rate under 30/min → Move to Step 2.

You’re not counting exact breaths. Is the breathing fast and labored, or reasonably normal? If it takes more than a few seconds to decide, it’s probably too fast. Tag and move.

The number to remember: 30. Respirations over 30 = RED.

Step 2: Perfusion → 2

Check capillary refill OR radial pulse.

Cap refill greater than 2 seconds (or no radial pulse) → RED. If there’s major hemorrhage, apply direct pressure or tourniquet — or delegate: “You — hold pressure here. Don’t let go.”
Cap refill 2 seconds or less (or radial pulse present) → Move to Step 3.

The number to remember: 2. Cap refill over 2 seconds = RED.

Step 3: Mental Status → Can Do

Can they follow a simple command?

“Squeeze my fingers.” “Open your eyes.”

Can’t follow commands → RED
Can follow commands → YELLOW (Delayed)

The phrase to remember: “Can Do.” Can they do what you ask? Yes = YELLOW. No = RED.

The Mnemonic: 30-2-Can Do

Check	Threshold	If Abnormal
Respirations	30 breaths/min	Over 30 → RED
Perfusion	2 seconds cap refill	Over 2 → RED
Mental Status	“Can Do” — follows commands	Can’t do → RED

30-2-Can Do. That’s the entire assessment for non-walking patients. Three checks, each with a binary decision. If any check is abnormal, stop — the patient is RED. If all three pass, the patient is YELLOW.

Two Interventions, Maximum

During START triage, you perform only two interventions:

Airway repositioning — one attempt at head-tilt/chin-lift for non-breathing patients
Hemorrhage control — direct pressure, tourniquet, or delegate to a bystander

That’s it. No IVs. No splints. No C-spine. No SAMPLE history. You’re sorting, not treating. Treatment happens in the Treatment Area. The hardest part of triage is walking away from the RED patient you just tagged without treating them — but if you stop, the patients you haven’t assessed yet may die waiting.

The Mistakes That Kill

Starting treatment during triage. You find a RED patient and start working them up. Meanwhile 15 patients haven’t been triaged. Tag and move.
Over-triaging. Everyone looks RED when adrenaline is flowing. Trust the algorithm. If they walked, they’re GREEN. If 30-2-Can Do all pass, they’re YELLOW.
Forgetting the walking wounded. GREEN patients need to be directed somewhere specific. If you don’t designate a collection area, they’ll wander back into the hot zone or leave the scene.
Spending too long on BLACK patients. No breathing after one airway repositioning attempt = BLACK. In a mass casualty incident, you don’t have resources for prolonged resuscitation. This is the hardest call. Make it and move.

Know the Limitations

START is widely used, but it’s not perfect. Empirical studies show accuracy ranging from 44% to 94%, with over-triage rates up to 53% and under-triage rates up to 20% (Purwadi et al., 2023). The walking filter can miss serious injuries — a patient with penetrating abdominal trauma who can still walk gets tagged GREEN.

START also doesn’t cover pediatric patients (you need JumpSTART for that) and has no Expectant category for patients who are alive but have non-survivable injuries. The newer SALT system addresses these gaps, though most North American systems still default to START.

Use what your system uses. But know where START’s blind spots are and watch for them during secondary triage.

Practice Until It’s Automatic

In the middle of an MCI, you don’t have time to think through an algorithm. You need it running on muscle memory. Here’s how to practice:

Mental rehearsal: Next time you’re in a waiting room, look at people. Can they walk? Respirations normal? Perfusion? Following commands? Run the algorithm silently.
Tabletop scenarios: Have a partner describe patients. Sort them in real time. “45-year-old male, ambulatory, holding his arm.” GREEN. Next.
Say it out loud: 30-2-Can Do. Walk, breathe, perfuse, think. Repeat it until it’s boring. Then repeat it again.

When the real call comes, you want the sort to be automatic so your brain is free for the hard decisions — scene management, resource allocation, and the call to walk past the patient you can’t save.

References

Benson M, Koenig KL, Schultz CH. Disaster triage: START, then SAVE — a new method of dynamic triage for victims of a catastrophic earthquake. Prehospital and Disaster Medicine. 1996;11(2):117-124.
Purwadi, et al. The SALT and START Triage System for Classifying Patient Acuity Level: A Systematic Review. Nurse Media Journal of Nursing. 2023;13(1). doi:10.14710/nmjn.v13i1.37008
Lerner EB, et al. Mass casualty triage: An evaluation of the data and development of a proposed national guideline. Disaster Medicine and Public Health Preparedness. 2008;2(S1):S25-S34.