Blog Layout

Updated Triage Tools

In April 2023, NHS England announced that following a review of major incident triage, two new triage tools have been developed and are ready for use.

  1. Major Incident Triage Tool - MITT
  2. Ten Second Triage Tool - TST

The new guidance has been developed following a period of time where challenging clinical incidents have occurred. This includes events resulting in blast injuries, penetrating injuries and the use of chemical agents that aren’t normally seen day to day. You can probably recall some of these incidents over the last few years, and it’s good to see lessons being learnt and new findings implemented.

Of course, you might be thinking that this doesn’t apply to you, or onboard your vessel - especially if you don’t work in the Cruise industry. On most vessels, there’s just not enough people to make any incident major is there?

But, the definition of a major incident is where the number of casualties are more than the available resources can cope with. So in reality, that could be just two casualties if you have limited resources - both in terms of people and equipment.

In any major incident, it is generally the people involved in the incident who become the first responders. As you might imagine, it takes time for agencies (Police, Fire, Ambulance and others) to assess the situation, plan and execute a response. This time may be as little as a few minutes, but for the casualties at the scene, that few minutes is the difference between life and death.

In the vital few minutes after any kind of incident, it will come down to those in the middle of it who need to act. In the inquiry following the Manchester Arena bombing, the actions of the Transport Police (the arena is also a tramway hub), the public and event staff were commended. The bomb was detonated at 22.31, the first solo Paramedic was on scene at 22.53, some 22 minutes later. It took a further 6 minutes for a second Paramedic to arrive. The triage of casualties started at 23.05, over half an hour after the detonation, meaning vital time was lost in assessing injuries and making life saving interventions. 

Speed of response to establish certain life saving measures is vital and in the UK, there is an ongoing campaign to train members of the public in ‘stop the bleed’ techniques. Both the TST and MITT triage plans focus on sorting severe and minor injuries and doing the most for the most.

The links below allow you to print out PDFs of both triage tools, including the METHANE reporting tool which goes hand in hand with triage. 

1. Ten Second Triage (TST)


The TST is designed to be quick, simple and effective at prioritising large numbers of casualties rapidly with a focus on immediately providing lifesaving interventions (LSI). These LSIs include bleeding control and opening the airway, which are known to be the key requirements to maximise patient survival in the early stages of injury.

The simplicity of the tool minimises cognitive burden and frees up bandwidth to assist responders to treat casualties in what will be very challenging circumstances.

There are no physiological parameters; breathing and pulse rate are not measured which means that the tool can be used by responders with little or no clinical training. In addition, the tool does not triage casualties to ‘dead’, but labels them as not breathing.This allows for appropriate interventions, such as recovery position or CPR, depending on the circumstances, until formal triage by a registered healthcare professional can take place.

The Ten Second Triage tool shows the recommended priority triage routes depending on incident characteristics. Each has a YES or NO answer, which guides you to the next question, or determines the casualty priority (P1, P2 and P3) or if they are Dead. 


Clinical instruction is in bold.


Walking – Yes = P3. This is regardless of any injuries they may have. 


Severe bleeding – Yes – you can apply Pressure, a Tourniquet, or Pack the wound = P1


Talking – Yes – Penetrating injury (front or back) Yes = P1 or No = P2


Breathing – open airway if able.

Place in recovery position Yes = P1

No = Note breathing – CPR if resources allow.


The tool then sets out the METHANE model – which brings structure and clarity to the initial stages of managing any multi-agency or major incident.


M – Major incident

E – Exact location

T – Type of incident

H – Hazardous

A – Access

N – Number of casualties

– Emergency services


The tool also provides option boxes to number how many patients are in each category of priority – P1, P2 and P3 as well as Not breathing from 1 to 19.


You can see how the Ten Second Triage should be implemented here: Ten Second Triage (TST) – training video


2. Major Incident Triage Tool MITT


The biggest change for the MITT, is that it has become a single tool for both adult and paediatric patients, while still allowing for rapid, reliable and reproducible triage. 

When compared to other triage tools, the MITT demonstrates an increased sensitivity and reduced rate of under-triage in those patients requiring lifesaving interventions. MITT will replace the current triage sieve tool, the triage sort tool and the paediatric triage tape.

The major incident triage tool (MITT) shows the recommended priority triage routes depending on incident characteristics. Each has a ‘yes’, which guides you to the next question, or ‘no’ answer which determines priority (P1, P2 and P3) or dead. 





Clinical instruction is in bold.


Catastrophic bleeding  – Yes – Pressure dressing, tourniquet, haemostatic packing = P1


Walking – Yes = P3


Breathing – No – Open airway if required = Dead. Or in children (under 12 years) who are not breathing. If resources allow, consider 5 rescue breaths if : submersion/immersion/smoke inhalation.


Responds to Voice – No – Place in recovery position = P1


Aged over 2 years – No = P1


Breathing rate 12 – 23 – No =  P1


Heart rate – No = P2


The tool then sets out the METHANE model – which brings structure and clarity to the initial stages of managing any multi-agency or major incident


M – Major incident

– Exact location

T – Type of incident

H – Hazardous

A – Access

N – Number of casualties

E – Emergency services


The tool then provides option boxes to number how many patients are in each category of priority – P1, P2 and P3 as well as Dead from 1 to 19.


You can find the full details of MITT here.  


If you have any questions about the new triage tools, or would like some help in putting together major incident and triage drills for your crew, please feel free to get in touch.



Do you find our blogs useful? Would you like to find out more about medicine at sea? Why not sign up for one of our free resources:


Annual Updates: We will send you an email once a year identifying all the latest changes in guidance for the provision of First Aid and Medical Care at sea.


Salt Water Solutions: This is a monthly learning resource that can be used as part of your crew training or simply to keep yourself up to date with the various first aid and medical skills that you may need to perform whilst on board.


Worse Things Happen at Sea!: This is our monthly digest that covers topics that are relevant within the maritime sector.


Just click on the images below to sign up.

by Rachel Smith 08 May, 2024
At Red Square Medical, we’re keen to support those who have a passion for maritime medicine. While we can’t provide placements for everyone, occasionally a request pops up at just the right time and we can provide some experience and insight into our unique and specialised world. Last year we were contacted by Jordan Lin, a medical student with a love of the ocean. This is his story… When I was a boy, my dad and I used to go fishing with a local fisherman off the Norfolk coast. I absolutely loved being on the sea and so for quite a long time, I wanted to be a fisherman. When I got a bit older I kind of forgot about this and think I may have been slightly put off by watching the TV series ‘World’s Deadliest Catch’! But I have always loved being on the water and spent a lot of time sailing dinghies; I was also a swimming teacher for children back in high school and college. Later, I decided to study medicine and I’m now a final year medical student at the University of Bristol where I completed an intercalated degree; a Masters in Health Sciences Research. I’m now looking forward to starting work as a qualified Doctor in August. Though having spent 6 years training, my next 2 years will be spent working for the required two foundation training years that must be completed before being able to work independently as a Doctor in the UK. At university, I joined the VITA network which is a group dedicated to developing a health and public health approach at the heart of any response to human trafficking and exploitation. I became the blog coordinator for the organisation and you can read the blogs, including those that I have written, here: https://vita-network.com/blog/ In my spare time, I have been involved with the Bristol University Hot Air Ballooning Society and trained through the society to get my Balloon pilots licence. So, I often spend weekends during the summer flying in a leisurely fashion over Bristol and the surrounding area!
by Rachel Smith 24 Apr, 2024
At Red Square Medical, we’re fascinated by the learning process - it’s key to our business after all. But we often wonder what happens when our students leave the classroom. Do they remember what they’ve learnt? What if they’re faced with a real emergency, will they know what to do? Is there a lightbulb moment when it all clicks into place? Skill fade is a very real issue, as we wrote about in this blog , and we know that setting up drills and practice scenarios when you’re back in your environment, with your kit and crew, can make a massive difference. It’s great to get some feedback from our students too. Last year, we received photos from the Southern Ocean from a solo round the world sailor who was able to successfully steri-strip a cut eyebrow closed. Or the Captain who recognised a heart attack in a crew member because they looked just like the guy he saw in the video on one of our courses.
by Rachel Smith 03 Apr, 2024
You might wonder about the title of this month’s guest blog, as Worse Things Happen at Sea is also the name of our monthly newsletter. But this month, we’re delighted to introduce Andrew Edwards as our Guest Blogger, and we felt his amazing story about life at sea really deserved a dramatic headline… Dysentery... In the summer of 1966, I was a cadet on a cargo ship that loaded in the UK for 9 ports in West, South and East Africa. Our first port of call was Luanda, the capital of Angola – which was then a colony of Portugal. Next, 300 miles down the coast we called in to Lobito – also in Angola. In Lobito two of the ship's company contracted dysentery; myself and a big Irishman called Reg. The shoreside Doctor we saw simply diagnosed the condition (amoebic dysentery) and said, ‘sorry but I have no antibiotics for this!’. Thankfully the ship’s purser stood our corner and demanded that the Doctor find some. The following day the antibiotics were flown in from the Belgian Congo. The Doctor gave us no advice as to how to deal with the condition, not a word about how contagious it was, not a word as to the importance of thoroughly washing our hands and maintaining scrupulous personal hygiene. Thankfully both Reg and I were quartered just a short sprint from the heads, and we were left to get on with it by our shipmates. It took about a week to get over the dysentery, by which time I had lost several stone in weight and was as weak as a kitten. By the time we arrived in Walvis Bay, South West Africa (now known as Namibia), a further 1000 miles south, I was just about fit enough to play football for the ship against a local team. Their football ground had a main road going right through the middle of it which made for some challenging moments, but they still beat us comfortably and they were playing in bare feet!
by Rachel Smith 20 Mar, 2024
As it’s Easter, we thought that it would be a very appropriate time, what with all that chocolate around, to take a closer look at the subject of Diabetes and why it’s such a huge problem in the UK and across the world. The Easter Bunny always looks so cute and cuddly, but is he a diabetes case waiting to happen? Or does his diet of grass and all that hopping around for the rest of the year make an important difference? According to the WHO, diabetes is a chronic, metabolic disease which is characterised by elevated levels of blood glucose (or blood sugar). Over time, this leads to serious damage to the heart, blood vessels, eyes, kidneys and nerves. The most common is type 2 diabetes, and it usually develops with a late onset in adults. It occurs when the body becomes resistant to insulin or doesn't make enough insulin. Worryingly, in the past 3 decades the prevalence of type 2 diabetes has risen dramatically in countries of all income levels and is closely linked to obesity, poor diet, and an unhealthy lifestyle. Symptoms for type 2 diabetes are generally similar to those of type 1 diabetes (need to urinate often, thirst, constant hunger, weight loss, vision changes and fatigue), but are often less marked. As a result, the disease may be diagnosed several years after onset, after complications have already arisen. For this reason, it is important to be aware of risk factors. Effective approaches are available to prevent type 2 diabetes and to prevent the complications and premature death that can result from all types of diabetes. These include policies and practices across whole populations and within specific settings (school, home, workplace) that contribute to good health for everyone, regardless of whether they have diabetes, such as exercising regularly, eating healthily, avoiding smoking, and controlling blood pressure and lipids. Type 1 diabetes, once known as juvenile diabetes or insulin-dependent diabetes, is a chronic condition in which the pancreas produces little or no insulin by itself. Normal onset is in younger people, but can also be in adults. Symptoms of type 1 diabetes include the need to urinate often, thirst, constant hunger, weight loss, vision changes and fatigue. These symptoms may occur suddenly. Type 1 diabetes cannot currently be prevented. It’s thought to be caused by an autoimmune reaction which destroys the cells in the pancreas that make insulin. It can also be caused by genetics, viruses, trauma, tumours, removal of the pancreas or other damage to the pancreas. About 422 million people worldwide have diabetes, the majority living in low-and middle-income countries, and 1.5 million deaths are directly attributed to diabetes each year. But the number of cases and the prevalence of diabetes have been steadily increasing over the past few decades. The starting point for living well with type one or type 2 diabetes is an early diagnosis – the longer a person lives with undiagnosed and untreated diabetes, the worse their health outcomes are likely to be. Easy access to basic diagnostics, such as blood glucose testing, should therefore be available in primary health care settings. Patients will need periodic specialist assessment or treatment for complications. A series of cost-effective interventions can improve patient outcomes, regardless of what type of diabetes they may have. These interventions include blood glucose control through a combination of diet, physical activity and, if necessary, medication; control of blood pressure and lipids to reduce cardiovascular risk and other complications; and regular screening for damage to the eyes, kidneys and feet to facilitate early treatment.
by Rachel Smith 21 Feb, 2024
Well, we’ve made it to February! How are your goals for the year going so far? As you’ll know, we do love a bit of goal setting at Red Square Medical HQ. But, we also understand the importance of Reflective Practice too. Especially in relation to setting goals. Want to know more? Please read on…
by Rachel Smith 07 Feb, 2024
Today we start the first in a series of blogs in conjunction with our friends at the Maritime Skills Academy, and kicking it all off is a Guest Blog from MSAs Head of Training, Sam Kelly. Sam is 37 and lives in southeast Kent, in the quaint seaside town of Deal with with his wife, two children and a ‘Golden Doodle’ called Pringle. He has lived in the area ever since his father, a serving Royal Marine at the Deal Depot, and mother decided this was the place to raise their family. And it is, quite frankly, an excellent place to live. Here is his story… I’m the Head of Training for the Maritime Skills Academy, based in our head office in Dover. I oversee a team of Maritime Safety Instructors who deliver all STCW training for seafarers. Outside the Dover base, we have MSA Gibraltar. This location is operated in partnership with the University of Gibraltar and delivers Basic Safety Training and most recently Operational Firefighting, We are actually in the process of building a state-of-the-art Fire Training Module on ‘the Rock’.
by Rachel Smith 17 Jan, 2024
So Christmas seems like years ago, and we’re all well into the New Year now. Did you make any resolutions? Some love to, some don’t. At Red Square Medical HQ, we love a goal or two and think the turn of the years can be a good prompt to make some positive changes. But, it’s well known that New Year resolutions don’t last. Forbes magazine tells us that 21% don’t make their resolution stick for even a month. While 34% state that it lasted for between one and three months. Is that a failure though? Or could it be all it takes to make some small changes that have a lasting impact? We thought it would be good to take a closer look at one of the most popular resolutions… Dry January! Now, let’s get one thing straight, the Red Square Medical team are not averse to a tipple or two! But as medics, we’re very aware of the short and long term benefits of giving our livers a little breather every so often. Of course, everyone responds differently to stopping drinking for a month, so the timeline below is just a guide. But it might help you to decide whether it’s a good idea to give the booze a break for a while, or work towards reducing your intake - we know it’s easy for it to creep up over time!
by Rachel Smith 03 Jan, 2024
What I miss most about the Ambulance Service… It’s been 12 months since I left the Ambulance service after 8 years of working frontline, and to be honest it’s flown by. A few weeks ago the team at Red Square Medical HQ were chatting about how life has changed in that time and what, if anything, I was missing from my former life! The list might just surprise you… Most of all, I miss my old colleagues and I definitely miss the patient contact. And driving on blue lights… that was one of the best parts of the job! Working in the ambulance service with regular partners who you get on well with really does create friendships for life. Or even doing a tricky job with someone you don’t know well provides a common bond forever. Every day you’re facing stressful situations and sometimes split second, life changing decisions. You rely on each other totally and make sure you keep each other safe in some difficult and challenging situations. I worked with 3 very different partners most of the time for my last few years and I miss them all. Happily though, I have some great new colleagues at Red Square Medical and Outreach Rescue, the other company that I work for.
by Rachel Smith 03 Jan, 2024
I was born in a tiny village in Northamptonshire but had a fairly nomadic childhood, eventually settling in the industrial town of St Helens in the north west. As a child I was horse mad, so boats never got a look in. Apparently ‘horse’ was the first word I said and despite the fact that we could never afford a horse, my dream was always to ride and work with horses. It’s perhaps an early indication of my goal-oriented side that I got a Saturday job as soon as I could. At the age of 13, I’d cycle a 12 mile round trip, twice a day, just to go and ‘muck out’ at a local farm where they bred Welsh ponies and Arab horses! There wasn’t even any riding. Later, I found myself working for the family of a young girl who would go on to represent Great Britain in dressage at the Olympics. The work was physically hard and the standards high. No corners were cut and I learnt the skills I needed the old fashioned way. I got to travel all over the UK in the branded horsebox which was pretty exciting for a teenager. But I think I will always be grateful for the solid work ethic and sense of responsibility that this job instilled in me. I always planned to leave school at 16 and go to ride racehorses. But I got quite reasonable exam results and a new degree course was announced in Equine Science and Business which changed the plan. So, after taking the required year out, when I worked in an eventing yard in Yorkshire, I started the 3 year course. For the two work placements, I opted to go abroad, to Italy and the USA, which supercharged my desire to travel. I continued working in the equestrian world for a couple more years, but the poor pay and prospects, plus a dose of pneumonia pushed me onto a different path. I got a job in telemarketing for a bank, and after putting forward the idea of finance for horses, I found myself transferred to Marketing for 6 months. 16 years later, I was still there!
by Rachel Smith 20 Dec, 2023
Christmas is coming and the season of parties is upon us. Of course this means that most of us will overindulge in large amounts of luscious food and, of course, a tipple or two. At Red Square Medical HQ, we have a method of categorising drunk people. During our combined careers, we’ve dealt with more drunks than we can remember; it’s easily running into several hundred. What we’ve learnt, amongst other things, is that most people who are drunk fall into one of these categories. Now please don’t judge as it is purely observation and also makes for an interesting chat when delivering the STCW Medical training, because we all know at least one person from each category and sometimes… a person can be in multiple categories depending on many other factors, or, we might even have been there ourselves! Once we have established these categories there is a serious note to this blog so please do keep reading.
More posts
Share by: