The myth of the golden hour ?

[tniuqs]

Emergency Medical Services Intervals and Survival in Trauma: Assessment of the “Golden Hour” in a North American Prospective Cohort

Presented as an abstract at the Society for Academic Emergency Medicine Annual Meeting, May 2008, Washington, DC.

Resuscitation Outcomes Consortium InvestigatorsCraig D. Newgard, MD, MPHa, Robert H. Schmicker, MSb, Jerris R. Hedges, MD, MS, MMMe, John P. Trickett, BScNf, Daniel P. Davis, MDh, Eileen M. Bulger, MDc, Tom P. Aufderheide, MDi, Joseph P. Minei, MDj, J. Steven Hata, MD, FCCP, MSck, K. Dean Gubler, DO, MPHl, Todd B. Brown, MD, MSPHm, Jean-Denis Yelle, MDg, Berit Bardarson, RNb, Graham Nichol, MD, MPHbd

Received 13 March 2009; received in revised form 19 June 2009; accepted 22 July 2009. published online 24 September 2009.

Corrected Proof

Study objective

The first hour after the onset of out-of-hospital traumatic injury is referred to as the “golden hour,” yet the relationship between time and outcome remains unclear. We evaluate the association between emergency medical services (EMS) intervals and mortality among trauma patients with field-based physiologic abnormality.

Methods

This was a secondary analysis of an out-of-hospital, prospective cohort registry of adult (aged ≥15 years) trauma patients transported by 146 EMS agencies to 51 Level I and II trauma hospitals in 10 sites across North America from December 1, 2005, through March 31, 2007. Inclusion criteria were systolic blood pressure less than or equal to 90 mm Hg, respiratory rate less than 10 or greater than 29 breaths/min, Glasgow Coma Scale score less than or equal to 12, or advanced airway intervention. The outcome was inhospital mortality. We evaluated EMS intervals (activation, response, on-scene, transport, and total time) with logistic regression and 2-step instrumental variable models, adjusted for field-based confounders.

Results

There were 3,656 trauma patients available for analysis, of whom 806 (22.0%) died. In multivariable analyses, there was no significant association between time and mortality for any EMS interval: activation (odds ratio [OR] 1.00; 95% confidence interval [CI] 0.95 to 1.05), response (OR 1.00; 95% CI 9.97 to 1.04), on-scene (OR 1.00; 95% CI 0.99 to 1.01), transport (OR 1.00; 95% CI 0.98 to 1.01), or total EMS time (OR 1.00; 95% CI 0.99 to 1.01). Subgroup and instrumental variable analyses did not qualitatively change these findings.

Conclusion

In this North American sample, there was no association between EMS intervals and mortality among injured patients with physiologic abnormality in the field.

[JackMaga]

I say this is old news... it always amazes me how some people take these dogma so literarly!

The golden hour concept was a great idea to make hospital administrations understand why having to call the surgeon from home wasn't good enough for a critical trauma patients: if you were going to need a surgeon at all, you needed it to be ready within few minutes, not a couple of hours or so! That said, I think the golden hour was and still is a great visual idea: everyone can imagine this big clock ticking away as minutes passes and the patient dies away, even your hospital budget manager!

Does this mean that saving 2 minutes will make a significant statistical difference in mortality? Of course not! I don't think even Dr. Cowley meant it...

[aussiephil]

While it may be old news, it is good to see that the study has been don & thaks squint for putting it on here.

It never ceases to amaze me the number of (new) people who are still taught & believe that this should be adhered to. I have said repeatedly that you need to think. Do not delay your time on scene, but there should not be any time restriction. Most know when to scoop & run or stay & play.

[JPINFV]

I say this is old news... it always amazes me how some people take these dogma so literarly!

...

That said, I think the golden hour was and still is a great visual idea: everyone can imagine this big clock ticking away as minutes passes and the patient dies away, even your hospital budget manager!

Does this mean that saving 2 minutes will make a significant statistical difference in mortality?

See... that's the problem. There are way too many providers who take it as a literally, "If the patient doesn't reach the OR in an hour following any traumatic event, they will drop dead." Heck, it even got air time on the pilot for Chronicles of EMS with the San Francisco fire medic talking about how the golden hour is ingrained at all levels of training. I wanted to leave a message on the JEMS Connect thread asking if he had any evidence that the golden hour exists.

[Kiwiology]

Don't be silly JP, the golden hour was invented by R. Adams Cowley who was a DOCTOR

Since 40 years later, Paramedics is still overseen by DOCTORS it MUST be true and therefore CANNOT be questioned!

[NRPinNEPA]

JP is right... generally there are three types of trauma patients who die: those who die in seconds to minutes, those who die in hours, and those who die in days. Seems like a pretty wide margin of variability to rely on a rule such as "the golden hour". How about instead training pre-hospital personnel how to recognize potential life threats or potentially unstable patients and letting them using critical thinking to determine whether or not they need to haul ass instead of saying "they're a trauma patient, we have to get the patient with an abrasion on his thigh to a trauma center in less than an hour or he'll drop dead!". EMTs and paramedics using thought and making decisions?!? UNHEARD OF!!!

[HERBIE1]

These studies are always difficult to quantify. Even in this area, there are wide variations in what defines a patient who should be evaluated at a Level 1 Trauma center. Some systems are quite conservative in order to capture as many borderline patients as possible. Other systems are quite "progressive" in their interpretations of which patients qualify as critically injured, or potentially critically injured enough to warrant transport to a Level One center.

I do agree that it is difficult to make blanket statements in medicine, but because we operate under the direction of a physician, there does need to be concrete rules(SMO's, SOP's) that are in place in case on line medical control is not available. Because of the variations in the levels of training of providers, the capabilities of each system, as well as the capabilities of the receiving hospitals. That "golden hour" may be completely unreasonable in rural areas, and easily accomplished in a busy urban setting.

Good article and food for thought...

[tniuqs]

I say this is old news... it always amazes me how some people take these dogma so literarly!

The golden hour concept was a great idea to make hospital administrations understand why having to call the surgeon from home wasn't good enough for a critical trauma patients: if you were going to need a surgeon at all, you needed it to be ready within few minutes, not a couple of hours or so! That said, I think the golden hour was and still is a great visual idea: everyone can imagine this big clock ticking away as minutes passes and the patient dies away, even your hospital budget manager!

Does this mean that saving 2 minutes will make a significant statistical difference in mortality? Of course not! I don't think even Dr. Cowley meant it...

It was explained to myself I believe it was Dr. BEB (?) that after Viet Nam that this "golden hour concept" was developed on a napkin in a bar in an attempt to bolster political support to employ the plethora of unemployed pilots in the US. Although there is merit in rapid transport to surgical facility the myth persists at infinitum. In fact while doing some research into Occupational Health and Safety requirements primarily for Oilpatch in Northern Alberta. I came across the "Golden Hour" in the actual legislation and guidelines (somewhat ancient in fact)I did forward this study to the regulators ... so in perhaps 20 or so years when they re write the legislation there may be a evidence based medical "perspective" to assist the new revisions.

While flying fixed wing in very Northern posts the ongoing "inside" joke was we were dealing with the Silver 6 .... hours of Trauma. Quite hilarious but sad in the same sentence that every little small hospital here do not have a Trauma Team on standby. The advent of advance life support and carrying volume expanders ie albumin, access to blood products and the newer pentaspan and hyper tonic saline "permissive hypotension" in addition to traction splinting, medications, protecting airways +++ and all the other goodies that we now have available. This said more current and timely study's should be undertaken to prove to the overseers (ie the MDs as they are study oriented) and the real worth of advanced care providers deployed in the rural vs urbal areas.

cheers

Edited February 22, 2010 by tniuqs

[chbare]

I always wondered if Dr. Cowley was being figurative as opposed to a literal golden hour. However, I have seen quotes where he specifically stated sixty minutes. The evidence for his statements appears to be based on reports of mortality from French military medics during world war one. Clearly, not the greatest evidence and during the late 1960's when he began to coin this golden hour concept, we really did not have solid trauma systems and good information tracking and gathering mechanisms in place. Even now, it has taken decades for us to fully appreciate the medical lessons from the Vietnam conflict that was in full swing during this time. In fact, we have revisited evidence from as far back as the Crimean war and have found uncontrolled extremity hemorrhage being a major problem. I remember being taught to load patients with crystalloids as an Army medic during the 1990's and strict adherence to 3:1 resuscitation was almost a standard of care. In fact, in many areas, you were negligent if you did not have at least a litre on board prior to ER arrival.

Something about humanity makes rewiring these dogmatic concepts very difficult. We like to latch onto these concepts and hold on for dear life. It occurs in many other areas as well. I always like to utilise the field of physics because it is an "academic" field with highly educated people that have also been tempted to hold onto past concepts. When relativistic theory (something that we now utilise to make the GPS system work) hit the scene in the early 1900's, there was much reluctance to let go of the Newton dogma. Then, the master mind of relativistic thinking was hesitant to let go of his thinking as a new period of quantum theory hit the scene. I imagine the string theorists of today would be reluctant to let go if a breakthrough were to occur.

It is difficult to let go of concepts that are simple and intuitive. The golden hour theory as I will call it is simple and easy. Give lots and fluids and make a mad rush for the OR. While intuitive, it may in fact not be the end all as we well know. I actually find the new age of resuscitation rather non-intuitive. We limit fluids and even surgical intervention. With the new damage control resuscitation techniques, we are taking people to OR and simply controlling hemorrhage without complete repair, then sending patients back to the ICU for additional stabilisation, and performing revision surgery at a later time.

In addition, it is my opinion and my opinion only that Dr. Cowley was pushing to institute a HEMS programme in Maryland and the catchy phrase of "golden hour" did go over well with both the medical and lay community. Therefore, part of me will always suspect that the term "golden hour" was pushed foreword with goals other than solid evidence based medicine in mind.

Take care,

chbare.

[armymedic571]

In addition, it is my opinion and my opinion only that Dr. Cowley was pushing to institute a HEMS programme in Maryland and the catchy phrase of "golden hour" did go over well with both the medical and lay community. Therefore, part of me will always suspect that the term "golden hour" was pushed foreword with goals other than solid evidence based medicine in mind.

Take care,

chbare.

You know..... It was my understanding as well, that Dr Cowley used this slogan as a means to market the trauma system he was involved with.

It is ironic that people still utilize this phrase in modern teachings within our community.