The Golden Hour

[rock_shoes]

FICTION

The critical time to intervention varies by patient and injury type to such a degree that arbitrarily dictating an ideal window of time to surgical intervention for every major trauma patient is impossible. One patient might have a realistic window of 30 minutes to intervention (developing pneumothorax perhaps) while another patient might have several hours (slow progressing closed head injury).

What can be clearly demonstrated is that reducing time to intervention can reduce absolute patient mortality in specific patient sub-groups. Rather than focusing on a specific time frame we should be focusing on research that guides our interventions, reducing scene times where appropriate, and perhaps even extending scene times in certain areas to perform critical interventions currently left out. This isn't calf roping where time to completion is the only thing that matters. The absolute focus of trauma care on time is only to our detriment. Time does matter. It is not however, the only thing that matters.

With regard to major trauma patients in general, talk to a Trauma Surgeon and he/she will likely tell you to target a MAP pressure during fluid resuscitation that is permissively hypotensive. Talk to a Neurosurgeon and he/she will likely tell you to maintain a MAP significantly higher than that specified by the Trauma Surgeon to maintain CPP. Who's correct? In reality both are correct and both are incorrect. The lower MAP will result in greater body survivability due to reduced blood loss. The higher MAP will result in a higher percentage of patients that survive remaining neurologically intact. In reality best practice would include tailoring the target MAP to each specific patient based on their presentation. Not all patients with intra-abdominal bleeding have a TBI and not all patients with a TBI have intra-abdominal bleeding. Sounds like a great argument for improved education to facilitate the level of patient assessment required for that to happen does it not?

[aussiephil]

How could I not enter this debate!!!!

The Golden Hour is specifically for Trauna & has been debunked as a mylth by many people including the well known Dr Bledsoe. I have referenced this in other threads.

The accepted principal now is that people are clasified in a Trimodal death sequence if they die, minutes, hours & days. This said, there is no excuse for mucking about on scene.

Minimisation of scene times are essential, the most appropriate place for a trauma patient is not on an ambulance stretcher, or in the back of an ambulance. It is in a hospital, with trauma specialists, this ensures the best chance of survival.

Lets look at how we can achieve this (paragods take note - WE ARE NOT DOCTORS) for the betterment of out patients.

[HellsBells]

But here is an interesting once in a lifetime call I'll share with you about CPR and the AED. My partner and I were called code 3 for a code. Pt was on the phone and collapsed, his partner call the ambulance were dispatch instructer her on CPR. She said she couldnt do so ran next door and the neighbour came over and carried on. We arrived within about 10 minutes (so the guy is down for about 15min at that time) on goes the AED and 3 no shocks later off we go. In the mean time one of VFF joined in getting him to the car, he carried on with CPR and that took another 10 mins (so now he is down for 25 min)at the hospital of course drugs are involved and the Dr. Zapped him twice and holy crap 40 min later this guy has a pulse. He crashed one more time and was again zapped and again regained his pulse. He was Medivaced about 4 hrs later to the cardiac center where he passed away with his son by his side. This senerio is so unusual we were getting calls from dispatch and all the paragods asking if this really happened. The moral of this story to me is that the AED was a big part of saving his life even if was just so his family could go into that emergency room to give him a kiss, hug and say good bye. The data that was gathered through our AED is actually being analyzed for our CPR abilities and what ever else it records to see if will help in further studies.

When I was an EMT working for a BLS service, we had a similiar situation involving a truamatic arrest MVC, the pt had agonal resps on scene, and by the time we'd moved him into the ambulance he coded. After approx. 30mins transport time to the hosp he was treated with ACLS drugs and an AED, after which he regained a pulse and lived for approx. 24 hours.

I agree completely that it is of benefit to the family to be able to say goodbye to their loved one. However, I disagree that it was the AED that specifically brought the pulse back to these pts, but the combination of ACLS drugs and defibrillation.

[cosgrojo]

I guess this debate makes me a little bit confused. Does the knowledge of the Golden Hour really cause pressure on providers to shirk their on-scene responsibilities? I know about the Golden Hour, but I don't think it ever even entered my mind during a call. On a trauma call I am focused on managing injuries, extricating and packaging, and doing the job I am there to do. I've never refused to do a required intervention because of this Golden Hour Principle that I learned about in EMT school. Is there a major storm brewing in your' respective areas about the Golden Hour and how it is the be all end all? Do companies actually set policy by it, as was implied earlier. Are job performances being judged by the Golden Hour concept? If so... that is ridiculous.

Are there really people out there doing this? I've never seen it. For the most part when people rush, skip intervention, and do a poor job, it is not because they are trying to observe the tenets of the Golden Hour... it is because they are scared, uncomfortable, and not good enough at their jobs to do it right.

I agree that the principle itself, "The Golden Hour," is a silly thing that does not accurately portray the pre-hospital needs of the trauma patient. Every patient is different... as others say, it is situational. I don't see providers putting much thought into the Golden Hour concept, I think that the vast majority of providers simply do their job as best as they can in the situation that they are placed in. Admittedly, some provider's "best" is not very good, but let's not place the blame on the Golden Hour.

I prefer to think of the Golden Hour this way: At every step during a call (trauma or medical), if I am not doing something to further the patient along to definitive care, then I am not doing my job. As long as I am not taking a time out to flirt with the Fire Fighters, and sip some Mai Tai's, then we are doing all right. I prefer never to rush, I feel that if my movements and assessments and interventions are done correctly, and with high efficiency, I am making up all the time that someone else gained by rushing. Concepts like the Golden hour, to me, are just reminders that we should always be moving towards the hospital.

[uglyEMT]

After reading the articles linked and doing some other research I agree to disagree LOL

Let me explain. While I do believe the golden hour is an arbitrary number I do belive it should still be followed. I am not going to rush and possibly further injure myself or the patient to meet the "deadline" but I will look to resources at my disposal. Eg Medivac for the extended entrapment with possible internal injureies, meet ALS enroute for the difficulty breathing if my O2 is not doing the trick on scene, FD to help lift an obese patient if I feel me and my crew can not do it ourselves.

Generic examples i know but wanting to show my logic. While I read the OPs article link i had to wonder to myself the statment that the golden hour follows no scientific method. That doesn't sound right, if a pt's survival is improved by any degree by getting to definitive care, especially in a trauma case, within a timely (in this case one hour) manner then doesn't that prove that it works? I understand that the term golden hour is what the folks get hung up on but isnt it more so a guide to help responders guage appropriate things during the course of a call? I know when i went through school thats how it was taught to me. Not a line in the sand but a gauge to help judge interventions.

I do like what others have posted about the trimodal, I haven't heard of that before so I thank you for giving me something new to learn about.

[chbare]

I disagree, the golden hour was a concept based on data from French world war I casualties. In fact, Cowley was quoted saying that critically injured patients have less than 60 minutes. The original concept was literally based on an hour. Now that we have better data and practice differently, we should not be using an inaccurate term to define our practice.

Take care,

chbare.

[tniuqs]

I disagree, the golden hour was a concept based on data from French world war I casualties. In fact, Cowley was quoted saying that critically injured patients have less than 60 minutes. The original concept was literally based on an hour. Now that we have better data and practice differently, we should not be using an inaccurate term to define our practice.

Take care,

chbare.

In WW 1 the (rough estimate) was that with a fractured femur the mortality / morbidity was in the neighborhood of 80% ... I like to keep that into proper perspective, ie horse drawn wagons.

I do take offense with this Cowley character as the "Golden Hour" was a concept applied (initially on a napkin in a lounge) to put ex Viet Nam "pilots" and "Medics" into a system of HEMS in the USA.

Just saying I believe in EMS we have gone so far over board that it is killing us ... just look at the latest stats by Bob Waddell ... that it is statistically safer to transport a child on a motorbike without a helmet than put a child in the back of an Ambulance these days, just what are we doing are we improving service to the public or actually killing with misguided kindness with the diesel bolus concept applied .

http://www.ems1.com/ems-products/ambulances/articles/756441-The-dos-and-donts-of-transporting-children-in-ambulances/

Now we have such a prostitution of this term it is beyond belief, by local EMS pushing people on scenes to "rush the victim to the hospital" (media driven) then Industrial EMS providers (marketing driven) HEMS proliferation to the point of ridiculous levels, and multiple fatal crashes, but best is the Darwinian award goes to government dictated First Aid Level courses continuing to promote this "Golden Hour" when it was never the truth in the first place.

So just WHEN are we going to use Evidence Based Medicine to guide our return trip to the Hospital ?

It is always assumed that in the generic calls as ugly refers too ..

That are all "possible" internal belly bleeds best treated by surgical intervention and a helo ?

Is that SOB patient needing ETI or just CPAP ?

Why is an obese patient requiring a rapid extrication ... ?

(besides and just who is providing the twinkies when they are bed ridden ?)

cheers

[uglyEMT]

I was just reading a good blog post about this sort of thing. Not the golden hour perse but treating the MOI and not the patient.

Had a point in it I think goes well here. When did we stop treating the patient and just start treat MOI? The golden hour is the same thing. It worked well for a while but with changing technolgy and more studies it has evolved into something different and needs to be changed.

I did reread my previous post just want to add something (being edit wont let me).. the possible internal bleed... I should have said the extended extrication with signs and symptoms of internal bleeding. (BTW I use medivac for that if they can fly only because its an hour by ground to the nearest Level 1 but only 20min by air)

Ok back on track now....

I do feel certain things are always going to be time crtical and in those instances speed is paramount. BUT not every emergency needs code 3 response or medivacs. What we need to do is start once again treating the patient and not the MOI. Should medivac be alerted for every entrapment? Yes ALERTED have BLS or ALS cancel when the patient assesment does not warrent it. Just because it might be an extrication doesnt mean the person is messed up. In a BLS / ALS system should ALS be alerted for every SOB or possible MI / Stroke/ ect ? Yes but have BLS cancel if not necessary.

See what i am getting at? Not every trauma needs the golden hour rule. Certain things do but the 98% of the time just getting to the hospital safe is enough. My driving instructor during EVOC said a great thing to the class on the first day right after hello.

"Remeber this class, no patient is going to survive if you kill them in the rig by having an accident."

I think certain terms inside EMS in general are in need of updates same with certain corriculums. Certain things get outdated or change in one place but not everywhere. I think that needs to change as well, make it standardised. Just as maine has that C-spine check list so not every patient gets collared yet other places every MVA gets boards and collars.

[Kiwiology]

The golden hour is absolute shyte; all trauma patients have a golden time period however this can be minutes to hours or even days ....

You shouldn't be staying on scene for two hours playing doctor (unless you happen to BE a HEMS Doctor or something) but nor should everybody with cut ifngers be run into hosopital on red lights at breakneck speed because "everybody with trauma needs a surgeon".

[Aussieaid]

You shouldn't be staying on scene for two hours playing doctor (unless you happen to BE a HEMS Doctor or something)/