The Golden Hour

[aussiephil]

Possibly, it's a concept that seems to be in a state of constant transition. In addition, give somebody a head injury and things may change.

Take care,

chbare.

Our protocols now reflect this as part of our practice. No longer do we simply pump fluids into trauma patients, but manage the patient to a palpable radial pulse through small bolus of fluids to maintain said pulse.

Lets maintain the clots that are there rather than blow them through over exuberence with fluids.

A lot of this argument also stems back to what i said earlier about Trimodal death patterns. We are not God(s) (although some like to think otherwise). If a person is going to exanuate, then chances are they have injuries to their Spleen, Liver, pancreas, probably pulmonary contusions, some renal issues as well. At some point we need to accept, as harsh as it sounds, that some patients will die. Regardless of our actions. Blood products have a short shelf life, so it is not practical to be carrying them, just in case, as we do with saline or ringers.

[armymedic571]

Our protocols now reflect this as part of our practice. No longer do we simply pump fluids into trauma patients, but manage the patient to a palpable radial pulse through small bolus of fluids to maintain said pulse.

Lets maintain the clots that are there rather than blow them through over exuberence with fluids.

A lot of this argument also stems back to what i said earlier about Trimodal death patterns. We are not God(s) (although some like to think otherwise). If a person is going to exanuate, then chances are they have injuries to their Spleen, Liver, pancreas, probably pulmonary contusions, some renal issues as well. At some point we need to accept, as harsh as it sounds, that some patients will die. Regardless of our actions. Blood products have a short shelf life, so it is not practical to be carrying them, just in case, as we do with saline or ringers.

Phil, I agree with your statement. I would just add radial pulses, and proper mentation ensuring the brain is getting enough. Not always possible I know, but good markers to go off of.

[zippyRN]

the biggest 'problem' with the concept of the '|Golden Hour' is when it moves from a concept aimed at reducing 'second peak' deaths and becomes a target or even a performance metric, It's another scenario where education vs training comes into play.

another factor to consider is how many of the 'prevented' second peak deaths become third peak deaths?

[armymedic571]

the biggest 'problem' with the concept of the '|Golden Hour' is when it moves from a concept aimed at reducing 'second peak' deaths and becomes a target or even a performance metric, It's another scenario where education vs training comes into play.

another factor to consider is how many of the 'prevented' second peak deaths become third peak deaths?

One could ague that the "Trimodal" trauma system plays right into the "Golden hour" as the first peak is time of injury to 1 hour. It has been argued that the trimodal system may not be valid, and can vary from system to system. There are also issues with types of trauma as the different types produce different results using the same parameters (Blunt vs. penetrating) http://www.journalacs.org/article/S1072-7515(05)00537-5/abstract.

I however agree with your second point, as to how many deaths are prevented as in they did not die of wounds received, but later die from infection, organ failure, etc......

IMHO, these two concepts need to be tossed, and we need to start re-evaluating our needs.

[aussiephil]

One could ague that the "Trimodal" trauma system plays right into the "Golden hour" as the first peak is time of injury to 1 hour. It has been argued that the trimodal system may not be valid, and can vary from system to system. There are also issues with types of trauma as the different types produce different results using the same parameters (Blunt vs. penetrating) http://www.journalacs.org/article/S1072-7515(05)00537-5/abstract.

I however agree with your second point, as to how many deaths are prevented as in they did not die of wounds received, but later die from infection, organ failure, etc......

IMHO, these two concepts need to be tossed, and we need to start re-evaluating our needs.

Army,

IMHO, we need to beat the crap out of medics who like to think they are more than medics. Minimisation of on scene time does not put a time frame on it. If you have a patient who is out of the vehicle, & can be stretchered, treated for spinal precautions (not all spinal patients need a LBB, but I have posted about this elsewhere), why not scoop & run, a line can be inserted en route, fluids can be set up, again en route. pain managment can be done, en route. Stop me if I am wrong, but lets complete a primary survey, detailed secondary survey, get them into the ambulance, then lets do another survey, once we have the other shit done.

Too many times we hear that all this should be done prior to departure. WHY? WHY? WHY?

Our patients, & one has to assume because this is a discussion on the Golden Hour that it is about trauma, need the difinitive care of an ER under the care of a Trauma Team. Not a bacteria infested back of an ambulance with a medic. Lets get rid of the attitudes that we are the greatest, yes we save lives, we save lives by delivering them to hospital in a stable condition. Nothing more (with the exception of a tension pneumothorax).

We do a lot of nivce to stuff, but at the end of the day, if we do nothing more than maintain an airway, ensure breating & monitor circulation, deliver the patient to hospital, where have we failed?

[Kiwiology]

I agree with Phil here; we are now teaching the Load And Treat Enroute (LATER) concept.

That however does not mean we have to race everybody into hospital on red lights at breakneck speeds just to deliver them to the trauma team nor that everybody should just be thrown on a scoop and extricated from the scene in the least time possible.

We need to focus on which patients are time critical and which we can spend a little more time on.

Should we have just ripped that old lady off the floor, thrown her on the scoop and driven to the hospital or was it appropriat fror us to spend an hour at the job ensuring adequate pain relief and minimally agressive extrication? ... as an example.

Edited August 13, 2010 by kiwimedic

[armymedic571]

Army,

IMHO, we need to beat the crap out of medics who like to think they are more than medics. Minimisation of on scene time does not put a time frame on it. If you have a patient who is out of the vehicle, & can be stretchered, treated for spinal precautions (not all spinal patients need a LBB, but I have posted about this elsewhere), why not scoop & run, a line can be inserted en route, fluids can be set up, again en route. pain managment can be done, en route. Stop me if I am wrong, but lets complete a primary survey, detailed secondary survey, get them into the ambulance, then lets do another survey, once we have the other shit done.

Too many times we hear that all this should be done prior to departure. WHY? WHY? WHY?

Our patients, & one has to assume because this is a discussion on the Golden Hour that it is about trauma, need the difinitive care of an ER under the care of a Trauma Team. Not a bacteria infested back of an ambulance with a medic. Lets get rid of the attitudes that we are the greatest, yes we save lives, we save lives by delivering them to hospital in a stable condition. Nothing more (with the exception of a tension pneumothorax).

We do a lot of nivce to stuff, but at the end of the day, if we do nothing more than maintain an airway, ensure breating & monitor circulation, deliver the patient to hospital, where have we failed?

Phil.....cannot say I disagree with you SURVEY of the situation. I need to apolgize as the first time I read this, I thought you where attacking me. Obviously not the case, but I find it funny now........I must need another cup of coffee..........

I would further what you said by saying that transport to definitive care is the key not just in trauma, but in medical patients as well.

I agree with Phil here; we are now teaching the Load And Treat Enroute (LATER) concept.

That however does not mean we have to race everybody into hospital on red lights at breakneck speeds just to deliver them to the trauma team nor that everybody should just be thrown on a scoop and extricated from the scene in the least time possible.

We need to focus on which patients are time critical and which we can spend a little more time on.

Should we have just ripped that old lady off the floor, thrown her on the scoop and driven to the hospital or was it appropriat fror us to spend an hour at the job ensuring adequate pain relief and minimally agressive extrication? ... as an example.

Kiwi.....is the LATER copyrighted (haha) or can I use that. Not only do I agree and practice that concept, it should be the standard of care regardless of type of model you work in.

Gents, enjoy your day.....

[tniuqs]

Trauma patients need definitive care.

Difinitive care is not in an ambulance.

We do however need to minimize on scene times. Trimodal death patterns are now accepted practice in hospitals for trauma. Minutes. Hours. Days. The underlying principal here is that if the patient dies in the first hour, they had multiple system trauma with little chance of survival, regardless of interventions. Those who die in hours have done so due to the laziness of a doctor in properly assessing their patient & getting them to theatre.

Those who die in days usually die from sepsis and this is a failing of the hospital & their infection control measures.

Does this give us an excuse to be on scene for extended periods (with the exception of a patient trapped)? NO NO NO

We provide emergency pre hospital care. Nothing more. Get them To hospital.

The golden hour is complete BS. The knowledge of this though should not allow us to waste time on scene.

Here endeth my sermon!

Dear Reverend:

So change the "scenario" just a bit, as in there is no Trauma Center to Load and Scoot TOO. Well accept for an intermediate level of care and basic clinic with very outdated diagnostic equipment and lucky if you can find an xray tech, this this within (3 hours by ground) as Helos do not fly here at night (well yet) and then an additional 2-3 hours by Air (fixed wing)to the almighty Trauma Center.

So are we educated enough or have enough of the right type of equipment for an accurate dx or give treatment that will not make blood into kool aid, should we stick to our Load and Go philosophy or look for ways to improve care, just saying when faced with this situation one is forced to look to other philosophic means to solve the problem.

This is a very realistic situation that I find myself in and daily when I am remotely deployed and then I hear the "Golden Hour" quoted by the clowns in safety and Medical Directors (that are located a thousand miles away) those that dictate and limit my actions and treatment options.

Any positive Ideas as to how to improve chances of survival for my patients, besides tranexamic acid, volume expanders, or Hypertonic Saline + .

Just trying to think outside the "Golden Hour" or "Load and Go" box.

I wish to introduce the term "Canadian Silver Six"

cheers

[HERBIE1]

Dear Reverend:

So change the "scenario" just a bit, as in there is no Trauma Center to Load and Scoot TOO. Well accept for an intermediate level of care and basic clinic with very outdated diagnostic equipment and lucky if you can find an xray tech, this this within (3 hours by ground) as Helos do not fly here at night (well yet) and then an additional 2-3 hours by Air (fixed wing)to the almighty Trauma Center.

So are we educated enough or have enough of the right type of equipment for an accurate dx or give treatment that will not make blood into kool aid, should we stick to our Load and Go philosophy or look for ways to improve care, just saying when faced with this situation one is forced to look to other philosophic means to solve the problem.

This is a very realistic situation that I find myself in and daily when I am remotely deployed and then I hear the "Golden Hour" quoted by the clowns in safety and Medical Directors (that are located a thousand miles away) those that dictate and limit my actions and treatment options.

Any positive Ideas as to how to improve chances of survival for my patients, besides tranexamic acid, volume expanders, or Hypertonic Saline + .

Just trying to think outside the "Golden Hour" or "Load and Go" box.

I wish to introduce the term "Canadian Silver Six"

cheers

I wish to introduce the term "Canadian Silver Six"

I love it! I have never worked in such a remote area so I cannot say I have dealt with the challenges you face up there. That gives "rural" a whole new meaning. LOL

[mobey]

I am with you squint.

There are many many remote sites in the Canadian provinces where the Golden hour is a laughable goal. I too am 3hrs from a trauma centre, the service I worked for in Sk was 2hrs from the closest health facility. Oh ya... No helos in either place BTW, fixed wing will be here in 90min LOL.

Hope I don't sound like too much of a jack ass here but maybe Golden hours work well in the US where helo's and trauma centres are more abundant, but up here, we have what... 2 overworked, understaffed, trauma centres per province? How many communities can the golden hour even apply too in Canada? Maybe within city limits?

I dunno, I have never considered the "Platinum 10, or golden hour" I just do what needs to be done, then transport as the patient requires.