The Golden Hour - is it a real a principal for EMS?

[aussiephil]

It is a curiosity that in my discussions with many in EMS, that there is a constant reference to 'The Golden Hour' in trauma.

Given that the majority of us work in civilian services, I wondered on the evidence to support this & what the implications were.

The basic belief held in the golden hour theory is that we have an hour to get into difinitive care & this would increase survival rate.

Is this true???????

We need to look at this subject in a logical manner & consider things a little differently.

Bryan Bedsloe in an article in JEMS (March 2007 Vol32 Issue 3) discusses a Trimodal distribution of death from civilian trauma & quotes trauma surgeon Dr Donald Trunkey :

In 1983, renowned trauma surgeon Donald Trunkey noted that deaths from civilian trauma followed a trimodal distribution. The first peak of deaths occurs within minutes of the event. These injuries are usually non-survivable, even with the most advanced medical resources immediately available. Approximately 50% of trauma deaths are in this group and usually result from neurological or vascular injury.

The second peak occurs in the first few hours after injury and accounts for some 30% of deaths. In this group, death usually results from hypoxia and hypovolemia. This is the group that stands to benefit the most from modern trauma care. The third peak accounts for approximately 20% of trauma deaths. It occurs days after the injury, with death often resulting from sepsis, multiple organ dysfunction syndrome and other complications.

Thus, for 50% of patients who die from trauma, EMS and trauma care provides no significant benefit. Therefore, the emphasis for modern EMS and trauma care should be on the second two groups. Here, too, studies have shown that an eight-minute response time does not improve outcomes with regard to victims of trauma. In all honesty, we don't know whether shorter prehospital response times improve trauma outcomes. Further, we don't know whether care provided in the prehospital setting improves or worsens trauma patient outcomes.

Do we, as EMS providors need to think more about our patients & look more closley paying more attention to our Primary & secondary assessments?

People in EMS are all to keen to quote the benefits of the golden hour in civilian trauma, without fully researching it & considering all the implications.

I admit I was one of those. But this principal, that we need to rush people at breaknect speed to a hospital for them to lie on a hospital bed for hours is in reality putting the saftey of EMS providors & civilians at a greater risk of injury through increased potential of a severe MVC.

I will be curious to read the thoughts of others.

Here is the full article:

http://www.jems.com/survivability/articles/281937/

[katbemeEMT-B]

May I first suggest that before anyone respond to this post, read the entire article. I agree with a lot of what is said in this article. I also disagree with some things.

When I went through school we were taught the "Golden Hour" theory. While it may have been briefly mentioned for trauma (I honestly don't remember), I do know that the concentration was on stroke victims and cardiac arrests. I did find that this article made contradicting statements. First it's talking about peak two and three patients who wouldn't benefit from the "Golden Hour" rule. At the end of the article it says there are no studies to prove that quick response times mean higher survival rates. So, wouldn't it make sense that the sooner a patient received definitive care, the higher their chances are to survive. As far as trauma patients getting roomed and then sitting there with no further care, this apparently is a problem in the larger hospitals. I personally have not seen this. the patient may have had to wait for corrective procedures but they have always been stabilized first and all life-threats dealt with.

It is important to get the patient to definitive care quickly it is equally important to get there safely. If there are those rogue drivers who feel they can speed excessively just because they have lights and sirens, then they need to be dealt with by the EMS manager or director. I also know from reading other threads on this site that some services jump all too quickly on the helo transport. What I would like to have seen included in this article is actual figures from secluded rural, rural, and urban areas and their usage. I live in a rural area and we do an average of two air transports a year. I also know that the hospitals around us use air transport primarily for cardiac patients that are in immediate need of specialized care. Again, I think this is an issue for the manager or director to deal with. We have certain protocols we follow before we call for air support. Maybe more services need to do this.

Anyway, just my thoughts. More facts and figures would have been beneficial.

[crazycanuck]

As mentioned in the link Phil posted, the concept of the Golden Hour goes back to R. Adams Cowley, founder of Shock Trauma in Baltimore. Cowley was a 1st Lieutenant of the Medical Corps of the US Army.

Ask Croaker if you're interested in this bit of history or check out the classic book Shock Trauma by R. Adams Cowley. It is a piece of EMS history and he was one of the "founding fathers" in the emergency medicine field. He devoted his life to the development of trauma protocols and the intensive study of the effect of shock on the body and outcomes.

Opinions aside I will leave the discussion to people here with more direct input but here are some references for your perusal. This is just on the general concept of the golden hour, though this can be applied to specific problems such as outcomes for intervention of CVA or penetrating trauma.

Reference #1 below was cited as the article of scientific review of cowley's principles that did not support the golden hour theory.

1) Lerner, EB; Moscati (2001). "The Golden Hour: Scientific Fact or Medical "Urban Legend?"". Academic Emergency Medicine 8 (7): 758-760.

http://www.aemj.org/cgi/content/full/8/7/758

2) Bledsoe, Bryan E (2002). "The Golden Hour: Fact or Fiction". Emergency Medical Services 6 (31): 105.

3) DJ Lockey - Resuscitation. 2001 Jan;48(1):5-15.

http://www.skyaid.org/Skyaid%20Org/Medical...al%20trauma.pdf

[aussiephil]

May I first suggest that before anyone respond to this post, read the entire article. I agree with a lot of what is said in this article. I also disagree with some things.

When I went through school we were taught the "Golden Hour" theory. While it may have been briefly mentioned for trauma (I honestly don't remember), I do know that the concentration was on stroke victims and cardiac arrests.

Minus 5 for not noting that on 2 separate occasions this was referred to as for Civilian Trauma. No mention of CVA or Cardiac issues

It is important to get the patient to definitive care quickly it is equally important to get there safely. If there are those rogue drivers who feel they can speed excessively just because they have lights and sirens, then they need to be dealt with by the EMS manager or director.

This is why I raised the issue, all too often the adrenaline can take over & unnecessary risks are taken.

I also know from reading other threads on this site that some services jump all too quickly on the helo transport. What I would like to have seen included in this article is actual figures from secluded rural, rural, and urban areas and their usage. I live in a rural area and we do an average of two air transports a year. I also know that the hospitals around us use air transport primarily for cardiac patients that are in immediate need of specialized care. Again, I think this is an issue for the manager or director to deal with. We have certain protocols we follow before we call for air support. Maybe more services need to do this.

There is a place for helicopter transport & the issue raised it the use of the Golden Hour theory to proliferate helicopter usage. I am also in a rural setting & the use of aeromedical is not for this purpose, but to ensure the patient receives timely treatment in the most appropriate hospital environment.

[JakeEMTP]

This is why I raised the issue, all too often the adrenaline can take over & unnecessary risks are taken.

I was riding with a new employee yesterday. They are still in the probationary stage and were riding as a third. Anyway, we were toned out to a MVC, UOA, we went to check occupants of both vehicles. People in Vehicle A were fine except for minor cuts. All no transported 8). Pt.s found in Vehicle B were unrestrained and required treatment and transport to the ED. n00b was assigned the driving duties. As soon as we loaded he had the ambulance in gear and started to roll. He was advised to stop as we had a few things to do first. I should add, we had 1 pt. on the stretcher on a LSB and the other on the bench seat also on a LSB. Once n00b was told to go, they start to run emergency traffic. They were told to down grade to routine traffic because the pt's injuries were not life threatening. They almost looked disappointed. I actually think they had a woody .

The golden hour may still have applied to this case because the pt's treatment at the ED would have taken place within the hour. It is, I think a guideline and not gospel ( a good name for a TV show though :wink:). It is all relevant to the extent of the pt.'s injuries.

[Dustdevil]

Even Cowley himself admitted that the "Golden Hour" was arbitrarily chosen as the time standard, without any real evidence to establish it. That doesn't make it a bad thing. It just tells us two things that remain true:

• 1. Time is indeed of the essence in critical trauma care.

2. Medical providers -- both in hospital and pre-hospital -- need to remain cognizant of this essence and be encouraged to expedite their assessments and limit their interventions.

• This leaves us with a dilemma. How do we encourage medical providers to watch their time unless we have a specific figure to give them, like one hour? You can't just tell people to hurry. That means something different to everybody who hears it. You have to establish specific criteria to define the time frame you are trying to achieve. And to do that with any credibility, it must be based upon validated scientific and statistical research. Unfortunately, Dr. Cowley's standard did not do that. And apparently, neither has anybody else. So, do we disregard the Golden Hour concept altogether as invalid, and just tell people to "hurry"? Or do we stick with it because it is all we've currently got? Obviously, simply failing to address it at all because we have no validated standard is not an option.

[katbemeEMT-B]

Minus 5 for not noting that on 2 separate occasions this was referred to as for Civilian Trauma. No mention of CVA or Cardiac issues

The article says that we are taught the "Golden Hour" rule for trauma. My point was that although it may have been mentioned in class for trauma the concentration was on stroke. This is also another reason why I suggested reading the article before posting. Just pointing out that not everyone had it pounded into their heads that definitive care is needed within that hour. Albeit trauma requires quick response but within safe limitations.

This is why I raised the issue, all too often the adrenaline can take over & unnecessary risks are taken.

I agree and that is why I also brought up that rogue drivers need to be dealt with.

There is a place for helicopter transport & the issue raised it the use of the Golden Hour theory to proliferate helicopter usage. I am also in a rural setting & the use of aeromedical is not for this purpose, but to ensure the patient receives timely treatment in the most appropriate hospital environment.

The article stated that all too many times a service will call in a helicopter to transport the patient. I was stating that I would like to have seen actual numbers of helo transports of patients from a hospital for higher level of care, transports from scene that were unnecessary and those that were. I'm not saying it isn't happening but numbers would have been nice to see. I used my area as an example. Our local hospital does not have the ability to care for a critically injured patient. The resources are very limited. We are a BLS service and I guess you could say they are a BLS hospital. Therefore, when we are put in this situation, we depend on air transport (usually from the scene) to take the patient to trauma center either 60 miles to the north or 85 miles to the south.

I think the overall point here is that getting your patient to definitive care quickly while doing it safely is your ultimate goal as a pre-hospital care provider. We also have a responsibility to transport that patient with due regard of those other people in the world. I think this is what was beat into my head and those of my classmates. Dispelling the "Golden Hour" theory whether for trauma, stroke, or any other medical condition we see puts patients at risk. It then becomes up to the individual provider to determine how long it takes them to reach the patient, remain on scene, and then transport. The "Golden Hour" at least sets a standard for all to follow. I would hope and believe as free thinking individuals who also have the ability to think critically we realize that this does not mean that some timer goes off in an hour and that there is some room for leeway.

[aussiephil]

Even Cowley himself admitted that the "Golden Hour" was arbitrarily chosen as the time standard, without any real evidence to establish it. That doesn't make it a bad thing. It just tells us two things that remain true:

• 1. Time is indeed of the essence in critical trauma care.

2. Medical providers -- both in hospital and pre-hospital -- need to remain cognizant of this essence and be encouraged to expedite their assessments and limit their interventions.

This leaves us with a dilemma. How do we encourage medical providers to watch their time unless we have a specific figure to give them, like one hour? You can't just tell people to hurry. That means something different to everybody who hears it. You have to establish specific criteria to define the time frame you are trying to achieve. And to do that with any credibility, it must be based upon validated scientific and statistical research. Unfortunately, Dr. Cowley's standard did not do that. And apparently, neither has anybody else. So, do we disregard the Golden Hour concept altogether as invalid, and just tell people to "hurry"? Or do we stick with it because it is all we've currently got? Obviously, simply failing to address it at all because we have no validated standard is not an option.

I agree completely dust, but, I have highlighted a couple of points of yours. They both indicate the same thing to me & that cant be taught, but comes with EXPERIENCE. Life experience & experience in practice. A solid education is needed before anyone can practice any sort of medicine, however, the knowledge of when to do what & the skill to do it expeditiously, comes with time. A good reason why you should work at each level for a period of time before stepping up.

I think that alternatives need to be looked at as to specify a time is, and be implemented with no evidence based practice to support puts lives at risk & increases the possibility of civilians, EMS workers & those who are already injured at a greater risk of injury, or further injury.

I think that no matter what you say or do, there will always be those who will perform an action(s) that in most cases be unnecessary, but the majority of us know the difference & use our brains as God intended.

[bbledsoe]

The preferred term is now "Golden Period." I see Jeff Salamone made the switch in PHTLS and we are making it in our paramedic texts. The fact is there is no evidence to support a "Golden Hour." The whole concept of EMS getting the "Platinum 10 Minutes" and emergency medicine getting the "Golden Hour" was pretty much refuted when surgeons often take the "Bronze Week" to treat many patients.

In the overall scheme of things, the trauma patient who will benefit from rapid transporrt and who requires emergency surgery is quite small. In fact, in Clayton Shatney's 10-year study of helicopter patients at Stanford he found that number to be 1.8%. Guess what? A response time of 8 minutes (the "gold standard") is not associated with improved outcomes in meical OR trauma patients.

The secret to survival of EMS is not to raise the dead--but to intervene earlier in the disease/injury process. You will save many more patients with a bottle of aspirin than you will save with a defibrillator.

BEB

[croaker260]

Brian (you dont seem the type to be hung up on "doctor", being a former medic. I can call you Dr. Brian if you prefer )

1- I certainly agree with the reference to the "bronze week". See it here as well.

2- I am not refuting your other comments, including that a response time of 8 minutes or less had no effect on major trauma.

3- I am sure you will correct me if I am wrong, and I am open to correction, but my understanding is that there is evidence for the golden hour, just not in humans. From reading SHOCKTRAUMA as well as other various sources, RA Cowley did his research in DOGS. Granted even he (as mentioned elsewhere) admits the chosen time of 1 hour was part marketing, it is not totally mercenary and unfounded as many want to claim. Given the state of medical research , and trauma research, and the atmosphere surrounding it at the time, I think it was a good ground work effort. Wouldnt be the ifrst time animal studies were the key to bigger and better things.

So perhaps a better statement is that there is not great evidence to support it, instead of no evidence. Just hate to see a guy who, like you, has given so much to EMS, be bad mouthed post mortum when it may be not entirely accurate. Again, I am sure you will correct me if I am wrong. Besides, I liked his style.

Personality goes a long way. Just ask Jules and Vincent.

BTW, I have looked and looked, I THINK this is the original study, but I could be wrong, I am having trouble accessing it due to its age. Perhaps you can assist, as you probably have better resources to do so. If you wanted to send me on the right track, I would also track it down at my expense, but I've hit a dead end.

Hemorrhagic shock in dogs treated with extracorporeal circulation. A study of survival time and blood chemistry levels.

COWLEY RA, DEMETRIADES A, MANSBERGER AR, ATTAR S, ESMOND WG, BESSMAN S. Surg Forum. 1960;11:110-2.Links

PMID: 13696112 [PubMed - OLDMEDLINE]

Anyway, looking forward to your reply.

-Steve