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

[Dustdevil]

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

Minus 5 for spelling.

It's Bryan, with a Y.

Obviously you went to a Mosby book school. :wink:

[aussiephil]

Minus 5 for spelling.

It's Bryan, with a Y.

Obviously you went to a Mosby book school. :wink:

minus 5 for you as well dust for missing prefere :wink:

[croaker260]

got it on the re-edit. You guys are too quick though.

[bbledsoe]

Read the following article (the URL is to the abstract):

http://www.ncbi.nlm.nih.gov/sites/entrez?D...Pubmed_RVDocSum

[crazycanuck]

Here is the link to fulltext article posted above ^ once again:

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

1: Acad Emerg Med. 2001 Jul;8(7):758-60

Lerner & Moscati

[croaker260]

After reading (again) the article in question, ONE STATEMENT STICKS OUT....

According to the text’s editor, the information came from a biography of Cowley entitled Shock–Trauma (Campell C, personal communication, April 7, 2000). This book credits Cowley as the originator of the term and states that the term is based on the findings of his research on cardiogenic shock conducted using a canine model, but no references for this research are given.

So I whipped out my trusty copy of this out of print book. The discussion is on page 10 and 11, some discussion on page 12. Speaks to removing the blood from the dogs and dripping it back in, and gauging "data" and recovery time.

Really sounds like the title description of that study.

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

It fills me with a need to really really find the article I cited above as POSSIBLY being the missing study. Curiously enough, it predates most other studies mentioned in the article by 9 years or more, and it did not come up for me on a search for the term "golden hour" (which was the primary search criteria for the article in question), only by looking at ALL the studies attributed to Dr. Cowley on medline did I find it. Simply put, according to the article, the term golden hour was earliest referenced in the early 70s and late late 60's. so (with out reading the study yet) it seems unlikely that Cowley had even conceived the term, or barely even the concept in 1960. of course this is pure speculation.

Not saying I am a master researcher...but given the comments in "SHOCKTRAUMA" (which was referenced in the article), the time frame (early 60's, late 50's, when his focus was still mainly cadiothoracic surgery) it seems to fit. Especially since it seems that the articles authors seems to let the trail of the "canine study" die quickly and quietly. While they discuss their medline search for the terms golden hour" and describe it in detail who referenced who, there is no mention of the canine study OTHER than it was not referenced in the book SHOCKTRAUMA.

I have queried the National Library Of congress to see if they archive these journals, or can point me on the tract of finding it. I am also thinking following up on the archive of his personal papers as well, looking for this specific study and not for the term "the golden hour". The American College of Surgeons does not have an archive link (I am not even sure they inherited this archive).

Bryan (got the name right that time) are you interested in putting me on the right track to find this OLD out of print article? Not asking you to fork over $$, just ideas. PM/email (colemedic@hotmail.com) me if you want. I have done a some amount of medical research reading and scavenger hunting, but nothing this old....

If it is found, wouldn't it conclude that the term "golden hour" was indeed based on some research, no matter how obscure, and not smoke and mirrors as the authors claim.

Not that I am passing judgment on the QUALITY or the RELEVANCE of that research, only that I suspect that is does INDEED exist, contrary to the findings of the 2001 article.

And like the researchers of the article state, I agree more research is needed.

Now all I got to do is actually find the damm thing.

Comments more than welcome

[bbledsoe]

I could probably get the article through GWUMC but the point is moot. One animal study in the 1960s is not going to trump the idea that there is no scientific basis for the "Golden Hour." The point of the "Golden Hour", allegedly developed on a cocktail napkin in a bar overlook Baltimore's Inner Harbor, was to market the newly-opened Maryland Shock Trauma unit--nothing more, nothing less.

Besides, the whole paradigm in prehospital trauma care has changed. We used to flood people with fluids--probably worsening outcomes. Today, we give little if any fluids. So, an animal study 50 years ago is meaningless.

The concept is not rooted in science and should be removed from our lexicon.

BEB

[croaker260]

Bryan,

You are misreading my point.

I am not arguing that the whole concept of trauma care has radically changed since then. The article itself does not debate or even address that.

My point is the principle, that the basic premise of the article (not of your thoughts) , that there is NO scientific evidence (not poor, not LOE 7, not inconclusive, not anything other than NO EVIDENCE), is not accurate, and therefore the article (since this was its sole basis and point) IS INVALID (assuming my theory on the missing study is correct).

One animal study in the 1960s is not going to trump the idea that there is no scientific basis for the "Golden Hour."

But, if (and only IF) I am right, then there IS scientific basis, just not good , relevant, or significant scientific basis, but some. A subtle difference, but an important one and the sum of my whole argument. That Cowley didn't pull it out of his @ss and bamboozled all of us for his own gain, which is the unspoken implication.

Does this change or effect any of the other thoughts you have put forth, no.

Is this meant to insult or any other way disparage you, no.

Does this mean that the concept of the golden hour holds water, no.

What it does mean (IF I am right) is that the articles research method was flawed, that they (the researchers) either deliberately or accidentally, failed to follow up on a single but crucial piece of evidence, and therefore came to an erroneous conclusion.

Why is this important?

The principle of the matter. (and yes, I have pissed off many many of my coworkers simply because of the principle, what can I say, its a serious character flaw that has caused me no end of trouble.)

OK, RA Cowley may have had it right or wrong..or both depending on how trauma care has changed since then. But that isnt the point. The point is that this article has been extrapolated to mean that the basic concept of the golden hour is wrong when the article does not address the validity of the concept at all, it only addresses if there is any verifiable research behind it (the golden hour concept).... Now if Cowley is wrong, he is wrong...if times have changed, then times have changed...what ever.....but lets get our facts straight. Rewriting history with out sound evidence is something I would expect out of many agencies and individuals, but not clinically oriented people and not out of you.

In short, whether you agree with the "golden hour" concept literally, generally, or not at all... it does not pertain....The point is that the article many people cite as proof the golden hour isnt a real concept may be flawed and basically inaccurate in its core assumption. All I'm saying is lets get the story right. After all Bryan, 15 years or more after you die, I would hope that when others (maybe me?)are writing text books and such, talking about people who advanced our profession, they get your story right too, and not imply that something you did was purely made up when in fact it wasn't.

Think of it as karma..the good deed you do today will comeback to you tomorrow.

After all, presenting the FACTS is a focus of one of your (very fine I might add, I attended it some years ago) lecture series, medical myths?

So the lingering question is, if I am right (and I intend to hunt down this study to see), and say you were to give a medical myth lecture series on the golden hour argument.... would you say there is no evidence, or poor and irrelevant evidence behind the golden hour?

By the way, if I am wrong, then I will of course admit it, and will owe you the microbrew/hard liqueur of your choice. They do drink bourbon in Texas don't they?

Comments welcome.

[Dustdevil]

I'm afraid I have to say you are splitting peach-fuzzy hairs here, Steve.

No evidence vs. poor evidence? No or poor evidence of what? Now you have to further break it down to define what concept we are actually debating. Are we debating whether or not there is scientifically determined statistical evidence to suggest that there is a "Golden Hour," which, I believe, would be Dr. Bledsoe's point? Or are we debating whether or not there is any scientifically determined statistical evidence to suggest that there is some kind of optimum window for the delivery of trauma care, which seems to be your point?

Two different points. Two different answers.

[BushyFromOz]

I thought it was a debate about the historical evolution of the golden hour mantra?? :?