Golden Hour, Golden Schmour
10 July 2010(Not to be confused with Golden Shower, incidentally–that’s something quite different.)
The concept of the “Golden Hour” has been so heavily ingrained in trauma care for so long that it’s proving nearly impossible to get rid of it–and EMS isn’t the only offender, though certainly a prominent one. Its creation is generally credited to the father of modern trauma care, R. Adams Cowley, but claims of where he got the concept are hard to verify. (One source suggests French WWI data, but my reading of the data shows that there is a golden three hours–where the mortality jumps from 12% to 33%.) We’re constantly told to get patients to a trauma center within that magical hour–but does it actually matter?
While there’s no doubt that earlier is better than later when it comes to caring for severely injured people, the notion of some cutoff is silly. (For a ruptured aorta, there’s a “golden 30 seconds,” for a small subdural, a “golden week.”) That’s why it’s not surprising that a fairly large study of the relationship between prehospital time and survival came up with nothing. It was actually a prospective study looking at almost 3700 patients with abnormal vital signs or altered mental status, and no matter how many ways they sliced the times (minute by minute, in 10-minute blocks, by quarters of the group, or by less/more than an hour), the results were still the same: no association between prehospital time and death.
Perhaps someday this notion of a Golden Hour (and its cousin, the Platinum Ten Minutes) will be something that’s merely worthy of mocking. In fact, that gives me a great idea for an EMS Drinking Game….
The first study I know about was from the US Army in the Southwest Pacific Theater in WWII and published in JAMA, I believe. Their “case controlled” study was an action where the men were poorly nourished but received medical care sooner than during an action where they were well nourished but experienced delayed care. The poorly nourished casualties fared better.
The original Cowley article that I found was an evaluation for the financial feasibility of helicopter transport by highway patrol EMTs. Those transported directly to the trauma center had higher survival than those retransported from non-trauma centers. Note that scene medics were EMTs and a surgeon wrote the article so we do not know if it was operative repair or the decision not to operate. A non-trauma surgeon with non-trauma nurses are more likely to operate then observe, an important role for trauma centers is the decision not to operate. For non-operative observation it seems time would not matter.
A friend of mine, Beth Mueller, published an article on potentially preventable trauma deaths in EMS. She called me to point out that time in the field up to 30 minutes did not contribute to death. She identified 3 of 19 deaths that had reversible injury died without field airway protection. One patient was not intubated because the paramedics were so close to the hospital.
My question has always been “Is the Golden Schmour the time to a surgeon’s evaluation, the decision not to operate, or time to an anesthesiologist acquiring the airway (something paramedics can do)?” A surgeon wrote the article.
Keep asking good questions. Best regards, Dave