It was her usual trip back from school in the evening when a speeding truck from behind lose its balance and slid to the roadside before crushing her timid body. There was a large crowd surrounding the scene when the siren’s noise filled the atmosphere. A pair of white-uniformed men came close and checked her vital signs before initiating basic life support. The truck driver was still being extricated by the firefighters. A moment later she has already lying on the stretcher in the ambulance. In no time, she was pulled on a trolley bed into an emergency room. The attending physician quickly restored her vital to a relatively stable level. From moment of injury until she received definitive care was less than one hour. Had she arrived later, she might has been pronounced dead the moment she arrived at the hospital. That was according to the concept of “golden hour”.
Firstly described by R Adams Cowley (1917-1991), widely regarded as the founder of emergency medicine and United States’ first trauma center in Maryland, he famously stated,
“There is a golden hour between life and death. If you are critically injured you have less than 60 minutes to survive. You might not die right then; it may be three days or two weeks later — but something has happened in your body that is irreparable.”
CAPTION: It has been suggested that Cowley created the Golden Hour concept from this French World War I data (source: http://www.trauma.org/archive/history/resuscitation.html)
This concept has become the fundamental aspect of emergency medicine; patients with trauma injury should be given definitive care ie. all treatments which are decisive in patients’ survival are to be done within 60 minutes. Any delay in treatment will result in profound increase of mortality rate. This time constraint has been proved hard to comply as there are at least three time intervals from occurrence of accident until the patient received definitive care that have to be minimized:
(1) The time from the event to the 911 call;
(2) EMS total transport time; and
(3) The interval from arrival to definitive care
This idea has spawned a billion dollar industry of trauma systems, trauma centers, aeromedical rescue (air ambulance), and advanced pre-hospital (on the scene) life support. Contemporary studies have shown opposing views on the authenticity and reliability of golden hour in reducing morbidity and mortality. It has even been suggested that the goal to reduce the total transport time may cause unnecessary fatality.
Rogers (2015) noted that there are two important studies that managed to found “a significant correlation between reduced out-of hospital time and decreased. A study by Sampalis et al. (1993) found that total pre-hospital time over 60 min was associated with a significant increase in odds of mortality, and the 1999 study by the same group of researchers found reduced pre-hospital time to be associated with reduced odds of dying, when controlling for injury severity and patient age. Additionally, reduced pre-hospital time has been found to be beneficial in specific patient populations, including severe head injury, intra-abdominal bleeds, severe thoracic injuries, and rural trauma patients with long EMS transport times.
Two EMS studies from the United States further supported the importance of shorter pre-hospital time periods. It is important to note that these studies contained mixed populations, including patients with non-traumatic cardiac arrest.”
Despite the findings of the aforementioned studies, the validity of the golden hour and the link between pre-hospital time and outcome are far from conclusive. With the exception of patients with non-traumatic cardiac arrest, no field-based population has consistently demonstrated a significant association between response interval and survival. One of the most comprehensive investigations of time to definitive care in trauma, a 2010 prospective cohort study by Newgard et al. of 146 EMS agencies transporting patients to 51 trauma centres in North America, identified no relationship between EMS intervals and inhospital mortality among injured patients with physiologic abnormality. (disclaimer: we should note that Newgard et al. study focused solely on EMS transport time interval and not considering the other time intervals). This finding persisted across several subgroups, including injury type, age, and mode of transport. Studies conducted in German, Canada, the United States and Italy found similar results, identifying no significant survival advantage for trauma patients with shorter pre-hospital rescue times.
Another article (Lerner 2001) noted that medical articles which used the term “golden hour” mainly attributed it back to Cowley and Trunkey but lack references. He also argued that early published researches supporting this concept are susceptible to ecologic fallacy and studied young healthy males suffering penetrating injuries group only.
Despite conflicting evidence regarding the golden hour, rapid EMS transport to medical facilities remains the standard of trauma care. In the aggregate, there is significant evidence indicating that many trauma patients do not need to be rushed to the hospital, with some research even indicating a slower, smoother transport to the hospital would be beneficial for both patients and pre-hospital providers. Chung et al. (2010) found that increased ambulance speed negatively affects the quality of chest compression during transport. EMS workers have a documented fatality rate of 12.7 per 100,000 workers, more than twice the national average of 5.0 per 100,000. By some estimates, the risk of transportation-related injury to EMS workers and their patients may be five times the national average risk of transit injury. These deaths and injuries are largely attributed to helicopter and ambulance crashes, resulting from the emphasis on shorter pre-hospital time frames .
While many studies have shown the lack of empirical evidence to the concept of “golden hour”, it is still nevertheless crucial for all trauma patients to receive immediate definitive care. A very recent study from Kotwal (September 2015) showed that a new policy from Secretary of Defence in 2009 to reduce the time between combat injury and receiving definitive care has increased casualty survival on the battlefield. However, the dictum to generalize critical care for all type of patients within an arbitrary time, such as one hour, needs more conclusive evidence to be implemented, for each patient coming through the emergency department doors is unique and different.
Are you interested in fast-paced, action-intense side of medicine? Join our Seminar Perubatan Iskandariah this year to learn more about emergency medicine by clicking this link: http://seminar.iskandariah.perubatan.org/
Muhammad Asyraf bin Din,
Intellectual and Language Unit
- University of Maryland Medical Center. The History of the UM R Adams Cowley Shock Trauma Center: http://umm.edu/programs/shock-trauma/about/history
2. Craig D. Newgard et al. (2010) Emergency Medical Services Intervals and Survival in Trauma: Assessment of the “Golden Hour” in a North American Prospective Cohort. Annals of Emergency Medicine.
- E. Brooke Lerner et al. (2001) The Golden Hour: Scientific Fact or Medical‘‘Urban Legend’’? Academic Emergency Medicine.
- Frederick B. Rogers et al. (2015) The golden hour in trauma: Dogma or medical folklore? Injury (International Journal of the Care of the Injured).
- Richard Fleet et al. (2015) Have We Killed the Golden Hour of Trauma? Annals of Emergency Medicine.
- Russ S. Kotwal et al. (2015) The Effect of a Golden Hour Policy on the Morbidity and Mortality of Combat Casualties. Journal of American Medical Association Surgery
- Sig Christenson (2015) ‘Golden hour’ really saves lives, study shows. San Antonio Express News [online]. Available at: http://www.expressnews.com/news/local/article/Golden-hour-really-saves-lives-study-shows-6589670.php?t=bdb66aa59b9582d581&cmpid=fb-premium