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.”
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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.

Argument For

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.”

Argument Against

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 .

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Perspective

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/

 

By

Muhammad Asyraf bin Din,

Intellectual and Language Unit

Academic Bureau.

 

Sources:

  1. 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.
  2. E. Brooke Lerner et al. (2001) The Golden Hour: Scientific Fact or Medical‘‘Urban Legend’’? Academic Emergency Medicine.
  3. Frederick B. Rogers et al. (2015) The  golden  hour  in  trauma:  Dogma  or  medical  folklore? Injury (International Journal of the Care of the Injured).
  4. Richard Fleet et al. (2015) Have We Killed the Golden Hour of Trauma? Annals of Emergency Medicine.
  5. 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
  6. 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

 

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