# The Golden Hour



## downunderwunda (Feb 5, 2009)

As I have stated in other threads, we in EMS must follow the trends of medicine & work on evidence based practice. That is the way we practice pre hospital medicine is done because there is clear evidence that what we do actually works & is not a myth of EMS or we do it like this because we always do it like this.

With this in mind, & looking at the attitudes of those who have postedin other threads, I am curious to see what the view of people is on The Golden Hour.

Personally I think it is a load of crap. 

If you have some evidence that there is justification for us to believe in this concept, post it here, lets debate the issue.


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## Shishkabob (Feb 5, 2009)

The Golden Hour has always been nothing more then a concept, not a rule to live by.


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## Sasha (Feb 5, 2009)

People don't automatically drop dead after 60 minutes. Please, someone enlighten me if I'm wrong, but if they were in such desperate in quick need of a hospital that there is little chance for survival, period, isn't there? 

Plus the Golden Hour spiel encourages reckless driving and "hero" tactics that put the safety of EMS providers, bystanders, etc at risk.


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## Veneficus (Feb 5, 2009)

golden hour is a myth.

Cut your carotid or femoral artery and see if 10 minutes on scene putting you on a backboard for spinal precations helps.

Some people have more than a hour, some don't. With the advent of techniques to non operatively manage conditions that used to automatically require surgery, that kind of kills the idea too.


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## Wyoming Medic (Feb 5, 2009)

Golden hour was a term coined some time ago by Dr. R Adams Cowley as saying, "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".

The media grabbed onto this with a fervor and started printing the term and using it like gospel (similar to "jaws of life").  

While I have no doubt that MD. Cowley was a fine doc, I don't know who or how or why his saying was taken so to heart.  It has some flaws IMO.  Most modern medical systems have dismissed it as media hype.  Still others have used it so much that they use other terms as an offshoot.  Around here we had the term "platinum 10 minutes" 

Drives me nuts personally,  But I will leave it up to your own opinions


Wy medic


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## emtfarva (Feb 5, 2009)

the golden hour is good for somethings rather than others. In our area we have one hosp (Morton) most of our 911 hits goto. in that area we also have 3 stemi (Charlton, Good Sam, Brockton) centers 20-30 mins away, (4 if you count RI hosp) a trauma center in RI 30 mins down the road and Boston less than an hour away. It is not uncommon to see stemis go to the other hosps in the area or traumas to go to RI. most of the time, depending on the medic, they will go to Morton and let them deicid what to do with them. I think the only real golden hours left are traumas and STEMIs. Even CVAs have three hours if they called 911 right away. And most of our STEMIs go to Charlton because they also do open heart surgery. Most of the time I don't belive in the golden hour. When you get there you see that the pt is crashing then get the person to the hosp. simple as that.


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## daedalus (Feb 6, 2009)

I agree with Sasha. Anyone that is going to die in one hour without medical attention, is probably going to die in surgery anyways. That does not mean we do not give them every chance, because we do. What we do not do is give them an inappropriate helicopter ride in the name of the golden hour when they really could have gone by a ground unit.


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## emtfarva (Feb 6, 2009)

daedalus said:


> I agree with Sasha. Anyone that is going to die in one hour without medical attention, is probably going to die in surgery anyways. That does not mean we do not give them every chance, because we do. What we do not do is give them an inappropriate helicopter ride in the name of the golden hour when they really could have gone by a ground unit.



I agree with the statment about the whirly bird. But what should also be taken into consideration is what type of hosp are around you and what they can handle and the condition of the Pt. If the Pt is stable enough to be ground transported to the local hosp evaled and then transported to higher level of care, that is the way to go. if not bring them straight to a trauma center. and if they are really bad fly them. Case in point, We do the contract for a motocross track. they once had a pt take a brake handle to the neck. the medic on scence what to the ground transport the pt to a local hosp the basic want to fly the pt. the medic transported by ground and goto the hosp the doctor called for medflight before the pt even hit there stretcher. (it was penitrating trauma.) I wasn't there so I couldn't tell you what the pt was like.


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## JPINFV (Feb 6, 2009)

Sasha said:


> People don't automatically drop dead after 60 minutes.


I've heard that before someplace.


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## jrm818 (Feb 6, 2009)

emtfarva said:


> I think the only real golden hours left are traumas and STEMIs. Even CVAs have three hours if they called 911 right away. .



Negative!  Well, really I guess you're right, but that shouldn't be taken to mean that CVA's should be treated any less urgently than traumas.  3 hours is (usually...some debate on if this should extend) the absolute longest time interval from onset of symptoms to tpa administration allowed.  That said, sooner is (significantly) better than later.

It is NOT the case that tpa at 60 minutes is just as good as tpa at 180 minutes...time is brain cells in strokes (to use the cheesy but true slogan), and brain cells do not grow back.  The longer the onset to tpa time, the greater the chance of a poor outcome.  CVA's are a true medical emergency and deserve transport to a stroke center without delay.

One of my major pet peeves is people who sit on scene for long periods of time with stroke patients.  For most medical things its OK to chill for a few minutes, hook up the monitor, get IV access, whatever.  Strokes should be load and go though - everything else can be done en route.

carry on with denigrating the once great golden hour.  can't argue there...unlike the time issue for strokes, there's not much scientific support that i've seen for trauma.


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## emtfarva (Feb 6, 2009)

jrm818 said:


> Negative!  Well, really I guess you're right, but that shouldn't be taken to mean that CVA's should be treated any less urgently than traumas.  3 hours is (usually...some debate on if this should extend) the absolute longest time interval from onset of symptoms to tpa administration allowed.  That said, sooner is (significantly) better than later.
> 
> It is NOT the case that tpa at 60 minutes is just as good as tpa at 180 minutes...time is brain cells in strokes (to use the cheesy but true slogan), and brain cells do not grow back.  The longer the onset to tpa time, the greater the chance of a poor outcome.  CVA's are a true medical emergency and deserve transport to a stroke center without delay.
> 
> ...



I understand about CVAs. I was just thinking about the timeframe in my area is not as bad as maybe other areas for transport. and I think the deal with trauma is that they could be bleeding internally and may require surigcal intervention. you are completly right about the cva thing though.


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## downunderwunda (Feb 6, 2009)

Well it is good to see some sensible comments. Wyoming medic was only half right with his comment



> Golden hour was a term coined some time ago by Dr. R Adams Cowley as saying, "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".



What he neglected to say was the honourable Dr Crowley coined this phrase & backed it with information gathered from the Vietnam war when he opened his own trauma centre & it was not being utilised in the 1970's.

Today the way the health systhe is judged is on a Tri (meaning three) modal death pattern. That is people will die Immediatly, within hours or within days.

So lets break this down further.

Point 1 is immediate death. This is represented by systemic multi system trauma. It is accepted in this case, probability says regardless of what interventions are undertaken, the pt would die regardless.

Point 2 is hours. If a patient dies in this time frame, then it falls on the doctor for failure to diagnose the problem & act accordingly, usually with immediate surgery.

The final point is Trauma patients who die dayslater. The majority of these patients die from sepsis. This is directly attributable to the health facility & their systems.

So I agree, the golden hour is a myth, but a myth that is still taught too often & believed by too many new people in EMS. Again, this is a change that needs to be beaten into the educators who still push that barrow.

Maybe they need to stop being educators & return to the real world.


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## spisco85 (Feb 6, 2009)

In order to understand where we are we need to understand history. The Golden Hour term was coined originally for medevacs in a WAR zone due to penetrating trauma. The major causes of death were "sucking chest wounds" and death due to extremity hemmorhage/amputation.

In these cases the units were typically days away from a higher level of care by ground. This is what caused the spark in military helicopter medevacs. Get the wounded soldier to the higher level of care faster so they can be patched up and hopefully saved.

I am in agreement though that the concept of the Golden Hour is really far fetched for most of us except maybe in the deep wilderness where it could be a day or two to get someone to a road and even then a couple hours by helicopter.

Another issue is the fact that so many new EMTs take the concept of the Golden Hour to heart and do not realize it is a guideline not a rule. More important would just be not fooling around on scene than longer than you need to in order to expedite transfer.

Just my .02 cents


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## Sasha (Feb 6, 2009)

JPINFV said:


> I've heard that before someplace.



Me too! Haha. It was a good point and worth repeating. ^_^


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## karaya (Feb 6, 2009)

downunderwunda said:


> So I agree, the golden hour is a myth, but a myth that is still taught too often & believed by too many new people in EMS. Again, this is a change that needs to be beaten into the educators who still push that barrow.
> 
> Maybe they need to stop being educators & return to the real world.


 
You're agreement that the Golden Hour is a myth is not exactly a news flash in the EMS education sector. As a matter of fact EMS authors and educators have begun to educate the Golden Period in lieu of the Golden Hour.

PHTLS has incorporated the Golden Period in its curriculum, which basically encompasses seven different time periods. From here this dove tails into what is coined as the _Platinum 10 Minutes; _defined in the PHTLS instructor guide as "factors that help EMS providers attain the 10 minute-scene goal when treating the patient with critical trauma." 

The latest edition of Dr. Bledsoe's 5 volume _Paramedic Care _textbooks (released last March 2008) has already adopted the PHTLS Golden Period (Volume 4 p. 12-13).


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## TransportJockey (Feb 6, 2009)

My trauma class stressed that it was just a theory, not a hard set rule.


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## downunderwunda (Feb 6, 2009)

:blush:





karaya said:


> The latest edition of Dr. Bledsoe's 5 volume _Paramedic Care _textbooks (released last March 2008) has already adopted the PHTLS Golden Period (Volume 4 p. 12-13).




With respect, the distinguished Dr Bledsoe has been discussing the myth since 2002, as can be seen here

http://www.bryanbledsoe.com/data/pdf/mags/Golden%20Hour.pdf

The challenge for anyone in ems it to develop the knowledge & understanding of which patient need to be expidited to difinitive care urgently. It is also about ems knowing their limitations. Understanding they are not as highly trained as the doctors in the ER. Not as Aseptic as a hospital (should be anyway). Our service aims to be on scene at major trauma cases for no more than 20 minutes. Of course this is delayed if the pt is trapped, difficult extrications etc, but it is to educate officers that the *HOSPITAL* is a better place for a critical patient than an ambulance.

It was good to see constructive debate in this thread.


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## karaya (Feb 6, 2009)

downunderwunda said:


> :blush:
> 
> 
> With respect, the distinguished Dr Bledsoe has been discussing the myth since 2002, as can be seen here...


 
You are completely missing my point. I'm not arguing that Bledsoe discussed the Golden Hour *then*. What has happened in the last couple of years is an educational shift from the Golden Hour to the PHTLS Golden Period. In Bledsoe's latest Paramedic Care edition, he dropped the Golden Hour and replaced the text in line with the PHTLS Golden Period.

In another book that I'm doing photography work on, I noticed the author did use the Golden Hour in his previous edition that was published four years ago. But, in his latest edition slated for release later this year, he too dropped the Golden Hour and replaced it with the Golden Period.


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## karaya (Feb 6, 2009)

downunderwunda said:


> :blush:
> 
> 
> Our service aims to be on scene at major trauma cases for no more than 20 minutes. Of course this is delayed if the pt is trapped, difficult extrications etc, but it is to educate officers that the *HOSPITAL* is a better place for a critical patient than an ambulance.


 
20 minutes on scene with a non-trapped critical trauma patient? That's a long time. The American College of Surgeons and PHTLS International came to a consensus of an optimal on-scene time of 10 minutes for non-entrapped major trauma patients. Also refereed to as the Platinum 10 Minutes.

What factors did you all use down under to come up with a 20 minute scene time?


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## downunderwunda (Feb 6, 2009)

karaya said:


> You are completely missing my point. I'm not arguing that Bledsoe discussed the Golden Hour *then*. What has happened in the last couple of years is an educational shift from the Golden Hour to the PHTLS Golden Period. In Bledsoe's latest Paramedic Care edition, he dropped the Golden Hour and replaced the text in line with the Golden Period.
> 
> In another book that I'm doing photography work on, I noticed the author did use the Golden Hour in his previous edition that was published four years ago. But, in his latest edition slated for release later this year, he too dropped the Golden Hour and replaced it with the Golden Period.



Apologies, i misread what you were saying.

This does prove though that change, as discussed in another thread on the use of backboards takes time, even for those with eminent qualifications such as Dr Bledsoe!


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## jochi1543 (Feb 6, 2009)

Sasha said:


> People don't automatically drop dead after 60 minutes. Please, someone enlighten me if I'm wrong, but if they were in such desperate in quick need of a hospital that there is little chance for survival, period, isn't there?



I don't think it's quite what they meant by that term (unless I am misinterpreting your POV), the way I've seen it interpreted in textbooks is that surgery within 60 minutes is the best predictor of a good outcome. So it's not that they'll drop dead after an hour, but that they are more likely to die from the injury if the injury is not surgically corrected within an hour. Then when you get them to the hospital, there's also the issue of running various tests before surgery is performed, which is yet another delay...I think the faster you get a trauma to the hospital, the better. You can never be 100% sure what exactly is happening without proper testing, or, at times, without cutting the person open. I think what it really comes down to is that if a guy's got internal bleeding or some other major problem, you are not gonna fix him, anyway, the dude who makes 2 million a year will, so might as well get him to the CT scan and OR as soon as possible.


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## jochi1543 (Feb 6, 2009)

karaya said:


> 20 minutes on scene with a non-trapped critical trauma patient? That's a long time. The American College of Surgeons and PHTLS International came to a consensus of an optimal on-scene time of 10 minutes for non-entrapped major trauma patients. Also refereed to as the Platinum 10 Minutes.



It's 10 minutes here, as well.


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## Veneficus (Feb 6, 2009)

jochi1543 said:


> the dude who makes 2 million a year will, .




That'd be great!!!!

unfortunately it is only like 200K :sad:


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## jochi1543 (Feb 6, 2009)

Veneficus said:


> That'd be great!!!!
> 
> unfortunately it is only like 200K :sad:



Well, depends on specialty and whether you consider gross or take-home after malpractice (which also varies) and taxes....of course I was exaggerating with 2 mil.


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## FF-EMT Diver (Feb 6, 2009)

jochi1543 said:


> I don't think it's quite what they meant by that term (unless I am misinterpreting your POV), the way I've seen it interpreted in textbooks is that surgery within 60 minutes is the best predictor of a good outcome. So it's not that they'll drop dead after an hour, but that they are more likely to die from the injury if the injury is not surgically corrected within an hour. Then when you get them to the hospital, there's also the issue of running various tests before surgery is performed, which is yet another delay...I think the faster you get a trauma to the hospital, the better. You can never be 100% sure what exactly is happening without proper testing, or, at times, without cutting the person open. I think what it really comes down to is that if a guy's got internal bleeding or some other major problem, you are not gonna fix him, anyway, the dude who makes 2 million a year will, so might as well get him to the CT scan and OR as soon as possible.



Point on!! we were taught on major tramua to analyze it as 10 min enroute, 10 min onscene, and 10 min enroute to ER has already burnt 1/2 of your "golden hour".

P.S. Rid and Vent I'm looknig forward to hearing from ya'll on this.


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## JPINFV (Feb 6, 2009)

Well, why not just drop all of the 'golden' BS then? Is the average EMS provider really so stupid that they need a snazzy saying to convince them to transport instead of screwing around on scene?


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## mycrofft (Feb 6, 2009)

*Golden Hour is outmoded in modern peacetime medicine.*

"SMACK" (gavel down). OK, release, drop it, good medics...

And soon your Platinum Ten", "Tungsten Twenty", and "Titanium Three" are all going to go the way of such conceptual scaffolding, taken too far to heart, worn out, then cast aside.

PS: majority of total _casualties_ in modern warefare are still accidents and disease although in Nam the _deaths_ in combat tended to be due to "low velocity" (frags not bullets) penetration of torso above the waist, despite nascent body armor. Nowadays burns have become a biggee, along with penetrating and non-penetrating injuries caused by proximity to AED's.

And last month the #1 cause of deaths among Army members was suicide.


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## downunderwunda (Feb 7, 2009)

20 minute times were determined as an absolute maxium, allowing for egress issues, depending on the scene & the need for interventions prior to moving the patient. 

Since the introduction of this as a target, we have seen average scene times drop to around 8 minutes.

We believe this is directly attributable to the fact that scrutiny is now being put onto officers to determine what they are doing on scene.

We do run into a different scenario here from time to time. In essence the patient is our responsibility until they are off our stretcher. We have ambulances that pull up to a Trauma Centre, the pateint is triaged, allong with all others who present, & determined not to be as high a priority as we considered, so we have to maintain interventions until the hospital is ready to accept the patient.

Again, this helps us throw a lot of these catch phrases out the window.


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## mycrofft (Feb 7, 2009)

*Gotta love evidence based and practical work.*

Downunda, I think here there is a tendency to try to make responders technically adept but their decision-making under remote control of the folks who buy the trucks or run the ER's. The good comes from responders with sense, experience and  who took their training seriously. The danger is "target fixation" on scene leading to overlong tx before movement versus length of travel time to hospital, and egos who think protocols are just a suggestion.

Of course, when things go bad, no matter the reason, suddenly control and the hospitals start talking about responders' "critical decision making" and "professional judgement" if the  protocols are weak or the hospital/control's actions lacking.<_<


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## mycrofft (Feb 7, 2009)

*or...*

..if their critical decision making or professional:blush: judgement are indeed lacking!


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## MSDeltaFlt (Feb 7, 2009)

The golden hour, golden period, and the platinum ten are all a philosophy.  Depending on the injury, sometimes the pt will have more than an hour, sometimes less *from the moment of injury until definitive care*.  Translation, when we get the call, we are already behind the 8 ball.  Do we need to PUHA (Pick Up and Haul *ss)?  No.  You treat immediate life threats on scene first (airway, chest decompression).  The rest are done enroute.

You don't rush.  You don't dilly dally.  You work efficiently.  You do what you can do, and you don't worry about the rest.


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## VentMedic (Feb 7, 2009)

The Golden Hour can be associated like many other recipes EMS has. Like the other recipes, they are better applied if one has an understanding of what is being dealt with and the resources available in their area. Not all injuries and not all hospitals are created equal. Often what can extend the time away from the OR or if surgery is required at all is if the appropriate interventions are available at the hospital. 

How many use some type of Severity Scoring system? How many have trauma centers and burn units nearby? Often the 911 ride to the hospital will have to be followed by a CCT. How much time are you going to allow for high enery trauma, burns, TBIs, SCIs, MIs, CVAs and sepsis? At each facility and including at scene? What about combination patients? How long before ARDS becomes are reality from the injuries? How many have enough protocols to cover every possibility as time passes on scene and in your truck? No two patients may present the same nor require the same recipe. No two EMS and/or trauma systems are the same as well for access. 

Without a few definitive diagnostics, one might not know which patients require much if any treatment at all. Some small hospital may delay activating the call to a TC until all tests are completed which may take a couple of hours if the CT Scan Technician is not in house. 

In some areas it may take up to 4 hours or longer for a patient to reach a hospital that can provide the appropriate care. The sending hospitals may have limited ability to stabilize or don't have the necessry protocols in place to initiate various therapies. 

Many also believe the Golden Hour phrase has been discouraged because in many areas it is difficult to obtain. Those that argue for or against may have their own agendas to look out for. Some of us do know Dr. Bledsoe's opinion about the use of HEMS and at times his words are often controversial. While his opinions for safety are respected, the time lapse for some patients is disputed. 

We even use a golden time period of some type in RT. The longer a baby has to spend at a local little general on a conventional ventilator, survival chances are decreased or permanent damage is strong possibility. Do we set 1 hour as a time limit? No but we do know after one hour and each hour that follows the battle gets more difficult. 

You could also use the FF/Paramedic injured yesterday in SF as an example. While one might be able to ventilate him conventionally for several hours, the TC he was taken to quickly can do a lot more ventilation methods to spare lung tissue...just like time is tissue for the MIs. Of course, no O2 transport in the body also affects a couple of other organs. 

The clock still starts ticking at the onset of injury or illness regardless of what you call it. No one can be certain of how long each patient has which can vary not only on injury or illness but also age and overall health of the patient. We even have different trauma criteria different age groups. The same percentage of burns can be considered fatal for one age and not another. 

Trauma is like the CPR chain of survival. There are many components to it and each is necessary. There must be a balance for time. 

How many really want to sit around arguing about a phrase when there is a bigger picture that must be recognized? 

The first step is recognition and that is done by education without arguments of "BLS or ALS". One must have the education to know what and how much should be done at scene. The next step is getting the patient to an appropriate facility. If the facility you transport to has limited abilities, the next step is setting up a transfer. But, in the meantime, can that hospital ED do the necessary interventions besides diagnositcs tests? Next comes the IFT. What are their capabilities? Not all are created equal. Finally, the patient arrives at the more appropriate facility. Does the clock start all over for those physicians and surgeons? 

One can argue about whatever myth but unless you know all the components in your system for each different injury or illness, it is hard to discredit any time period for definitive care. 



Sasha said:


> People don't automatically drop dead after 60 minutes.


At the TC, 60 minutes is usually the time we will be aggressive in resuscitating a trauma. At one hour the doctors are usually able to determine if we have any possibilities of life. Usually not and life ceases.


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## Veneficus (Feb 7, 2009)

Vent,

I think the reason most of it are calling it a myth is because of all the factors you described. At least that was my take on it.


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## VentMedic (Feb 7, 2009)

Veneficus said:


> Vent,
> 
> I think the reason most of it are calling it a myth is because of all the factors you described. At least that was my take on it.


 
A myth is something that is unfounded or false. There is little room to dspute that if definitive therapy of some type is not initiated within an hour, survival chances start to decrease. While this may not always be surgery since we now don't always rush a trauma patient immediately into the OR, it doesn't mean that we are not doing some type of intervention be it blood or pharmacological agents to advanced ventilatory techniques. Many of these advances have come about since the phrase was coined when surgery was the most obvious means of alleviating certain situations. But, medicine advances. That doesn't mean we sit and wait for an hour to see if the patient does die and we do know the quicker definitive therapy of some type is started the odds for survival improve. It just doesn't always mean surgery but something will be done for the patient from the list of medical advances available.

It also puts a time frame for motivating those that need a little guidance or recipe to think about what abilities and resources they have at hand.
There are also some in EMS that believe they provide definitive therapy by making a few symptoms improve and don't see the bigger picture. Some little general EDs sit, watch and wait until a patient starts to crash before calling for the CCT or helicopter and want them there real fast right now. Our flight time to some hospitals is over an hour after activation of the alert. I have walked into some serious disasters where the patient presented with enough symptoms and injuries during the first hour to call a TC for an alert but "things got a little better" so they waited. Now they want the patient out of their hospital yesterday. We also have EMS crews that get a false sense of security because things look great at first but the overall picture of the mechanism and injury could provide clues that this period of comfort won't last with one still being on scene dilly dallying when it does. 

On the other hand, as Bledsoe has argued HEMS is not always needed but that doesn't mean the goal changes for initiating definitive diagnostics and treatment. It just means there can still be other alternatives utilized depending on the situation toward definitive treatments.


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## Veneficus (Feb 7, 2009)

VentMedic said:


> It also puts a time frame for motivating those that need a little guidance or recipe to think about what abilities and resources they have at hand..



There have been many attempts to fix this, in many places. In my experience it is not EMS providers, but hospitals who are the major problem in the flow. Even docs at outlying facilities do not know how serious injuries are when they see them. I could provide anecdotes about this for weeks. They run a battery of tests which all take considerable time that even if they are positive there is nothing they can do about them. That's when they decide they want the patient out yesterday. They also examine a patient decide nothing is wrong, because as we know many severe injuries present over time, they are put in a bed or a hall and an hour later when somebody comes to take vitals they are crashing. Don't get me started on the quality of tests they run like imaging.I just love to see CXRs without lung bases or spine films that look like somebody just threw milk across the film.

Not saying that EMS is w/o blame, how many services go to the nearest hospital no matter what? With every excuse I can think of. Poor training, not enough treatment protocols, have to get back in service for the next big one etc. 



VentMedic said:


> There are also some in EMS that believe they provide definitive therapy by making a few symptoms improve and don't see the bigger picture. Some little general EDs sit, watch and wait until a patient starts to crash before calling for the CCT or helicopter and want them there real fast right now..



That is because ER physicians do not all understand their role in trauma. One of the best EM docs I know always tells residents: "The EDs job with trauma is to wave good bye on ther way to surgery." (meaning the service not always the theatre) I also like the phrase "don't open a chest if you can't close it." Don't get me wrong, I like EMs, but just like medics, they are not definitive care for these kinds of patients. You know you can sit on an incomplete aortic tear for hours, but once it ruptures it's over. Like you said, when do they call? after it ruptures.



VentMedic said:


> We also have EMS crews that get a false sense of security because things look great at first but the overall picture of the mechanism and injury could provide clues that this period of comfort won't last with one still being on scene dilly dallying when it does.



For certain, goes back to my argument about proper assessment. Which goes back to our common argument about proper education. simply telling providers to hurry up because of the legendary "golden hour", "platinum 10 minutes,"  "Lead hour and a half," or "uranium 12 seconds" is not going to solve the problems with trauma care. We are trying to make up for poor quality with speed and that is a fool's endeavor.



VentMedic said:


> On the other hand, as Bledsoe has argued HEMS is not always needed but that doesn't mean the goal changes for initiating definitive diagnostics and treatment. It just means there can still be other alternatives utilized depending on the situation toward definitive treatments.



I think HEMS for IFT is a seperate issue from golden hour. Without opening up a debate I will just state my opinion is that HEMS is beneficial, but needs to be better regulated. There is no legitimate reason highly trained providers cannot be put on ground units which would be a better service to most patients, not to mention safer and cheaper. 

I better not start on the fact these little podunk ERs actually bill for their crappy service between EMS and sending the patient where they needed to go in the first place.


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## downunderwunda (Feb 7, 2009)

mycrofft said:


> Downunda, I think here there is a tendency to try to make responders technically adept but their decision-making under remote control of the folks who buy the trucks or run the ER's. The good comes from responders with sense, experience and  who took their training seriously. The danger is "target fixation" on scene leading to overlong tx before movement versus length of travel time to hospital, and egos who think protocols are just a suggestion.
> 
> Of course, when things go bad, no matter the reason, suddenly control and the hospitals start talking about responders' "critical decision making" and "professional judgement" if the  protocols are weak or the hospital/control's actions lacking.<_<



mycrofft, 

while in some ways i agree with your comments on giving officers the ability to use their judgment, to take their training seriously & not become fixed on a target, look at the flip side.

Too often we see medics who are taking it upon themselves to try to play doctor, offer a differential diagnosis & advise the patient of their treatment course. Sometimes we need to put boundaries in to stop this from happening. Protocols or as i prefer to call the guidelines should be flexible enough to allow for this. 

20 mins is a target for us, not a hard & fast rule. However, rather than target specific officers, bring this rule across the board, see if they still have the problem & then target them. We also have the same objective for suspected Myocardial Ischaemia, however, it has been conceeded that where we have extended transport times, we are better to ensure we have the patient heading to be pain free before we load (an extended transport is considered 30 min+ & we get quite a few of them). 

Protocols are written for the lowest common mental denominator. Unfortunatley EMS is filled with poeple who are incapable of thinking for themselves & sit behind the protocol book & what the medical director says. 

Is it any wonder EMS does not have the respect & recognition it really does deserve?


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## VentMedic (Feb 7, 2009)

Veneficus said:


> For certain, goes back to my argument about proper assessment. Which goes back to our common argument about proper education. simply telling providers to hurry up because of the legendary "golden hour", "platinum 10 minutes," "Lead hour and a half," or "uranium 12 seconds" is not going to solve the problems with trauma care. We are trying to make up for poor quality with speed and that is a fool's endeavor.


 
There are many trauma based injuries (and burns) that prehospital providers must realize their limitations. 

If it is a crush injury or traumatic amputation, time is tis sure. Getting a patient to the appropriate facility may mean saving an extremity as well as preventing infection from starting.

Burned airways need to be addressed quickly. Just intubating is not enough. 

Myths or whatever you want to call them have existed in many areas of medicine and theories or applications change as more research is done. Of course we have seen this with MAST, trendelenberg and turning blood to water with massive fluid resuscitation. Defining the Golden Hour has also evolved as medicine progressed. 

Hypothermia for ROSC and other uses has been around for many years. When it was tried in both the prehospital and hospital environment during the mid 1980s, the results were not as expected largely do to inadequate means of cooling. It was however successful in some pediatric areas of medicine. The jury is still out on the future of hypothermia as the results are mixed. The problem lies in the ability to provide definitive stabilization in prehospital before cooling. 

CPAP has been around for several decades as has the Demand or Elder value. Attempts were made to use the pressure valve as a form of CPAP almost 30 years ago. Today, the Demand valve appears and disappears. 

Ideas about fluid resuscitation come and go. It is a necessity for burns and sepsis but not necessarily so for trauma. 

I don't dismiss the Golden Hour. The care, technology and medicine has evolved to where rushing to the OR immediately is not always necessary in a Trauma Center. However, not every hospital has the same technology, medications and staff as the trauma centers.


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## BossyCow (Feb 8, 2009)

It's my understanding that the 'golden hour' was create to explain the need for pre hospital treatment. It has become a sort of guideline within EMS but I don't believe it has ever been based on anything other than anecdotal information. The point of prehospital care is to stabilize the trauma victim so they can be seen in the ER and those tests run. When Bubba and BillyBob load Buford in the back of the pickup truck and run him to the ER, the urgency of Buford's care will be much higher than if he has been assessed for life threatening injuries, stabilized, possibly medicated, splinted, c-spined, etc. 

I have always been taught that the golden hour applied to those who had a traumatic event and that EMS's purpose was to extend that time if possible. Also, always been told that some people have a golden two seconds and some not even that.


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## VentMedic (Feb 8, 2009)

For those in Florida, you might find this an interesting read and some insight on the trauma registry paperwork.

http://www.flsenate.gov/data/session/2006/House/bills/analysis/pdf/h0715.HCR.pdf

Dr. Bledsoe's article also only sited two references with the one being the Lerner and Moscati article. It mentioned that little research found when in fact there is numerous articles throughout the world using international scoring systems for trauma such as ISS and AIS. There may also have been some bias as to where they were doing a literature search. Research can be done to prove or disprove just about anything. That is why it is necessary to learn to read the original article and determine if the methodologies and limitation disclosures could have given a different angle on the data.

From another view point, if Dr. Cowley has not instituted such thoughts of rapid treatment, would the Shock Trauma concept have taken off to advance where it is today? Would states have received funding to build their EMS systems? 

For those of you who don't know who Dr. Cowley is:

University of Maryland Medical Center "Shock Trauma Center"
http://www.umm.edu/shocktrauma/

1988 interview with Dr.Cowley. 

http://www.youtube.com/watch?v=8e6gkbw9FbI&feature=user

Yes, the Medevac helicopters are controversial today but when used wisely, helicopters do get some to definitive care quicker when it is needed. 
[youtube]http://www.youtube.com/watch?v=8e6gkbw9FbI[/youtube]


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## Veneficus (Feb 8, 2009)

*times change*

Vent,

With the advance of technology and understanding medicine has advanced. Things that did not work 20 years ago work today. But we are still teaching prehospital trauma the same way it was taught 20 years ago. Most of resuscitation for that matter. 

We have to stop taking complicated issues like trauma and teaching oversimplified versions. Between my surgical text and trauma text there is more than 4000 pages of type. How is it we can conscience spending so little time with trauma in EMS education? 

since we are o longer cutting every patient open because of advances, why are we not reminding people that while all trauma is surgical (meaning the surgical specialty) that surgical intervention doesn't always mean cutting anymore? A field provider is no less capable of starting treatment protocols than I am. There are even some interventions (done by protocol in house) that if started prehospital would be of benefit to certain patients.

Perhaps I am just like everyone, passionate enough about my medical interests that I think it deserves more focus; at least equal to other parts of medicine like say...cardiology.


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## daedalus (Feb 8, 2009)

You hate cardiology 

Maybe Paramedics need to spend a few weeks ON THE TRAUMA SERVICE. How wonderful would that be for training? They would see the definitive care through the bitter end on trauma patients! They would be treated like PGY-1s and be expected to scrub in on cases and observe, perhaps hold retraction etc, be required to attend code traumas in the ER, learn about physical therapists, etc.


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## Veneficus (Feb 8, 2009)

daedalus said:


> You hate cardiology
> 
> Maybe Paramedics need to spend a few weeks ON THE TRAUMA SERVICE. How wonderful would that be for training? They would see the definitive care through the bitter end on trauma patients! They would be treated like PGY-1s and be expected to scrub in on cases and observe, perhaps hold retraction etc, be required to attend code traumas in the ER, learn about physical therapists, etc.




That is a great idea! but it would shut down a lot of medic mills or places that do clinicals at community hospitals. 

yes I do hate cardio, too much cookbook, not enough thinking.


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## Ridryder911 (Feb 8, 2009)

Although R Adams Cowley was a pioneer in Trauma Care the "Golden Hour" has been proven through multiple studies as flawed. What many fail to remember or even know is the term "Golden Hour" was more a bureaucratic term. *The whole intention was to receive funding *...period. It is well known it was numbers for a bureaucratic dream. 

Yes, it was ingenious in the intent of shifting and focusing upon funding and very instrumental upon the development of trauma systems. I am not demeaning the results of what occurred but the statements that there is a specific and certain time involved is foolish and never have been proven. As Vent and others describe there are numerous of time sensitive injuries from CVA, AMI to even an ischemic bowel. Dependent upon several factors what type and if repair or treatment can make a difference. 

Many are not aware, but for over three years I studied Trauma Systems and was declared a Trauma Specialist that developed state wide and intrastate trauma protocols for various states. This also included specific(s) guidelines for determine what trauma centers should consist of. So, I do have some experience in this area. I also am quite aware of what true facts are out there and what is assumed to be right. 

I am quite aware that trauma is a well studied injury and illness. One can almost predict and almost pinpoint survivability. That one could review TRISS and other type of statistics to determine the probability of survivability of trauma patients. It is a no brainer that delaying care both prehospital and even in hospital could and is detrimental to many type of patients. Yet, it is essential to recognize how delay usually occurs and how that may be minimized. 

Yes, HEMS are effective in some areas and in some instances. I have witnessed and participated in many of those circumstances. There are also a "myth" that just because a patient is able to be flown, reduction of mortality and morbidity occurs. Something that has never been proven. Again, it is all in proportion to the time to a proper receiving facility that is appropriately prepared for such injuries and illnesses, and time it takes to get to that facility. Majority of the time ground units may actually be faster and safer than air units. 

One has to remember that an aircraft cannot just "take off" it takes time. Time of dispatch, locating, checking weather, preparing aircraft for take off, flying time, then a safe landing. None of this cannot be eliminated and one needs to consider this time factor also. I have witnessed flights that were within reasonable time to transport per ground in comparison to await for an aircraft. This is part of the need of intense education and critical thinking skills, something that needs to emphasized more and more. When it is appropriate to wait or a split decision to transport or even rendezvous. A quick but accurate assessment to provide an accurate triage assessment to transport the patient *not to the closest facility but the most appropriate facility. * One of the most important points Dr Cowley fought hard to speak out. 

One has to remember, a large caliber GSW to the chest or brain has the same results if it occurred in the parking lot of a Trauma Center or 60 miles away. There are injuries, no matter what, no matter where that occur cannot be saved and then again there are injuries that can be... 

Well developed regional trauma plans along with Paramedic judgemental protocols so such critical thinking skills are allowed are essential. Continuation of education, reevaluation of systems and the sucess has to occurr. 

R/r 911


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## reaper (Feb 8, 2009)

Very well stated RR.

I have been pushing this thinking for HEMS usage. Some just don't get it or are scared to treat a pt in their unit. Hopefuly that will change with education.


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