The Golden Hour

downunderwunda

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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.
 

Shishkabob

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

Sasha

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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.
 

Veneficus

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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.
 

Wyoming Medic

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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" :rolleyes:

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


Wy medic
 

emtfarva

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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

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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.
 

emtfarva

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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.
 

jrm818

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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.
 

emtfarva

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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.

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

downunderwunda

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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.
 

spisco85

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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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karaya

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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).
 

TransportJockey

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

downunderwunda

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:blush:
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.
 

karaya

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: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

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: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

downunderwunda

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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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