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.
The Golden Hour
- Thread starter downunderwunda
- Start date
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.
It's 10 minutes here, as well.
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.
FF-EMT Diver
Forum Captain
- 289
- 12
- 18
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.
Last edited by a moderator:
JPINFV
Gadfly
- 12,681
- 197
- 63
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?
mycrofft
Still crazy but elsewhere
- 11,322
- 48
- 48
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.
"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.
OP
OP
downunderwunda
Forum Captain
- 260
- 0
- 0
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.
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.
mycrofft
Still crazy but elsewhere
- 11,322
- 48
- 48
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.<_<
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.<_<
Last edited by a moderator:
mycrofft
Still crazy but elsewhere
- 11,322
- 48
- 48
or...
..if their critical decision making or professional:blush: judgement are indeed lacking!
..if their critical decision making or professional:blush: judgement are indeed lacking!
MSDeltaFlt
RRT/NRP
- 1,422
- 35
- 48
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.
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.
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.
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.
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.
Last edited by a moderator:
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.
Last edited by a moderator:
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.
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.
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.
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.
Last edited by a moderator:
OP
OP
downunderwunda
Forum Captain
- 260
- 0
- 0
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?
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.
BossyCow
Forum Deputy Chief
- 2,910
- 7
- 0
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.
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.
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]
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]
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.
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.