The Golden Hour

Rogue Medic seems to have fixated on “The Golden Hour” of late. Try as I might, I can’t figure out his fascination with a conceptual tool that was developed sometime in the 1970s. Not only that, but it was a conceptual tool used to train residents in the hospital. The point being that patients with survivable injuries need to be in the OR (not the hospital) as quickly as possible. I know that this is likely to give RM a stroke, but for EMS the concept was “The Platinum Ten Minutes”. Which is likely where our silly rule of ten minutes on scene for trauma comes from. Once again it was designed to be a conceptual tool to implant the idea in EMTs and paramedics that getting trauma patients to the hospital and thus the OR as quickly as possible is the key to increasing survival.

I’ve been in EMS for a long time. When I started paramedics were more of a novelty than a viable option in my part of the country. Sure, Johnny and Roy were just wrapping up their careers with the LA County (not CITY) Fire Department, but even in California ALS wasn’t wide spread. Nor was it in the rest of the country for that matter. That’s background that mostly tells you I’m officially an old fart. Or, as Ron White says, “I told you all that so that I can tell you this”,

I worked on the street when it was routine for paramedics to treat trauma cardiac arrests exactly the same as they did medical cardiac arrests. IVs, Epinephrine, Sodium Bicarb, Atropine, and all the rest of the medications PLUS fluid volume, and intubation. On scene, before moving to the ambulance. Scene times of Forty Five minutes were not uncommon, they were closer to the norm. This in a system with transport times averaging ten minutes to the Emergency Department. Trauma Center designations were in their infancy, so we went to the closest ED. Which of course continued the silliness in many cases. The hospitals that were going to be trauma centers were better and in fact started the push for us to treat trauma differently. Those hospitals had surgeons and many of those surgeons, although old to us kids, were young enough that they had extensive experience with trauma in Vietnam. They understood that rapid evacuation of casualties from the scene to an Operating Room was the key to patient survival from trauma. They also knew, but it would be years before they could push through change, that the dead stay dead. That is, cardiac arrests from trauma have a very dismal prognosis. Blunt trauma is even worse than penetrating trauma, and for penetrating trauma we’re talking single digit percentages when it comes to survival. Low single digits.

Because the surgeons were so concerned about our general lollygagging around when it came to trauma patients, even those who weren’t in cardiac arrest, the surgeons started to agitate, OK rant and rave, about paramedics “wasting” time on scene. Some surgeons actively promoted getting rid of paramedics all together. Of course the medical doctors would have none of that since they saw the benefits of paramedics when it came to medical problems. As a result, the “Golden Hour” was dragged out of the hospital and incorporated into EMS training programs.

We were told to shorten our scene times for trauma patients, trauma centers were designated and we were directed to transport to them, and on scene times were reviewed and critiqued. At some point in time the history of all of this got lost and we were left with an erroneous impression of what the Golden Hour was. Or was supposed to be.

The take home message, which Rogue Medic and his acolytes seems to have lost sight of, was this. Don’t screw around on scene with trauma patients. Get them to the hospital, preferably a trauma center, as quickly as safely possible. Do only immediately life preserving measures, Airway, Breathing, Circulation, on scene. The full trauma assessment, other treatment, and everything else can wait until the patient is in the ambulance and the wheels on the ambulance are going round and round. Oh, and notify the hospital early enough for them to muster the troops to greet the patient as soon as your roll in the door.

Ironically, this message has spread across the aisle to the medical side. Now paramedics (and EMTs) are encouraged to spend as little time as possible on scene with STEMI and Stroke patients. Do the initial treatment where you find the patient, move to the ambulance as soon as possible, continue treating in the ambulance, notify the hospital.

Now can we stop beating that poor “Golden Hour” horse to death and get on with obsessing about what color stripe on the ambulance is most effective?