Without evidence of benefit, an intervention should not be presumed to be beneficial or safe.

- Rogue Medic

Is there any evidence to support the Golden Hour?

 

In the comments to Emergency Medical Services Intervals and Survival in Trauma – Assessment of the “Golden Hour”[1] is the following from someone identifying herself as Mrs Roberta S Cowley,M.Ed.CCC-SLP.
 

Re Dr. R Adams Cowley inventor of the Concept of the Golden Hour. I recommend that you research the results of Army Contract DA-42-193-MD-229. 1959.
The results of the research studies on “The Golden Hour” as well as ALL professional works were requested by and donated to the University of Utah, Marriott Library. I recommend that you study the thousands and thousands of documents donated to the University before you show the world your
ignorance.

 

I would like to see these documents that you claim support the invention of the Golden Hour.

Please provide some link to the actual documents, because searching Army Contract DA-42-193-MD-229 provides nothing.

Researchers have looked for evidence to support the Golden Hour in the thousands of documents do not support the claims of R Adams Cowley.
 

We made an attempt to identify the origin of the ‘‘golden hour’’ and the scientific evidence upon which it is based.[2]

 

What is in the documents that this person claims contain the evidence that supports the Golden Hour?
 

Cowley passed away in 1991 and the University of Utah maintains his personal papers. A request to the University of Utah library for any additional information on the origins of the golden hour yielded two outlines of Cowley speeches.[2]

 

Thousands and thousands of documents, but all that they include is two outlines of speeches related to the Golden Hour.

These speeches appear to continue R Adams Cowley’s pattern of making claims about the Golden Hour without any valid evidence.
 

A search of research articles by Cowley on trauma provided several leads. One was a trauma case series of 760 patients that he co-authored in 1979.11 This case series gives no details of the patients’ times to definitive care and their relation to outcome.[2]

 

Without any details about time, the research cannot be honestly used to support any claim about time.
 

Within this 1975 article, another review of the Maryland emergency medical services system, he states that: ‘‘the first hour after injury will largely determine a critically-injured person’s chances for survival,’’ but no data or reference is provided.16 [2]

 

A claim with no evidence to support it. That is what I have been criticizing about the Golden Hour.
 

While it appears the term most likely did originate with Cowley, it does not appear to have originated from explicit research findings.[2]

 

Unfortunately, the basis for the Golden Hour appears to be as valid as a used car salesman’s claims about a car only being driven to church by a little old lady.

The Golden Hour is a marketing gimmick to sell trauma systems and routine helicopter transport to the uninformed. While trauma centers appear to be good, routinely flying patients, to avoid a drive of 45 minutes to an hour, is not good.
 

Image credit.
 

It is crucial for medical researchers to critically examine concepts such as the golden hour that are widely accepted but are in fact not scientifically supported. We frequently strive to push ever higher the ceiling of medical knowledge, but we must also ensure that the knowledge base upon which we stand is solid.[2]

 

The Golden Hour, Trendelenburg position, “spinal immobilization,” high-volume fluid resuscitation, MAST (Medical Anti-Shock Trousers), and other superstitious treatments are still encouraged by some trauma specialists.

These superstitions are not based on valid evidence.

Footnotes:

[1] Emergency Medical Services Intervals and Survival in Trauma – Assessment of the “Golden Hour”
Fri, 20 Nov 2009
Rogue Medic
Article

[2] The golden hour: scientific fact or medical “urban legend”?
Lerner EB, Moscati RM.
Acad Emerg Med. 2001 Jul;8(7):758-60. Review.
PMID: 11435197 [PubMed – indexed for MEDLINE]

Link to Free Full Text Download in PDF format from Academic Emergency Medicine

.

Comments

  1. Not that the State of NJ is leading the EMS charge, but in my recent recertification class, which was last year, they are no longer teaching to Golden Hour as the instructors state there is no evidence to support it. They now teach the Golden Period, which is the idea that a patient needs to bee seen at a hospital in a period of time that best serves their condition. IE the Golden Period for a CVA is 3 hours, but for an arterial laceration its 5 minutes.

  2. Once again I’ll point out the fact that seems to elude many people. The Golden Hour was a conceptual tool to teach EMS practitioners 40 or more years ago that farting around on scene with critical trauma patients was not the thing to do. Trauma patients that have survival injuries which require surgical intervention require transport to the big building filled with doctors and nurses where the ORs are.

    The “Golden Hour” is a sales tool, or a teaching tool if you prefer. It’s unfortunate that other people turned it into a “rule” and that still other people rebel against the rule.

    Although it would be more accurate, the “Get the patient to the hospital as soon as you can, but in no set time” rule just wasn’t as sexy. Nor is likely that R. Cowley Adams could have written it on a cocktail napkin as legend has it he did.

    MI,CVA, and trauma patients share the common characteristic that the sooner the patient gets to definitive care the better their likely outcome.

    For proof that screwing around on scene is bad for patients, all you need to do is ask Princess Diana. Oh, wait. You can’t do that,can you? Seems she died because some French physicians believed as you do that there’s no great rush to get a patient with survival trauma to a hospital with surgeons and an OR standing by.

    • Too old To Work,

      As the authors of the paper state –

      It is crucial for medical researchers to critically examine concepts such as the golden hour that are widely accepted but are in fact not scientifically supported. We frequently strive to push ever higher the ceiling of medical knowledge, but we must also ensure that the knowledge base upon which we stand is solid.

      Just because something seems like common sense does not mean that it is true.

      If we encourage people to make up stories to explain things that are not understood, then we encourage ignorance.

      We should not rely on anecdotes, because we can justify anything we want if we treat anecdotes as evidence. We do not put patients in a helicopter because of What if . . . ? or because of the Golden Hour.

      That is just catering to the lowest common denominator, which only results in having to lower the bar to accommodate ever lower common denominators.

      Eventually, we will have lowered our standards so much that McDonald’s will send their rejects to us.

      .

    • TOTWTYTR,

      Although it would be more accurate, the “Get the patient to the hospital as soon as you can, but in no set time” rule just wasn’t as sexy. Nor is likely that R. Cowley Adams could have written it on a cocktail napkin as legend has it he did.

      Actually, according to the University of Maryland Medical Center, Cowley explicitly stated 60 minutes as the limit of survival from time of injury.

      I don’t think anyone is calling for people to spend more time “playing” on-scene with critically injured trauma patients. What we need is a less biased risk-reward assessment regarding types of transport for those injuries. Certainly in many “trauma” cases, the risk of either helicopter transport or Code 3 transport is not justified by the small reward of getting there sooner. For how many situations is higher-risk transport justified? We don’t know, and as long as the myth of the “Golden Hour” persists rather than the more accurate rule you stated, we’ll never know.

      The “Golden Hour” is just another example of the same types of problems we have with protocols. It substitutes an artificial deadline (60 minutes) in place of paramedic judgement about the individual situation. The “Golden Hour” is another example of the medical profession not believing paramedics are capable of critical thinking and good judgement.

      • With all the emphasis on examining patients and understanding what is and what isn’t a critical injury in our training, I have to question the competence of any paramedic (or EMT) that can’t examine a patient and determine if his injury is serious or not.

        If you need further convincing, look at the trend of decreasing military deaths from World War II to the current wars. One of, if not THE, key difference is the decrease in from time of injury to definitive care.

        • TOTW,

          You did not address anything in the comment from mpatk, who wrote –

          The “Golden Hour” is just another example of the same types of problems we have with protocols. It substitutes an artificial deadline (60 minutes) in place of paramedic judgement about the individual situation.

          Then you write something that is specifically discounted in the paper.

          If you need further convincing, look at the trend of decreasing military deaths from World War II to the current wars. One of, if not THE, key difference is the decrease in from time of injury to definitive care.

          Here is what the authors wrote.

          Early published studies that support the golden hour concept came from the Vietnam War, where the survival rate in medical facilities was increased 2% over previous wars and the average time to definitive care was reduced from an average of five hours in the Korean War to only one hour.20 It is difficult to apply these findings in the civilian U.S. population since these data probably describe only young healthy males suffering penetrating injuries. Further, there is no evidence that these conclusions do not suffer from the ecologic fallacy (i.e., no data to show that soldiers who had shorter out-of-hospital times had better outcomes)

          As you can see, they discourage jumping to the unsupportable conclusion that you have embraced.

          .

  3. I don’t think that there is enough evidence to suggest that shorter prehospital times improve patient outcomes but I also don’t think that there is sufficient evidence to negate it. And a definitive answer might be all but impossible.

    3 variables I think would be difficult to control…

    -Quality of the responding EMS crews

    Particulary in relation to studies regarding EMS vs. Helicopter transport. Some of the larger studies I’ve seen have actually indicated that the difference in training, higher educational standards, and wider scope of practice for flight services COULD be reason for the disparity between ground and helicopter transport survival rates and not neccessarily transport times. This one in particular

    http://jama.jamanetwork.com/article.aspx?articleid=1148152#qundefined

    Interjection of personal experience #1: I worked for a ground service that adopted a “packaged for the OR” philosophy. Anything that would need to be done prior to the patient going to the OR we would strive to have done prior to arrival at the hospital. This included RSI for securing the airway, iStat Chem 8 and INR, HTN in head injuries treated with a Cleviprex drip, blood drawn labled and pt banded for a stat type and cross on arrival in addition to the standard fare of EMS care. An excellent physical assessment was the cornerstone of our practice and as such the recieving physicians put a lot of trust in us when it came to how the pt was directed on arrival. It wasn’t uncommon to meet the receiving team in CT or directly in the OR completely bypassing an ER workup. We looked at our times when helicopters were dispatched and while we had longer prehospital times we felt it was justified by the reduction in door to OR times. There simply wasn’t enough room on the aircraft to accomplish some of the interventions we performed. Services similar to this one whose scope of practice and standard of care met or exceeded those offered by flight services, would offer an opportunity to identify any adjustments that would need to be considered in larger scale studies for quality of prehospital care. Unfortunately these ground services are few and far between so collecting a sufficient sample size may be difficult. And it might be a long time before everyone is brought to the same standard.

    I now work in the greater metro atlanta area and I can’t tell you what a complete 180 it is. It doesn’t matter how fast you get them to the hospital or what you’ve done before hand (not that we can do much) because they won’t be going ANYWHERE outside of that trauma room for at least 30 minutes and you’re lucky if the receiving physician will even listen to your report let alone utilize anything you say in decisions regarding patient care.

    Which brings me to my next near uncontrollable variable

    -How well pre-hospital interventions are incorporated into the continuum of care

    If you walk into a hospital and patient care essentially starts over than maybe there IS a substantial difference in outcome in patients with shorter prehospital times. If only because “time to definitive care” includes time wasted in the emergency department doing interventions that could have been done prehospital or worse are disregarded by receiving facilities (i:e: replacing a combitube or LMA “because it’s not as good as an ET tube”, or tossing my drawn blood into the sharps container).
    We have the advantage of having a provider to patient ratio of at least 1:1 (sometimes 2:1 depending on how liberal the service is about letting other first responder agencies drive) and a well trained crew can accomplish a lot in a short amount of time. But this would only matter if the recieving facility is willing to receive it. And this can vary not only from system to system but may depend on the physician running the trauma. Which takes me to my last near uncontrollable variable

    – Not all trauma surgeons are created equal

    This I think would be the most difficult variable to account for. EMS you can argue that adherence to the same protocols and utilizing the exact same interventions should produce a fairly consistent outcome in regards to overall patient mortality. Surgeons are not held to such strict guidelines.

    Interjection of personal experience #2: In a previous trauma center that I worked at there was a physician who was a big believer in permissive hypotension. There was a second physician who preferred his pressures to “allow for a little more leeway” and routinely administered large isotonic fluid boluses to increase systolic pressure. Both practices were considered acceptable because though several studies suggest the benefits of permissive hypotension there is nothing to force a physician to incorporate it into their practice. A similar example can be made of physicians who prefer imaging studies prior to making the first cut so they know what they’re getting into vs. doctors who just dig in. How do you account for this in large scale studies where the identifiable objectives are patient mortality and condition at discharge?

    I realize personal experience is not nearly as good as objective data but it’s the only thing that I had to illustrate my point.

    Of course there is nothing to prove or disprove the “Golden Hour” and there probably won’t be for a long time IF the debate is ever truly settled. Time is an impossible variable to isolate when it comes to prehospital care and how it relates to patient outcomes.

Trackbacks

  1. […] Tim Noonan, a.k.a. the “Roguemedic” likes to challenge the status quo and entrenched ideas in the world of EMS and medical care. He has looked at everything from substandard pain management protocols to the harm caused by routine back boarding of patients following motor vehicle accidents. In this article at RogueMedic.com, Tim takes on the “Golden Hour” of trauma care. […]

  2. […] a recent column over at Roguemedic.com, Tim takes on the time honored trauma concept of the “Golden Hour.” The Golden Hour was a term coined by Dr. R. Adams Cowley, founder of the Maryland Shock Trauma […]

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