The Golden Hour

[aussiephil]

Trauma patients need definitive care.

Difinitive care is not in an ambulance.

We do however need to minimize on scene times. Trimodal death patterns are now accepted practice in hospitals for trauma. Minutes. Hours. Days. The underlying principal here is that if the patient dies in the first hour, they had multiple system trauma with little chance of survival, regardless of interventions. Those who die in hours have done so due to the laziness of a doctor in properly assessing their patient & getting them to theatre.

Those who die in days usually die from sepsis and this is a failing of the hospital & their infection control measures.

Does this give us an excuse to be on scene for extended periods (with the exception of a patient trapped)? NO NO NO

We provide emergency pre hospital care. Nothing more. Get them To hospital.

The golden hour is complete BS. The knowledge of this though should not allow us to waste time on scene.

Here endeth my sermon!

[Kiwiology]

Trauma patients need definitive care.

Difinitive care is not in an ambulance.

Especially if I turn up in it ....

For easily accessable multiply injured patients with severe physiologic abnormality (if memory serves) 10-12 minutes is our goal from locating the patient to having them on the way to hospital.

I think we should bear in mind that trauma is increasingly a non surgical disease and the most common surgical procedure for trauma patients (I will find a source) is an ex lap.

Perhaps I am reading too much into your statement (I think I am).

Let's say you go to an RTA where somebody has been hit by a bus. They are unconscious with multiple long bone fractures, a bloody airway and very hypotensive. If you are 10 minutes down the road from the hsopital what do you do? How does thta change if you are an hour away or have a major trauma centre an extra 10 minutes down the road?

My thoughts are lots of suction, whip out a fanny gag and throw it down thier gob, blow up the cuff, ventilate, infuse a small amount of fluid (~500cc) and red lights into hospital. Now, if you are an hour down the road it might just be worth spending the extra five minutes to shove a tube down his throat and gain a better airway. Might even be worth ringing up the big flying thing to have them come swann out the sky and take him to the trauma team.

My point is really that a sensible and systematically thinking Ambuance Officer will recognise who needs to go with much of the fastness or in the big noisy contraption to a trauma centre and who does not. However there are many who do not and simply run everybody in in the big white van lit up like a christmas tree and do nothing to help advance Ambulance praxis or simply get wiped out by a cement mixer one block from the hospital because the driving Officer did not notice as he was too busy focused on alternating between yelp and wail.

[aussiephil]

Trauma or medical we need to remember Airway, once patent, Breathing, once ok Circulation. Eberything else is a nice to do, but without these 3 we have lost our patient.

We are advanced first aiders. We are not trauma specialists. Our aim is to get the patient to hospital alive for them to take over & assume full ongoing care of the patient.

Our part in a patients journey is only a small part. We need to remember that.

[armymedic571]

How could I not enter this debate!!!!

The Golden Hour is specifically for Trauna & has been debunked as a mylth by many people including the well known Dr Bledsoe. I have referenced this in other threads.

The accepted principal now is that people are clasified in a Trimodal death sequence if they die, minutes, hours & days. This said, there is no excuse for mucking about on scene.

Minimisation of scene times are essential, the most appropriate place for a trauma patient is not on an ambulance stretcher, or in the back of an ambulance. It is in a hospital, with trauma specialists, this ensures the best chance of survival.

Lets look at how we can achieve this (paragods take note - WE ARE NOT DOCTORS) for the betterment of out patients.

I disagree, the golden hour was a concept based on data from French world war I casualties. In fact, Cowley was quoted saying that critically injured patients have less than 60 minutes. The original concept was literally based on an hour. Now that we have better data and practice differently, we should not be using an inaccurate term to define our practice.

Take care,

chbare.

I think we need to remember that Dr Cowley was trying at the time to sell a concept. Regardless of his data, or where it came from. He was selling the concept of a trauma system, not the hour itself. The "Golden hour" was the punch line if you will, and as Phil has already pointed out, it has been debunked. The fact that educated people still use it only shows their own ignorance.

[chbare]

I think we need to remember that Dr Cowley was trying at the time to sell a concept. Regardless of his data, or where it came from. He was selling the concept of a trauma system, not the hour itself. The "Golden hour" was the punch line if you will, and as Phil has already pointed out, it has been debunked. The fact that educated people still use it only shows their own ignorance.

I am not calling bad on Dr. Cowley. In fact, I think his heart was in the right place. However, now that we have new evidence, new ideas and perhaps a better idea of how to deal with trauma patients, it is time to move on.

Take care,

chbare.

[Lone Star]

WHen I was in EMT-B school, the concept of 'The Golden Hour' was further reinforced with the 'Platinum Ten' for extrication.

Not every patient will need 'rapid extrication', and not every patient will die because they haven't been delivered to the local E.D. within that 'golden hour'.

While the concept is to reinforce that there are 'load and go situations' and other situations where time isn't so critical; we need to start basing our education on FACT rather than 'impressive anecdotes'.

Yes, some patients (multiple system compromise) ARE 'time critical', if we continuously hear the ticking of that 'one hour clock' in our head, it's going to cause some (especially the new people in the field) to become obsessed with time as opposed to treating the patient's conditon. When this happens, mistakes will be made, and we know that 'mistakes' can end up doing more harm than good.

[Dragoon]

Hearing "load and go" makes me want to vomit. Practitioners get that in their head and it's what they focus on. I see it a lot from EMTs to paramedics, from the green newbie to the crusty old guy or gal. They make patient contact, throw them on the stretcher, get some v/s and go. Maybe an assessment is completed and they are then off. What have they done for the patient other than drive?

During my EMT course we learned how to conduct a rapid trauma assessment. I think we all remember that and how to do it. You practice it enough times until it becomes muscle memory ("Slow is smooth, smooth is fast.") and when you get onscene it's not going to take more than 2 to 3 minutes to do it.

Knowing what you can do for a critical patient is the key. ABCs as mentioned and discussed. I hate to use numbers but 10-12 minutes as Kiwi mentioned is ideal. You can complete a good assessment and start critical interventions in that time. The big thing is not to keep screwing around with things: i.e repeated tube attempts or failed lines. That also doesn't mean splinting every broken finger and bandaging all the moderate and minor lacerations. On the way to the hospital reassess and maybe if you have the time splint that broken bone and bandage that laceration.

Some of the best traumas I've worked have resulted in me yelling "STOP!" and kicking people out of my bus or off the immediate scene so that my partner and I can do an assessment. Usually they are the ones yelling "LET'S GO! HURRY UP!". One of us starts at the head, the other at the feet and we meet at some point. Never have I ever been onscene for more than 15 minutes with a critical trauma patient. And you know what? We get to the hospital with a fully assessed patient and can give a good report to the staff.

Now is that a matter of education or experience? And how do we teach that way of thinking?

[Kiwiology]

It stands to logic that the faster a trauma patient can be assessed and treated by a Doctor that they stand a higher chance of a normal recovery.

That does not mean we should run everybody into hospital on red lights and increase our risk of having an RTA 3000% or stand around the Fire Service like a fly on shit yelling "HURRY UP AND CUT THIS GUY OUT THE CAR!"

Can I fix somebody who has been shanked and is bleeding internally from a lacerated liver? No.

Does that bag of fluid I am infusing replace the haemoglobin carring properties of blood? No.

When we speak of the "golden hour" I feel that we are primarly speaking of hypovolaemic shock patients that will require surgical intervention to fix whatever bit of plumbing has gone kaput. While a severe cardiogenically shocked patient requires more than I can give them in the back of the big white van with tinted windows that plays funny noises we need to seperate who is actually time critical and who is not.

Is may not be appropriate to spend thirty minutes trying to intubate a head injured patient on scene when the hospital is twenty minutes away but it may be entirely appropriate to spend thirty minutes on scene ensuring adequate packaging and analgesia for somebody who has broken thier leg.

What is being taught here now is consider time to an appropriate hospital vs time to get backup or do what you want to do and at least put the patient in the big white van with tinted windows that plays noises attractive to children and treat enroute. Just make sure I am not the one driving

[Lone Star]

Just make sure I am not the one driving

And by your own admission, not the person treating as well!

[Kiwiology]

And by your own admission, not the person treating as well!

Hey shut up, thats only if you are giving birth.

Oh and that last bit should have said can IV fluids replace the oxygen carrying properties of lost haemoglobin, no it can not. They need blood and not salty water in a plastic bag from the Ambo's batman kit.