The Golden Hour

R. Adams Cowley, the founder of Maryland’s well-known Shock Trauma hospital in downtown Baltimore, famously said:

“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 Merriam-Webster On-Line dictionary defines “golden hour” as “the hour immediately following traumatic injury in which medical treatment to prevent irreversible internal damage and optimize the chance of survival is most effective.”

“Give us an hour…We will give you a lifetime” is the motto of Vanderbilt Life Flight, and perhaps, other helicopter services. Again from the Vanderbilt Life Flight web site: “Within one hour of the trauma, irreparable organ damage occurs but superior care before that one hour makes all the difference.”

The 2nd edition of the Prehospital Trauma Life Support said “The critical trauma patient has only 60 minutes to reach definitive surgical care or the odds of a successful recovery diminish dramatically.”

(It is my guess that this is no longer in the current edition.)

The following quotes are from a 2001 Academic Emergency Medicine journal article:

“The Golden Hour: Scientific Fact or Medical Urban Legend?”

“The golden hour justifies much of our current trauma system…scoop and run, aeromedical transport, and trauma center designations with trauma teams in place are, in part, predicated on the idea that time is a critical factor in the management of injured patients….While it seems intuitive that less time is better for trauma patients, there are risks and costs involved in attempting to deliver patients to trauma centers within an hour…These may be justified if there is a benefit, but may not be if there is no proven benefit or if the benefit applies only to certain circumstances.”

In the article they researched Cowley and any mention of the golden hour. What they found was articles referencing articles that referenced articles that had no reference.

A text on trauma edited by Cowley contains a chapter authored by Shakar, which discusses “Cowley’s Golden Hour,” referencing a 1976 Cowley article.

“The 1976 article …describes Maryland’s trauma system and states that the first 60 minutes after an injury determines a patient’s resulting mortality.” It references a Cowley paper of 1975.

“1975 Cowley article states ‘the first hour after injury will largely determine a critically-injured person’s chances for survival,’ but no data or reference is provided.”

They they looked at the scientific evidence about time and trauma. They found research studies both supporting a link and not supporting a link. As a rule the articles had poor quality, selection bias, small samples, and uncontrolled variables.

These were their conclusions:

“Our search into the background of this term yielded little scientific evidence to support it.”

“There are no large, well-controlled studies in the civilian population that either strongly support or refute the idea that faster is universally better in trauma care.”

“The intuitive nature of the concept and the prestige of those who originally expressed it resulted in its widespread application and acceptance.”

Which leads me back to a story I heard many years ago about the origins of the golden hour. Cowley, trying to win support for a the shock trauma hospital and what would become Maryland’s elite helicopter program that would fly trauma victims from all over the state to the Baltimore hospital, determined with a helicopter any trauma victim in the state could reach the hospital in 60 minutes, thus “the Golden Hour.”

Whether that story is true or not, I don’t know. I do know there is nothing magic about 60 minutes. True some few may only have sixty minutes, but some have only forty, some five, and some none at all, while others may have two hours, two days or a lifetime.

Prehospital people need to look at each patient individually, weigh the risks (lights and sirens versus with traffic, helicopter versus ground), use their best judgment and common sense on a case by case basis. Err on the side of the patient. When in doubt contact medical control.

Clearly the more critical a patient the less time they have. Some patients truly need scoop and run. Ten minutes scene time won’t cut it for them, many others may benefit by a slower, safer pace.

Promoting a definite time, not supported by evidence, serves no one.

***

Today as I was getting ready to post this, I came across the following “Article in Press” from the Annals of Emergency Medicine:

Emergency Medical Services Intervals and Survival in Trauma: Assessment of the “Golden Hour” in a North American Prospective Cohort.

Here’s the conclusion:

“In this North American sample (Level I and Level II trauma centers in 10 cities, over 3500 patients among whom 20% died), there was no association between EMS intervals* and mortality among injured patients with physiologic abnormality in the field.”

* Intervals include activation, response, scene-time, transport, or total EMS time.

The Editor’s capsule summary offers the following: “This study suggests that in our current out-of-hospital and emergency care system time may be less crucial than once thought. Routine lights and sirens transport for trauma patients, with its inherent risks may not be warranted.”

The article does state that their research adds further support to the concept that where a patient is transported is more important than how fast they are taken to the hospital.

4 Comments

  • ...KMG-365, -Clear says:

    Very nice essay. Thanks for bringing up this "sacred cow" again. Bledsoe et al, have done work on debunking this also – it is felt that an over-application of said mysterious golden hour, "could" be a influencer to activate HEMS more than is truly justified with the subsequent result being more aircrews, patients and ground crews being put in jeopardy in an already hazardous mission.

    The debunk of the golden hour also is supported by other work of Bledsoe's, specifically looking at patient outcomes with non-urgent (IE no lights/sirens) responses by ground EMS – it's really amazing the time savings is minimal.

    Good essay.
    -MB

  • AlisonH says:

    Interesting… I have an old high school friend who was airlifted into that hospital last month after being hit by a car on his bicycle. He was not breathing when the paramedics arrived and was totally paralyzed. Now he's in rehab and has some upper body and hand use back, and his family is very, very grateful to have him still alive. I have no idea whether the helicopter/time saved helped, but I do know that all the medical intervention did, and I am grateful.

  • Christopher says:

    Can we expand this further to the national standard for responce time? The "8:59" is based around ACLS and early defibrilation, obviously. But in a busy urban system where most calls are minor/non-urgent complaint how do we establish a standard without setting some specific time?

    Maybe "the golden hour" isn't totally scientific but if we don't set a standard then the bean counters will run us to the ground. But in the end I support clinical judgment over everything else.

  • Rogue Medic says:

    Nice commentary on the topic.

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