Back in 1977, when I was first employed by the City of St. Louis, I found myself sitting in an EMT class. Our medical director at the time, Dr. George Wettach, preached the concept of the "Golden Hour" and how it was imperative that our trauma patients reach the operating room within the first hour if they had any chance to survive. Therefore, Dr. Wettach stressed not "playing around" on the scene and transporting patients to an emergency room as soon as possible.
Dr. Wettach was a pretty smart and brilliant guy. I admired him for his knowledge and his ability to interact with the ordinary street medic. Besides being an outstanding physician, he was an educator and took the time to explain things. So when Dr. Wettach said, "don't play around with your patients on the scene, just get them to the emergency room," I accepted it as gospel.
But a funny thing happened after we brought our serious trauma patients to the emergency room. Many just sat there. They were not taken straight to the operating room. They were stabilized in the emergency room. X-rays were taken. Blood was drawn. Paperwork was filled out.
What about this "Golden Hour"? I thought they were supposed to be in the operating room within the first hour. Interestingly, I saw many patients still in the emergency room more than one hour after the incident and they were still alive. How could this be?
The term "Golden Hour" was coined by Dr. R. Adams Cowley, founder of the Shock Trauma Center at the University of Baltimore, in the early 1970s. Dr. Cowley died in 1991. He theorized that most patients who suffered trauma died from shock, which comes from the uncoupling of body functions, and if you could break the cycle early (within the first hour), then the patient would live. He further advocated that surgical intervention to stop this uncoupling process was imperative within the first hour if the patient was going to survive.
Unfortunately, I have seen trauma patients who died within the first five minutes of the incident and I have heard of auto accident victims lying in their cars in remote ravines for days before being found, still alive. The concept of the "Golden Hour" has become the cornerstone of EMS and trauma systems through the decades. The term can be found in many textbooks and has been the basis for handing out many federal grants.
Is the concept of a "Golden Hour" a fallacy? Recently, I posed this question to a respected trauma surgeon. He said he once heard from some of his colleagues that the "Golden Hour" was created to stop this new concept of EMT and paramedics (remember, it was the early 1970s that the term "Golden Hour" was coined) from "playing doctor on the scene."
Anybody with common sense knows that the sooner somebody with severe trauma receives optimal care, the better the chances of survival. But is it really limited to the first 60 minutes? Maybe it is 30 minutes, or maybe it is two hours. Maybe time is not really applicable, but the nature and severity of the injury dictates the survivability of the patient.
Two researchers with the Department of Emergency Medicine at the State University of New York at Buffalo, E. Brooke Lerner, EMT-P, and Ronald M. Moscati, M.D., published a paper in the July 2001 issue of Academic Emergency Medicine on the subject. The paper was titled "The Golden Hour: Scientific Fact or Medical Urban Legend?" and it looked at all the medical literature they could find on the concept of the "Golden Hour."
During their comprehensive and thorough research, they were unable to locate any scientific articles that supported or denied the concept of a "Golden Hour." Many articles referenced back to another article, which they found with further research, but it made no mention of the "Golden Hour."
They concluded, "The intuitive nature of the concept and the prestige of those who originally expressed it resulted in its widespread application and acceptance. Despite the lack of definitive scientific evidence, numerous research studies and requests for funding are based on achieving the 'Golden Hour' for all trauma patients and take for granted that time always matters."
Since EMTs and paramedics started appearing in the late 1960s and early 1970s, there have been continued advancements in both training and technology with respect to prehospital emergency medicine. The old days of "throw and go" or "scoop and swoop" are virtually gone. With all this advancement in training and technology, is the "Golden Hour" even still appropriate?
It is not my place to say. I certainly have done no clinical research. There is no doubt that a patient who receives major trauma should be transported to a hospital as soon as possible, but at what cost? Do we injure emergency response personnel and others speeding to a hospital with a trauma patient because they need to be in an operating room within the first hour? I think not!
After 25 years, I think Dr. Wettach would now being teaching us that the answer to survivability of the patient lies somewhere between early prehospital medical intervention and safe and efficient transport to a trauma center in a timely and appropriate fashion.
Gary Ludwig, MS, EMT-P, a Firehouse® contributing editor, is the chief of Special Operations for Jefferson County, MO. He retired in 2001 as the chief paramedic for the St. Louis Fire Department after serving the City of St. Louis for 25 years. He is also vice chairman of the EMS Section of the International Association of Fire Chiefs (IAFC). He is a frequent speaker at EMS and fire conferences nationally and internationally, and is on the faculty of three colleges. Ludwig has a master's degree in management and business and a bachelor's degree in business administration, and is a licensed paramedic. He also operates The Ludwig Group, a professional consulting firm. He can be reached at 636-789-5660 or via www.garyludwig.com.
