Video Transcript:
The lights and sirens people associate with emergency vehicles serve one main purpose: to help transport the patient to the hospital as fast and safe as possible. The length of transport time to the hospital has long been said to be the single most important factor in the survival of trauma patient and has been captured by the phrase “the golden hour.”
The term the “golden hour” was coined in 1975 as a way of stressing the importance of fast trauma patient transport to the hospital. The idea was that if patients didn’t receive definitive care within an hour of injury that they would have a decreased chance of survival. The term has since been adopted to varying degrees as being the standard for EMS and trauma centers to strive for. The idea of the “golden hour” was initially supported by observational studies comparing patient data, injury severity, transport times, and mortality, but more recently, new studies have started to call into question the importance of a strict adherence to the “golden hour” (Rogers et al. 2015). Other factors effecting trauma patient mortality are now being further explored as a way of showing that trauma patient survival doesn’t only depend on transport time.
In 2019, a study was conducted in Germany using data collected by their national trauma registry. Trauma patient data was sorted into three groups based off of transport time: Short, Medium, and long transport times being defined as 10-50 minutes, 51-75 minutes, and greater than 75 minutes respectively. Each patient data set was then matched with patient data from both of the other groups that had the same type and severity of injury, and similar age to control for any confounding variables in the data analysis (Klein et al. 2019).
Unlike the early studies done on the significance of the “golden hour,” this study in Germany showed no correlation between increased prehospital transport times and patient mortality. The study even goes as far as to suggest other factors such as on scene stabilization that may be just as important or even more important than the actual transport time. It is suggested that taking extra scene time to stabilize a patient could be more beneficial than simply prioritizing fast transport.
If at the scene of a motor vehicle collision (MVC), the patient has a partially amputated leg and a tourniquet is not applied, it will not matter how fast the ambulance gets to the hospital if he is bleeding out the entire time (Pollak et al. 2017). It is in scenarios such as these where transport time is not the most important factor and the presence of a prehospital intervention is.
While the data collected does seem to suggest that transport time is less important than previously believed, it in no way means that transport time is not a factor in the survival of trauma patients. If the same patient with the partially amputated leg and tourniquet is left on scene for extended periods of time, and not taken to the hospital with any haste, their chance of survival would decrease. Even though they aren’t losing any more blood, they could still be compensating for hypovolemic shock from the blood loss prior to the application of a tourniquet. In this scenario, the patient’s body would begin by initially compensating for the physiological changes and loss of blood volume with an increased heart rate and vasoconstriction in the extremities, but the increased strain on the body causes an increased energy use that the body is not able to keep up with for extended periods of time. Even with further blood loss halted, the patient may decompensate before arrival at the hospital—increasing patient mortality—if transport is delayed (Pollak et al. 2017). So while the use of prehospital interventions such as tourniquet application is more important in this scenario, the continued importance of fast transport is still evident.
The challenge with research in emergency medicine and the reason new study findings are often contradictory to earlier studies is the unpredictable and highly variable nature of traumatic injuries. No two traumatic injuries are exactly the same, so the many confounding variables makes standardizing or replicating a study nearly impossible. Additionally, it would be unethical to inflict a traumatic injury on someone, either withhold or selectively provide care, and record whether or not that person died. There is, in a sense, no good way to perform an experiment that could conclusively prove the importance of different factors in trauma patient survival.
The study referenced is an observational study evaluating data collected from recorded patient outcomes. It is not an experiment, so only correlations—not definitive conclusions—can be drawn from it. Observational studies can suggest that two variables may be related, but they are not able to prove that relationship like experimental studies can. Additionally, the articles application in the US might not be as relevant as it is in Germany because of the differences in the scope of practice for prehospital providers. The article mentions the use of chest tubes in the field in Germany, an intervention which the highest level of EMS certification—the paramedic level—is not taught or allowed to perform in the US (Klein et al. 2019). The presence of more definitive forms of treatment in the field in Germany may contribute to transport time being less important than in the US where less definitive forms of care are available in the field.
This new study represents a trend of new data that is calling into question the importance of the “golden hour.” While this new data is not able to definitively prove anything, it does help to shape prehospital medical care for the future. By figuring out what to prioritize—fast transport or a greater emphasis on prehospital interventions— EMTs and Paramedics are able to provide better care for their patients leading to better patient outcomes in the end.
Klein K, Lefering R, Jungbluth P, Lendemans S, Hussmann B. 2019. Is prehospital time important for the treatment of severely injured patients? A matched tripley analysis of 13,851 patients from the TraumaRegister DGU. Biomed Research International. 2019:1-11. https://doi.org/10.1155/2019/5936345
Rogers F, Rittenhouse K, Gross B. 2015. The golden hour in trauma: Dogma or medical folklore? 46(4): 525-527 https://doi.org/10.1016/j.injury.2014.08.043
Pollak A, Edgerly D, McKenna K, Vitberg D. 2017. Emergency Care and Transportation of the Sick and Injured. 11th Edition. Burlington (MA): Jones and Bartlett Learning.
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