Emergency medical treatment: the Golden Hour

Recently epitomised in the excellent television programme called ‘An Hour to Save Your Life’, the ‘Golden Hour’ is the crucial period of time of 60 minutes or less when prompt effective emergency care can mean a difference between surviving or not. The ‘Golden Hour’ was first described by Dr Adams Cowley at the University of Maryland in Baltimore. This was from his personal experience and observations in post-WWII Europe and then in Baltimore in the Sixties. Dr Cowley recognised that the sooner trauma patients reached definitive care, particularly if they arrived within sixty minutes of their injury, the better their chance of survival.

Field hospitals (who can forget M*A*S*H*?) and medivac helicopters in the Korean and Vietnam Wars contributed to increasing survival rates. Improvements in medications, medical techniques and instruments were key to survival, but none of these were of any value if the patient was not seen by a doctor.

First Response

The job of the first responder, whether an ambulance paramedic or a doctor on the air ambulance service is threefold:

1. Get to the patient quickly;

2. Stabilise (i.e. fix what can be fixed);

3. Scoop-and-go, (i.e. get the patient quickly to the right hospital safely).

Remember Your Alphabet.

Central to this initial assessment and management at the scene is the principle of ‘ABC’:

• Airway;
• Breathing;
• Circulation.

All the above come under the umbrella of perfusion management. The aim is to return and maintain a patient’s cellular perfusion (oxygen delivery to the cells) and then get the patient promptly to the right facility.

Almost every lifesaving intervention has to do with establishing or maintaining cellular perfusion.  For example:

• An external defibrillator or basic CPR can allow the heart to return to a perfusion rhythm.
• Allowing the hypotensive (low blood pressure) patient to breathe on his/her own instead of using muscle paralysing agents (necessary for inserting a breathing tube-intubation) encourages blood return to the central circulation.
• Decompressing the chest, stopping bleeding, maintaining the airway, and ventilating patients unable to maintain their own airway with poor oxygen levels, can all improve perfusion.

Pre- Hospital Intubation

In particular, field intubation secures the patient’s airway and allows for proper oxygenation and ventilation of patients. Intubation is passing a breathing tube through the vocal cords into the trachea (wind pipe) and can now be completed swiftly and appropriately. This is often referred to as ‘Rapid Sequence Induction’ (RSI) and should only be undertaken by a skilled professional, and where there is no other option to maintain the patient’s airway and ventilation. A poor skill-set can only extend scene time resulting in a hypoxic patient.

Good post-intubation management is also essential otherwise this can lead to unrecognised and misplaced tubes: An endotracheal tube (tube placed in the windpipe to assist breathing) pushed too far has the tendency to lodge in the right main bronchus, thereby only ventilating one lung, for example.

Having worked as an intensive care sister looking after trauma patients including those with neurological injury, brought in by HEMS (Helicopter Emergency Medical Service) I have seen, first-hand, how initial early life-saving measures can make a significant difference to the outcome.

The Association of Anaesthetists of Great Britain and Northern Ireland (A.A.G.B.I.) has detailed guidelines in relation to out of hospital intubation, as does the organisation NICE – the National Institute for Health and Care Excellence. The following simply represents the main themes in such guidance.

Although field intubation can be a good thing, it is not always the correct thing to do. Good judgment calls are essential. In considering these factors, and setting aside the obvious need for enhanced intubation skills and the correct equipment, the medic must consider:

• How sick is the patient?
• Is the airway patent (open)?
• What is the level of oxygen saturation?
• Are they adequately ventilated (breathing/taking in oxygen)?
• Will they survive transport without intubation?
• What is your transport time?
• If scene time exceeds transport time, will the intubation make a difference? Is good BLS (basic life support) and rapid transport a better option?  Spending 20 minutes on the scene making multiple intubation attempts thereby letting the patient’s oxygen saturation level drop will not be the best thing for the patient.

Now practising as a clinical negligence lawyer, I assist patients and their families with claims related to a wide range of emergency treatment.  Such cases also highlight how early treatment decisions can affect the outcome for the patient.