5.11.2010

Questioning the Golden Hour for Ambulance Response

How fast should an ambulance go? In our rural area you are always at least 30 minutes from a hospital -- whether we go Code 3 in the Ambulance or put you on a helicopter. Still, we often drive sick patients to the hospital faster -- with lights and sirens blazing.

Of course, ambulances are not above traffic laws. We aren't supposed to fly through red lights or exceed the listed speed limit. Often running lights spook the other drivers into slowing to a crawl as they panic about getting off the road and out of the way. This is such a problem -- our lights and siren are such a hazard in some places -- that we turn them off to avoid making matters worse.

Moreover, Code 3 is dangerous. Accidents involving ambulances most often occur when responding with lights, siren and "turbo-diesel therapy." Medics are killed a rate three times higher than average workers mostly due to these accidents.

Yet time is muscle and speed saves lives right?

As reported this morning Slate Magazine, maybe not. New research indicates that the so called Golden Hour for the severely injured may not be as important as once thought. As Emergency doctors Pines and Meisel write:

Now a recent study in the Annals of Emergency Medicine casts further doubt to the concept of the golden hour for patients with severe injury. The authors studied more than 3,000 trauma patients—those with low blood pressures from bleeding, head injuries, and difficulty breathing—and looked at various time intervals after a 9-1-1 call. The times were compared with outcomes for the patients in the hospital. The result: shorter intervals did not appear to improve survival. These results are fascinating, in part because the principal question—how important is speed in the care of trauma patients before they get to the hospital?—has never been so elegantly explored. Previous efforts to measure the effect of ambulance time on survival have been plagued by the fundamental problem that medics may behave differently, like driving faster or spending more time working on patients, depending on the severity of the condition, making it impossible to tease out the effect of time on survival. While some of these biases remain, the authors of this study used sophisticated methods to account for many of these problems, allowing the reader to reasonably conclude that for ambulance care, a few minutes either way neither saves nor costs lives for patients with severe trauma.
 So what are we to think in all this? Do we need to "slow down with all due haste" as my dad used to say. Time does count when it comes to cells not getting oxygen. Time counts when a trauma center can prevent someone from bleeding out. However, we are increasingly able to do more in the field to buy time for transport.

I think application of Code 3 is required to come with some judgement -- not just as to the severity of the injury but also to whether seconds really count for this particular conditions.

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