Tech Rescue

Golden Hour vs. Golden Period

Issue 1 and Volume 8.

The idea that injury outcomes improve with a reduction in time to definitive care is a basic principle of trauma and EMS systems. The first 60 minutes after traumatic injury has been termed the Golden Hour. And the idea that definitive trauma care must be initiated within this 60-minute window has been practiced for more than three decades. To accomplish this goal, the initial patient assessment, emergency stabilization, patient packaging and initiation of transport should ideally take less than 10 minutes, also referred to as the Platinum 10 Minutes.

However, in recent years, a similar, but slightly different, approach has been developed: the Golden Period. The main principle of this approach is that while some patients do need a shorter time to receive definitive care, many other patients may have more than an hour—a determination based on the extent of the patient’s injuries, not a predetermined time that generalizes all trauma patients.

Before we delve deeper into the Golden Period, let’s first consider why some first responders are quick to follow the Golden Hour approach—and some problems that could result.

Misperceptions & Moving Too Fast
The amount of vehicle damage has significantly increased with the addition of crumple zones and designed failure of certain components. Like other safety features, these crumple zones have increased occupant survival rates. However, responders may initially see the significant damage and assume they have arrived at a non-survival incident or a patient with multisystem trauma when, in fact, the occupants may have limited and non-life-threatening injuries.

Further, we’ve been led to believe that when responders suspect that patients have sustained traumatic injuries, they’re justified in expediting operations even if it involves less attention to detail. Using mechanism of injury as a determining factor or an “eyeball” assessment, responders may initiate a rapid removal scenario, even when the patient condition does not warrant it. And when responders take a rapid-removal approach, they are expediting operations in a way that may lead to a decrease in safety, may open the door for errors and may increase patient injuries when no life-threatening conditions are present.

What to Do on Scene
With all this in mind, you’re probably wondering if our approach to motor vehicle collisions (MVCs) should change. First, regardless of the type of incident, conduct the initial steps of the extrication process in the same manner; this will help ensure our safety. This process includes being appropriately prepared, establishing a command system, conducting a proper scene evaluation, requesting additional resources as needed and mitigating potential hazards.

Once patient contact has been made, the interior rescuer can form a general impression and conduct a quick primary assessment. The entire assessment shouldn’t take longer than 10 to 15 seconds.

The disentanglement supervisor should then use the information provided by the interior rescuer to determine the level of tactics based on the appropriate timeframe. This should be communicated as quickly as possible. Without this information, the disentanglement supervisor will understandably begin to form their own impressions about incident needs. (Note: If the disentanglement supervisor does not receive this information in a timely manner, they should request it from the interior rescuer.) Further, all resulting findings and decisions should be conveyed to the entire group to ensure clear and coordinated efforts. This is especially true when your agency is not the sole provider of services, and multiple agencies are responding to the same incident. In short, the handling of incident needs is all about pace, and the disentanglement supervisor should be the one to dictate it.

Standard vs. Rapid Removal
Until this point, we’ve assumed that there are no external hazards (e.g, fuel leaks, fires) that would complicate the decision-making process—but those factors are always a possibility. In an effort to understand whether you need to initiate a standard vs. rapid removal, follow the A-B-C-D acronym. As always, A means airway; B means breathing; and C means circulatory. In this case, D stands for danger. If the patient has an injury that compromises any of the three major body systems, or if there is eminent danger on the scene, the patient should be rapidly extricated. In the case of a rapid removal, it’s an all-out sprint, whereas with a more standard removal, it’s more like a hard jog. For example, a rapid-removal avoids more time-consuming tasks, such as additional stabilization, creating larger paths of egress, increased medical procedures on the vehicle’s interior, etc.

Summary    
The purpose of this article is not to insinuate that we should not treat MVCs as emergencies; I am simply saying that in some cases, we do have more time than we think to evaluate the situation and make solid decisions. A few extra seconds or minutes to deploy the best tool for the job, harden the egress, stabilize the patient, etc., may prevent further injury of the patient or injury to responders.

Just like hearing “structure fire” over the dispatch, the word “extrication” automatically increases emotions. The same can be said of first seeing the vehicle damage. However, the vehicle damage does not necessarily indicate the level of patient injury. In some cases, a patient’s Golden Period could be an hour—or less. But in most cases, a patient’s Golden Period can be longer. The disentanglement supervisor must rely on good information from the interior rescuer, while taking into account external factors, in order to accurately determine the pace of operations.