Shedding light on the 'golden hour' concept

MEDICAL MATTERS:'Abandonment' of principle concerns medics

WITH QUITE a number of smaller hospitals around the State about to lose 24-hour emergency services, naturally the issue of what constitutes a safe alternative preoccupies local communities.

Last week, GPs in the Roscommon hospital catchment area asked the Irish Heart Foundation (IHF) if it could advise on the immediate management of patients who presented with “acute symptoms suggesting heart attack”.

The doctors’ concerns were prompted by what they perceived to be the abandonment of the concept of the “golden hour”, a term used to define the time during which there is a high chance that prompt medical treatment will prevent death following major trauma or an acute medical event such as heart attack or stroke.

The Roscommon medics said it would take two to two-and-a-half hours to collect and transport a patient to University Hospital Galway. They asked the IHF to advise “regarding the recommended time it should take for a patient to receive treatment so that the patient has a better outcome and survival”.

The term “golden hour” is attributed to the late military surgeon Dr R Adams Cowley. It may have its origins in statistics from the first World War. “There is a golden hour between life and death. If you are critically injured you have less than 60 minutes to survive. You might not die right then; it may be three days or two weeks later – but something has happened in your body that is irreparable,” Cowley said.

While no one can argue that a person’s chances of survival are greatest if they receive appropriate care within the shortest time period, critics of the golden hour say there is no evidence to suggest that survival rates suddenly decrease once the first 60 minutes have elapsed.

Swiss research from 2002 suggests the golden hour can be extended safely in many cases of multiple blunt trauma. And there is certainly a dearth of scientific literature concerning the validity of the golden hour concept.

Doctors from the Department of Emergency Medicine at State University of New York at Buffalo attempted to verify the origin of the term. Early published studies that support the golden hour concept came from the Vietnam War, where the survival rate in medical facilities was increased by 2 per cent over previous wars and the time to definitive care was reduced from an average of five hours in the Korean War to only one hour in Vietnam.

However, they found papers from Cowley stating the mortality of patients transported from outlying hospitals was twice that of patients transported directly from the scene to a trauma centre. The golden hour originator also claimed the care given to a person in the first hour can determine the extent of organ damage they sustain.

But the evidence is much stronger when you consider acute coronary syndromes and heart attacks. A 2007 editorial in the BMJclearly states: "Necrosis [irreversible damage] of viable heart muscle predominantly occurs between 30-90 minutes after coronary artery occlusion."

Guidelines from the European Society of Cardiology now state that angioplasty (opening the closed artery using a balloon) is the preferred therapeutic option when it is performed “within 90 minutes after the first medical contact”.

I asked the IHF for its view. Its medical director, Angie Brown, had this to say: “The Irish Heart Foundation is a national independent charity fighting heart disease and stroke and our first concern and priority is that heart attack patients receive the best possible care and attention. Survival rates can be improved by as much as 50 per cent if patients access appropriate treatments within one hour of symptom onset. Where emergency departments in hospitals are closed, our charity calls on the HSE to clarify what alternate arrangements they have put in place to ensure that patients access appropriate care as quickly as possible.”

It would seem the golden hour is conceptually sound, albeit for some period in excess of 60 minutes.