Merriam Webster defines “golden hour” as the hour immediately following traumatic injury in which medical treatment to prevent irreversible internal damage and optimize the chance of survival is most effective.
Most patients suffering from serious injury or illness in need of transport to the emergency department pre-EMS (prior to the mid-1960s) experienced firsthand the load-and-go mentality of the horizontal taxi. Once the patient arrived in the “emergency room,” they were treated by whichever physician happened to be at the hospital. Whether on-hand physicians were dermatologists or primary care physicians, they responded to heart attacks, traumas and any other illness or injury presenting itself.
It wasn’t until the first hospital-based critical care units were created around 1965 that the approach to emergency medical care began to change. This change was in part due to advances made in military medicine during Vietnam and such technologies as telemetry developed within the U.S. space program. Since then, we’ve come a long way in a relatively short period of time advancing technologies, improving care protocols, creating specialty intensive care units and moving from emergency rooms to emergency departments staffed by board-certified physicians.
Time Really Does Matter
Further refining and specializing EMS, we now recognize some injuries require timely interventions to preserve life and limb, and to retain normal function. No emergencies are “routine” anymore because this time-sensitive approach has now been proven to benefit patients with cardiac, stroke and vascular injuries. If completed in a timely manner, interventions for these particular illnesses can, in a growing number of cases, bring about complete cures—cures that were unimaginable 20 years ago.
In many communities today, the scene looks like this: A call goes out to EMS. Paramedics arrive and are immediately alerted to the signs of a possible heart attack. An ECG is performed and transmitted to the closest percutaneous coronary intervention (PCI) center while en route. A care team comprising an emergency department physician and nurses, a cardiologist and a catheterization lab staff are assembled and ready to respond upon the patient’s arrival. The patient is then whisked immediately to the cath lab for an intervention. Similar stories can be told for stroke and vascular issues.
Of course, the technology and staff time necessary to perform these life-altering interventions is expensive, but the return is absolute if the solutions make lives better. And, the cost of the alternative—patients not being cured and requiring care for life—far outstrips anything you could spend on the technology, not to mention an improved quality of life for the patient.
Changes for EMS
These miraculous recoveries all start with quick recognition by EMS. Today, EMS has more responsibility to screen in the field and move patients to an appropriate care facility that is ready to go 24 hours a day, seven days a week, 365 days a year. It also means transport decisions need to be made faster than ever. When time matters, you don’t want to be sitting in the field.
In years past, the vast majority of stroke and ST-segment elevation myocardial infarction patients were delivered to the local hospital that often ended up calling EMS a second time for transport to a tertiary care facility. Now, this same patient is taken directly to the center capable of performing the intervention, meaning if the patient meets the clinical criteria, EMS bypasses the closest hospital; a very different team transport pattern than in years past.
However, as a result of the importance of these timely interventions, some technologies, such as PCI, previously restricted to major medical centers, are slowly being adopted by community hospitals, enabling interventions to be done closer to home without transfers. Although, many of the more specialized, riskier interventions must still be completed at major medical centers because they require highly specialized physicians and staff, 27 hours a day, seven days a week and 365 days a year, as well as expensive equipment and supplies
For EMS, these protocol changes may mean sicker patients must be transferred further distances using the fastest available safe transport. It also means that EMS providers, especially in rural areas, must be more vigilant than ever and be prepared to identify and transfer to the appropriate facility ensuring the best possible outcome for patients.
In some cases for rural EMS providers, they must also be ready to deliver life-saving doses of TPA. And more urban EMS providers are now called on to start such interventions in the field as induced hypothermia—a proven technique to cool the body and preserve function for victims of an MI.
Furthermore, we can do things today we couldn’t in the past with today’s smaller, smarter, faster optics and cameras. As a result, EMS has greater access to electronic communication in the vehicles, including iPhones, iPads and cameras that facilitate two-way communication with stroke, trauma or PCI centers. We can now get information from practically anywhere on the globe in our vehicles.
Rules and regulations set the minimum standards on where to transfer patients. These protocols vary from state-to-state and are then often modified from system to system, but the basics are the same across the EMS. Destination plans for STEMIs, stroke, and trauma patients dictate that the patient be transported to the closest facility to best expedite the patient’s care, hopefully within the precious golden hour. If done efficiently, the results are often absolutely amazing. (Although we all know there’s a certain category of patient for whom these interventions will not make a difference regardless of when they are performed.) With the ability to intervene, the right people, the right intervention and a little luck, many STEMI, stroke, and vascular patients will be able to go home in a short period of time.
We should welcome the major clinical advances being made all around us while also recognizing these changes will in many cases also directly impact EMS field treatment and destination decisions and policy. However, we should always remember and celebrate the fact that the EMS exists to help patients receive the best care possible whether it is delivered in the field or at an appropriate medical facility.