The Golden Hour – the Border Between Life and Death
When Richard Armitage pulled on his orange jumpsuit and took to the skies as Dr Alec Track, he brought to life the hectic and unpredictable work of a doctor in the Helicopter Emergency Medical Service (HEMS) in order to explore the pressured world of the Golden Hour, the magical 60 minutes that many emergency physicians believe is the difference between life and death for the critically ill. Behind the drama of the television programme lies the reality of the London’s Air Ambulance, and the knowledge that every minute counts for the patients they treat.
The term “the golden hour” is believed to have been used first by an American cardiac surgeon R. Adams Crowley in the 1960s although the connection between delay in treatment and mortality was recognized first by French medics in the First World War. It was observed that critically injured patients who received treatment within an hour of being wounded had a 10% mortality rate, which increased to 75% where the delay was 8 hours or longer.
It was Dr. R. Adams Crowley who first articulated the importance of the golden hour in modern medicine, although awareness of the concept had been developing prior to this. Crowley stated, “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.”
Crowley introduced the first helicopter medevac service in Maryland, USA in 1969, liaising with military helicopters to have critically ill patients brought to hospital within the ‘golden hour’. From this initiative the concept of the helicopter medevac has spread around the world. In the UK the Royal College of Surgeons produced a report in 1980 into delays in delivering care and treatment to critically ill patients under the existing system. In 1989 the London’s Air Ambulance (LAA) was created to address these concerns, and it began service out of the Royal London Hospital in 1990.
Today HEMS teams are involved on a daily basis in cases of major trauma around London. The LAA site reports that since its inception the LAA has flown over 17 000 missions including major disaster response as well as daily road accidents, industrial accidents and violent crimes. HEMS works closely with paramedic teams to assess and treat victims at the site before transport to hospital. Each team consists of a pilot, co-pilot, emergency doctor, paramedic and often a trainee doctor. Crews are also equipped with Thomas packs which operate as mini-Accident and Emergency (A&E) units.
Many tertiary hospitals in large cities operate a medevac team. In recent times the concept of the Golden Hour has come under fire from some trauma surgeons who claim that there is no substantive literature to support the notion that there is a ‘magical’ time operating for critically ill patients. However evidence does seem to demonstrate at least that rapid response does increase the chances of survival for the critically ill, particularly in cases of cardiac arrest.
The television drama The Golden Hour and the heroic Dr Track may have been short-lived, but they provided an insight into the work of the HEMS and the focus and intensity of the doctors who staff it. Fortunately the real life service lives on to help anyone unlucky enough to find themselves in a major accident or incident, and with public and government support it is to be hoped they will do so for a long time to come.
References and credits