Expanding the Golden Hour

R Adams Cowley of Maryland Shock Trauma was the first to describe "the golden hour," the critical hour after injury during which action must be taken to save a patient's life. Treatment of injury is time-sensitive. Patients must be treated in that first hour after injury, before they bleed out and before the body's predetermined biological processes set the scene for shock to take hold. 

But getting a patient to a hospital within that first hour is not always possible and when it's not we need to think of ways to expand the golden hour, to give our patients their best chances of survival in the field. Nowhere has this been better demonstrated than on the battlefield, particularly in the last decade of war. 

One of the best ways to expand the golden hour and buy time for a patient in the field is to stop the bleeding. Military doctors found that most combat casualties die within ten minutes of being wounded and usually from exsanguination. Tourniquets had fallen out of favor during World War II and Vietnam over concerns about choking off the blood supply to a damaged limb but they have made a comeback because of concerns over fatal hemorrhage. 

The Combat Application Tourniquet (CAT) is a simple tourniquet that can be applied by a wounded soldier using only one hand. Applying a tourniquet before a patient goes into shock can improve survival by 90 percent. Tourniquets have been so effective in combat that the CAT is becoming part of standard civilian EMS procedure again and even some police are carrying them.

Other ways to expand the golden hour include using hemostatic bandages like QuikClot Combat Gauze, bandages impregnated with kaolin, an agent that accelerates the body's own clotting mechanisms. There is even a way to stem suspected internal bleeding. The XStat, the "medical version of Fix-a-Flat," is a syringe filled with small spongelike discs impregnated with a clotting agent. The syringe can be deployed into an open wound like a bullet hole in the abdomen to help tamponade internal bleeding. 

These hemorrhage control measures will only buy so much time for the injured. When effective, however, they might just delay the onset of shock and expand the golden hour sufficiently to save the patient. 

More on bleeding and R Adams Cowley in Chapters 6 & 7 of HURT: the inspiring, untold story of trauma care.