The Golden Hour in vehicle rescue: still relevant?

The Golden Hour in vehicle rescue: still relevant? By Colin Deiner, Chief Director, Disaster Management and Fire Brigade Services, Western Cape Government The Golden Hour was observed extensively during the wars in Korea and Vietnam Since the early eighties emergency responders have learnt about the concept of the Golden Hour. The term is derived from the concept that trauma victims will have the best chance of survival if they receive definitive medical intervention within the first hour of suffering their injury. Recent opinions have been divided on the relevance of the Golden Hour in modern day emergency response. Advanced life support techniques provide a higher level of intervention on the roadside and thereby buys time for the patient. The improved design of motor vehicles has also improved the survival rates of crash victims. The negative side of this, however, is that the visible 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 but also increased the time needed for patient extrication. It is, simply put, more difficult to work through a crumple zone than just pop the dash. The appearance of a car featuring new car technology in an accident might also give the impression to the inexperienced rescuer of a much more involved extrication challenge than is actually the case. Origin The concept of the Golden Hour was originally promoted by an American medic, Dr R Adams Cowley, first in his capacity as a military surgeon and later as head of the University of Maryland Shock Trauma Centre. Interestingly enough the data initially used to motivate the concept may have been derived from data collected by the French armed forces during the First World War. The R Adams Cowley Shock Trauma Centre section of the University of Maryland Medical Centre s website quotes Cowley as saying, 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. The Golden Hour was observed extensively during the wars in Korea and Vietnam. The widespread use of medevac helicopters, particularly in Vietnam, resulted in much quicker access to emergency care by the victim (mostly major gunshot trauma). This, together with constantly evolving equipment and techniques, maximised the 38 FIRE AND RESCUE INTERNATIONAL Volume 3 No 10

the patient s pain under control can indeed assist and expedite the extrication, said Dr Smith. Task benchmarks time spent accessing the victim to the moment he was presented to the surgical team. As with many medical concepts this thinking has not been without controversy. Various peer reviews over the years have criticised the Golden Hour idea as not having any scientific basis. Medical professionals across the board do, however, agree that any delays in getting the patient to definitive medical care are undesirable. This sort of places medical rescue services somewhere in the middle. How do we then approach this? The responsibility of emergency medical services (EMS) in this argument was best described by a flight operations supervisor and flight paramedic for the Maryland State Police, Charlie Eisele, in 2008, Our job in EMS is threefold, 1) get to the patient quickly; 2) fix what we can fix and 3) quickly get the patient to the right hospital. Anything we can do to compress each of these time periods is good for the patient. Dr Wayne Smith, Emergency Care Specialist at the Western Cape Emergency Medical Services, shared his thoughts with me recently and is of the opinion that the extrication should be done as fast as possible, keeping in mind additional hazards and safety. He stressed the importance of assessing the extrication in a holistic manner whereby all efforts should be synchronised to the maximum benefit of the patient. The patient assessment is a priority and the decision to do a slow controlled versus a rapid extrication must have some medical input. Sometimes just getting The Golden Hour It does come back to the first command decision that needs to be made (after the initial assessment and the scene is secured), do we do a rapid or controlled release? This will all depend on what we find at the crash site, what our resources are and how precarious the situation is. Let s assume that we don t have a car on fire or almost floating in some vicious hazardous material and that we have sufficient medical support on hand. We then have to get the vehicle stable enough for the senior medic to access the patient and make the call as to how much time we have to perform the extrication. Everything else will flow from these initial actions. The ideal result: A controlled, rapid release. From an extrication perspective I still believe that the Golden Hour concept is still very relevant. It must, however, be adjusted at both ends to allow for the challenges of new car technology and accommodate the advantages of highly specialised advanced life support. If nothing else it gives us an effective standard operating procedure (SOP) for extrication operations. The MVA value chain Let us agree for the purposes of this article that the Golden Hour concept is still relevant (within the limits described above). We now need to unpack those sixty minutes. Each phase of the motor vehicle accident (MVA) value chain needs to be optimised. The value chain consists of the following phases: Incident detection Incident reporting Mobilisation and emergency response Arrival and scene stabilisation Extrication Patient transport (surface or aeromedical) and Definitive medical care Within the MVA value chain is a range of procedures and protocols that have to happen in perfect harmony. This 14-step process starts the moment the first responders arrive on-scene. As with a structural fire, your preliminary size-up has already started the moment you received the call. A call received from the public will, at best, give you some basic information on what you are heading to. They will most probably not be able to confirm if someone is trapped or give you any precise information on the condition of the patient(s). Modern cellular communications does, however, allow the calltaker to question a person reporting an incident from the scene and therefore improves the quality of information provided by the reporter. A report from a freeway patrolman will generally be more accurate due to their experience in working such incidents. Your size-up continues on the way to the scene as you evaluate the weather conditions and draw on your (and your crews) experience of the road and area where the incident has happened. While approaching the scene, try to gather as much information as you can 40 FIRE AND RESCUE INTERNATIONAL Volume 3 No 10

as to what is happening. Do you see any downed utilities? How many cars are involved? Will you have sufficient police officers to provide protection from traffic? Do you need additional lighting? Do you have enough space for an EMS helicopter to land if required? Is a hazardous cargo involved? By the time you establish and announce your command position you should already have a fair idea of the challenge ahead of you and what additional resources might be required. Your initial on-scene size-up should now begin. By doing a walk-around the accident scene with your entire crew you can identify the position of the patients, get an idea of their injuries, ascertain the stability of the vehicles and evaluate the extrication options. Once receiving feedback from your crew you can then start the stabilisation and extrication process. If we consider that the transportation of the patient and eventual delivery to the surgical intervention team should take around half-anhour, you are left with twenty minutes to do our thing as rescuers. The science of vehicle extrication is to properly manage those twenty minutes so that you are able to provide the medical crew with a viable patient which can be transported in a stable condition and hopefully walk out of hospital somewhere down the line. Stabilisation (The four Ss) Emergency services will be arriving at a crash site and generally be greeted with a great deal of chaos. It is critical that every crew member gets dialled-in to the situation as quick as possible. Personnel must absorb the scene and appreciate the challenges they will be facing for the next hour (or hopefully less). The initial walkaround assessment will achieve two goals. Firstly, it will give the incident commander the necessary information needed to develop a plan of action and secondly, it will provide the responders with an opportunity to ground themselves. By grounding themselves, I am referring to a process of shutting out any other issues that might be on their minds and focussing totally on the incident in front of them. That is the first S, stabilise yourself. The second S, stabilise the scene, are those actions needed to ensure safe and unimpeded access to the vehicle and ultimately, the patient. Identification of the myriad of hazards such as traffic, fire, hazardous materials, visibility, downed electrical wires, bystanders and the effects of inclement weather need to be addressed here. We now get to the third S, stabilise the vehicle. The golden rule here is not to allow anyone to access the patient before the vehicle is stable enough for someone to enter it. You will, however, have very frightened, injured, confused, observing people walking around him/ her, not actually rushing in to help. It is therefore important to make contact with the victim at this point. Ideally have your medic stand directly in front of the patient and only then call out to them. This will prevent the patient from having to inadvertently turn their head to face the medic and possibly cause further injury to themselves. The 14 step principle Finally, the fourth S, stabilise the patient. Both the extrication and the patient care must happen simultaneously. Getting a medic into the car and near the patient will be your next priority. Victim stabilisation and emergency care can then happen while you are creating the egress route along which the patient will eventually be removed out of the vehicle. I have in previous articles written extensively of shoring and stabilisation of loads, which I will not repeat here save to say that the initial shoring should only be sufficient enough for the medic to safely enter the vehicle. Subsequent (secondary) shoring should support the instability created by the actual extrication effort. It can come later. Also remember that stabilisation is an ongoing process and all shoring must be continuously checked to ensure that it didn t move while your crew was busy removing a door or some other part of the vehicle. Shoring: are we overkilling I know I will be challenging some ingrained beliefs here but I think we should get this conversation going. Ever since stabilisation of vehicles involved in accidents became an accepted practice in this country, around the mid-eighties, many rescue services have increased the amount of shoring chocks, blocks and wedges on their rescue vehicles exponentially. In extrication competitions sometimes very good teams have failed to win events due to them not shoring properly or not rechecking their stabilisation systems. In the same time, vehicles design has improved to such an extent that they are stronger in many areas and can better absorb accident damage. I remember a World Extrication Challenge in Prague, Czech Republic in 2002 where the incident commander of one of the British rescue teams decided against placing supplemental shoring next to the pillars of a car on its roof. His rational was that the roof pillars were strong enough and that by placing any additional shoring around them he would be compromising the egress route he had planned for the patient. It was a good decision but created quite a stir among some traditionalists who believe that there should be no other option. Volume 3 No 10 FIRE AND RESCUE INTERNATIONAL 41

Emergency services will be arriving at a crash site and generally be greeted with a great deal of chaos I am of the opinion that we should have a relook at the way we stabilise vehicles in future and let the position and condition of the car have a greater influence on how we approach this area. I welcome your input on this. Doing it in twenty minutes The initial assessment and vehicle stabilisation should not have taken more than one and a half minutes. The next step should be to get the medic into the car and near enough to the patient to enable him/her to conduct their primary assessment and commence their life support activities with as much freedom of movement as possible. You might have to remove some glass and relocate certain vehicle components to do this. Only do what is required to access the patient. You can start breaking glass and relocation metal immediately after providing medic access. As you start removing glass, take the time to evaluate each piece of glass that has not already been broken and be aware that indirect force on a particular part of the vehicle during the metal relocation phase could cause a sudden fracture of still intact windows with the resultant missiles of small pieces of glass. This is a surprise you don t need. A good technique in the past was to roll down the windows until only a small part stuck out of the door and then to cover it with a tarp before breaking it with a hammer and allowing the broken glass to fall into the door and be out of the way. Almost all new cars, however, have automatic window winders that only work if the car is powered. Glass removal must therefore be done with utmost care to ensure it does not become a problem for the patient who might be suffering from airway problems or exposed wounds. Although some activities could be done simultaneously, it would almost never be possible to start with glass removal while the medic is still accessing the car and patient. All possible exposures must be protected with the necessary soft protection before the windows are popped. Once you are satisfied that all glass hazards are removed, the metal relocation can start. What you are trying to achieve is to make a hole big enough for the rescuers to reach the patient and then for the patient to be moved out. All activities must be deliberate and every second must see the team moving in a positive direction in relation to the task. I have often observed rescue teams on the road and in challenges wasting precious minutes in doing a whole range of tasks that are not contributing to the release of the patient. I call this Dead Time and the incident commander must take care to identify if this is happening and take steps to avoid. You should be halfway into the time recommended for the extrication by the time your metal relocation is complete. A complicated entrapment will obviously increase this time and it is therefore critical that the rescue sector 42 FIRE AND RESCUE INTERNATIONAL Volume 3 No 10

communicates with the medic to ascertain the needs of the patient in relation to their operations. The medic must be able to (through the incident commander) direct the operation. The incident commander must always keep the big picture in mind and also advise the medic about certain aspects of the operation that he/she (the medic) might not be aware of or any changing conditions ie weather changes or safety being compromised. Many rescuers will argue that the time allocated for these activities is way too short and that it is virtually impossible to achieve so rapidly. I have in a previous article on reciprocating (recip) saws elaborated on the need for multi-tasking. One two-person crews on the hydraulics and a further rescuer on the recip saw or air chisel can cut your metal relocation time in half. And yes, it is possible to multi-task with only three rescuers. Your back-up rescuer on the hydraulics becomes your back-up rescuer on the saws and pneumatics. Moving the patient After making an opening big enough for the rescuer to get to the patient you will get a better idea of what is needed to extricate the patient and how much time might be needed. The medic will always be focussing on maintaining a sustainable airway and supporting breathing and circulation. He/she will mostly be confined to a small position either behind or next to the patient and might not have a full view of the entire body, making a secondary survey impossible. The rescuers should now be able to get eyes on any extremities that might be trapped and must then inform the medic and incident commanders of their observations as well as how they see the release happening. all times secured to whatever extrication device you are using and that all intravenous (IV) lines and monitoring equipment stays intact. In our 20 minutes we have allowed for five minutes dead time, which will more often than not have been used up in an earlier phase of the rescue effort. Once the patient is released and handed over to the ambulance crew, they will certainly also need time to prepare him/her for the trip to the hospital. In closing The twenty minutes we have allocated to the rescue effort within the Golden Hour is obviously a guideline. It cannot be taken as a rule as there are too many variable and curve balls that may come your way during the operation. At a time when the relevance of the Golden Hour is being questioned, it is still in the best interests of the patient to be extricated safely in the shortest time possible. I would, in closing, like to thank a dear friend and colleague, Andre Tomlinson, for sharing his insight and knowledge with me. Andre was responsible for introducing the first extrication competition in South Africa in 1992. He also brought a large number of international experts to this country over the years who collectively improved our capacity and ultimately saved the lives of many victims of motor vehicle accidents. On top of all of this was his own innovation and thinking that provided a quality to the science that cannot be measured. The level of entrapment could play havoc with our idea of a 20-minute extrication. A victim of a vehicle underride might require comprehensive immobilisation before a load is released off him/her. A dashboard relocation evolution might require you to move more metal in order to make additional base plates on which to anchor hydraulic rams. Patient extrication will generally always be the most challenging part of the rescue effort. You are working with huge forces, sharp blades and exothermic equipment very close to a person who is not as well protected as you and your colleagues. This work will require the rescuers to always ensure that there is sufficient protection placed between the patient and the tool. This takes time. Be properly prepared by ensuring that you carry various sizes of hard timber sheets on your rescue truck that can be easily inserted into small spaces to protect the victims and medics. One of my favourite adages of vehicle rescue is that in the old days, we used to remove the victim from the wreck; nowadays we remove the wreck from around the victim. So, now that we have done that, it becomes time to immobilise move the victim and move him/her out of the vehicle. This must be the domain of the medic. A firm control must be taken by the medic at this point who must communicate in a clear voice as to what must be done. You might have to move the patient vertically before levelling the spinal board out. Make sure the patient is at Volume 3 No 10 FIRE AND RESCUE INTERNATIONAL 43