The first hour after a medical trauma has long been viewed as the difference between life and death. Now, a new study from the U.S. Army Institute of Surgical Research and the Texas A&M Health Science Center College of Medicine, confirms that receiving trauma care within the first hour has saved the lives of U.S. service men and women on the battlefield.

This first hour after a trauma is commonly known as ‘the golden hour,’ a phrase first coined by Dr. R Adams Cowley at the University of Maryland Medical Center in Baltimore in 1957. In 2009, Secretary of Defense Robert M. Gates mandated a golden hour protocol for United States military personnel with life-threatening injuries. This cut the previous military standard in half, and research shows use of the golden hour is having a dramatic impact.

“I had the privilege of meeting with Secretary Gates personally, showing him our findings and telling him that his policy had saved hundreds of American lives,” said Russ S. Kotwal, M.D., M.P.H., of the U.S. Army Institute of Surgical Research and adjunct assistant professor at the Texas A&M College of Medicine. “There is not a doubt in my mind that his leadership and subsequent policy saved lives.”

Complicated Implementation

The golden hour mandate presented a number of logistical and practical hurdles. “Ideally we’d land a helicopter to medevac a wounded soldier, but that’s not always possible in the middle of a firefight in mountainous terrain in the dead of night,” Kotwal said. “What the military also did was push medical capability forward on aircraft and on the ground in order to be better able to treat life-threatening injuries immediately.”

Even when a medevac was a feasible option, ordering a helicopter often meant layers of bureaucracy, which military leadership worked to slim down. “Previously there were a number of levels of command involved in ordering a helicopter,” Kotwal said. “Leadership streamlined that procedure and in the process decreased the amount of time it took to get the wounded to the care they needed.”

Kotwal emphasized the role of accountability in implementing the golden hour mandate. “Many folks will mandate something, but they will not always follow up by enforcing that mandate,” he said. “The golden hour wasn’t only mandated, but Secretary Gates requested weekly updates on outcomes and if a flight didn’t make it in an hour, he wanted to know why and how we were going to fix it the next time.”

Findings

The study’s authors analyzed battlefield data for more than 21,000 military casualties during the U.S. involvement in the Afghanistan conflict. The data covered September 11, 2001 to March 31, 2014, comparing outcomes before and after the June 15, 2009 implementation of the golden hour mandate.

Before the golden hour mandate was implemented, the median time to transport a wounded service member was 90 minutes. After the mandate, the transport time dropped to 43 minutes. Cutting the average transport time in half also cut the fatality rate nearly in half, from 13.7 to 7.6 percent. Additionally, the final projected versus the actual case fatality rate equated to 359 lives saved.

Issues With Field Data

Incomplete or inaccessible data complicated the study’s findings in several instances. “Unlike in a traditional hospital setting where physicians write the course of treatment down immediately after the procedure or use a scribe, battlefield medics are often working in a mass casualty scenario in the dark of night in the middle of a firefight,” Kotwal explains. “Sometimes prehospital care does not get recorded properly—or at all—and that has left us with a hole in the data.”

Kotwal points out that this isn’t just an accuracy issue, it’s also crucial to ensuring the wounded get proper care when they reach trauma facilities. “Medical providers need to know what’s already been done, what interventions and how much blood products, antibiotics, or pain meds they’ve already received,” he added. Kotwal says he’d like to see the military mandate accurate and timely recording of battlefield trauma care to improve not only data collection, but trauma outcomes.

Recently the Department of Defense has developed new prehospital documentation tools to address this issue. Service members have begun training to use these new tools, developed by the Joint Trauma System, to improve data collection. While there is currently no mandate that service members use these tools, Kotwal is hopeful they will improve care and future research efforts.

— Leslie Waghorn