An internet response to question about the origins of the "Golden Hour" from June 3, 2006, by one of the EMS Legends who was THERE...  kpr

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I" have answered this question a couple of times over the years........and don't mind doing it again.

The Golden Hour was based on the concept that the sooner you got a seriously injured patient to a facility (THAT COULD TAKE CARE OF THEM) the better the chances of survival and better outcome. Looking back at war experiences over the years it was easy to see that things had improved.......some from medicines that were not available earlier, and obviously some from the rapid intervention from medical folks. As the time shortened the mortality declined.............that didn't take a statistician to figure out.........it just took common sense. Many people knew it..........

R.Adams Cowley did something with the information. He couldn't build his own hospital to prove his point so he set up a system in a large state hospital, the University of Maryland, where he did research on the dying patients from the rest of the hospital. He was a dumping ground for those that other doctors felt that were doomed to die. So rather than keep them on their floors or in their service they transferred them to Dr. Cowley’s 2 bed unit. The death rate on the floors improved :>)

It is a fact that the original area was called the Death Lab by hospital staff. It was sort of an organization of unorthodox outcasts in the eyes of traditionalists. We loved it and showing his distain for being confused with other hospital staff due to the wearing of the green or blue scrubs, RA chose pink. That’s where the color came from.   He wanted us to be different and stand out.

His idea was to study the act of dying and thusly see what interventions made a difference. Rather than just sit and watch they tried different things.........and some of them worked. Patients that others had given up on began to survive.............protocols were developed......the military medical folks were very interested in his activities and became a part of his studies. That also brought some equipment and funding grants with it. The hospital was getting upset with the attention that he was getting. It was a constant battle with bureaucracy in the large hospital that wanted control of everything one night they even refused to let the trauma Docs use any of the OR's. That’s how shitty it got.

As luck would have it ( bad luck for the individual, but wonderful luck for the future of Trauma Care) a close political friend of then Governor Marvin Mandell, was seriously hurt in an accident.   The Gov called R.A. who said “fly him here”.   The patient wrote on a piece of paper something to the effect of "Do all you can, I want to live", and that note was reportedly kept by the Governor.

Shortly thereafter the Governor, by executive action, went over the heads of the people trying to control R.A. and declared the Shock Trauma unit basically independent. R.A. and the Governor were in close contact frequently and as the trauma center and its concept grew it became not only the Clinical Center but the heart of the State EMS program.  

The agency that was previously in charge of EMT training, the Maryland State Health Department of EMS, was put under the control of the newly named "Cowleyville" (that was our inside name for our building a network). The funding for the only regional EMS Communication in existence at that time was put under him as well, and we had the nucleus of the Current Statewide Communications for EMS. R.A. had the reina and it just got bigger and better as time went on.

One of the clearest things first noted was that by assembling a core group of nurses, MD’s of various disciplines, and support staff the Center for the Study of Trauma (our first name) didn't treat the patient after the fact as most other hospitals did.   Other hospitals would call in Ortho after the X-rays had been taken and the radiologist on call came in and read them. Then the Ortho guy would say lets go to the OR and then look for one that was open.   Next, they would call and assemble a staff, then get the anesthesiologist to come in.  

Let’s just say the standard practice was to build the team after the fact......while the patient went into shock, bled out internally or just stopped breathing and beating. That was state of the art medicine in the 60's in most places........and still is in many places today.

On the other hand, R.A. had a team that was already in-house, and they stayed with the patient from the time they hit the door till the time they went to the OR, or the recovery room ......the same team basically stayed with the patient. There wasn't the pass off of care....they didn't do the surgery and then leave an intern to look after the patient with directions to "Call me if he gets worse........I'll be on my pager".   The care and caregivers were there on staff, doing something else until the patient arrived.   The staff worked together doing just about everything,   but they were already present if needed. "The patients needs dictate his treatment" was a common remark made to new staff, as a way to let them know where the focus was placed in the Shock Trauma Unit (our next name).
 
“The Golden Hour” was chosen as a realistic time frame because it had a ring to it. (It could have been the Golden 47 minutes, but that wouldn't have been catchy.) Looking at the time that was wasted in other facilities getting their staff and plan of treatment together, and knowing that we could air lift in patients with the fledgling MSP (Maryland State Police) program within the hour also helped coin the phrase.

As patients were brought to local facilities and waited to be treated, it was later planned to educate the ER nurses and the MD's they 'Advised" in the local areas.   A group of Nurse Coordinators was developed at the Trauma Center who then offered workshops in many advanced (for that time) nursing skills and the local nurses were asked to spend some time at the trauma center watching and working alongside the staff.   Seeing was believing, and the nurses in the local hospitals started suggesting to the other local MD's that the seriously injured patient might have a better chance if they were immediately transferred to the U of MD Trauma Center.

So, we began to get a trickle of patients.   There was concern when hospitals saw money being sent away from their facilities, so the response instead was to develop an evaluation of the resources of hospitals services. Some, of course, thought they could do what was needed and had the staff and facilities available in the appropriate period of time. Some tried, succeeded, and became regional centers.   Others just couldn't afford it and decided that they would be good community hospitals. This became referred to as the “Echelons of Care” and “Trauma Center” designations.

Dr. David Boyd had the grant monies to give to good facilities, thus another stroke of luck for better care took place. Dr. Boyd knew and worked closely with Dr. Cowley. I am sure that Dr. Boyd's and Dr. Cowleys’ successes were due to their collective ability to make visions come true and provide examples of progress that were easily verifiable. Care was measurably better. They were on a roll.....WE were on a roll and the concept was emulated in other places as well.

I am one of the luckiest guys in the world to have been able to know Dr. Cowley and work with him for so many years. From a young ambulance attendant that started on the street with a 16 hour Red Cross First Aid card, to the positions and places I have been, the opportunities and the abilities to see what EMS has progressed to has been a dream nobody could have ever thought of years ago.

My accomplishments are not just mine - they are ours, all of EMS’s accomplishments.   I know there were many others that were living a dream just like me in other areas of the country and world. Many of them I know, and far too many of them have passed on.  EMS History was being written, and it still is, and there are the others out there that are writing it today.......but they have an advantage.   They have a history to look back on.....and us old farts lived it.

 Lou Jordan    June 3, 2006