The Golden Hour

There is a concept in health care known as the golden hour, one very familiar to many people outside the health care community thanks to the fact that it plays a prominent role in film, television, and other media. Strictly speaking, it doesn’t last for a chronological hour, but it refers to that critically important period, counted in minutes and sometimes hours, at the onset of an acute health emergency, when certain interventions do the most good. Medications for stroke that are most effective when provided immediately, for example, or rapid surgery to address a patient experiencing a severe cardiac event.

If patients don’t get care within this time period, depending on the situation, they could die. Or they could have a substantially worse outcome. A stroke patient who might have developed minor symptoms and needed some rehabilitation could have serious impairments making it difficult to walk, talk, eat, and perform tasks of daily living, requiring months of therapy and possibly the assistance of an aide, especially at first. A patient could have permanent cardiac damage because she didn’t get the medication or surgery or catheterisation or other treatments she needed fast enough.

That’s why people are encouraged to hasten to the emergency room when they have acute symptoms, and why emergency transport, like ambulances and helicopters, gets patients where they need to go, fast. In urban areas, people can be transported by first responders to EMS and into full-scale hospitals very, very quickly, allowing for rapid triage and interventions when they’re in accidents, experience sudden onset health problems, or just wake up one morning knowing that something is off. 

While many people in urban environments don’t have cars, which can make it a real challenge to get to care (public transit is not really the greatest option when you’re kind of in a hurry, and, for that matter, street traffic including cabs and cars can get snarled in traffic), what they do have is access to strong emergency transport systems. Call 911 and an ambulance will be there fast thanks to a web of first responders and hospitals in the area, and the patient will be moved quickly to an ER for treatment; transfers can also happen, and very quickly, if they need to. For example, a pediatric patient might go to the closest ER for emergency care, and then be moved to a pediatric facility as soon as possible once stabilized enough for transport to get specialized care.

Residents of rural areas, however, are not so fortunate. First there’s the calling of EMS, which has to route one of a likely limited number of ambulances or fire department rescue vehicles to the site. Many rural fire departments, as I’ve discussed before, also include paramedics on their staffs and provide basic medical response. Why? Because they know that it can take 30 minutes or more for the hospital’s ambulance or a private transport to arrive, and someone in the fire district having a medical emergency doesn’t have that long; in the time it takes for the ambulance to get there, the patient could easily die, and she’s definitely losing valuable golden hour time.

And then the transport back to the hospital, which can last another half hour or more; if a patient is in severe distress, the first responders may opt to have a helicopter sent out, but airlifting isn’t necessarily faster. The helicopter has to be dispatched, it has to find a place to land, and it has to be routed to the closest appropriate regional trauma center. Sometimes, patients are transported all the way to a rural base hospital, which usually has a helicopter pad, just to get them out to a hospital that can treat them.

It can take hours for a patient to reach a hospital that can provide meaningful interventions, as happened during my father’s heart attack in 2012, when his partner drove him to the emergency room, he went through a series of workups and tests, he was given some medical treatment, and then he was airlifted to Santa Rosa. He went into surgery over 12 hours after the first signs of his heart attack occurred, because it took that long to get through medical imaging, pull together a care team, and decide on the best course of action. (The fact that my father is a stubborn patient probably did not help.)

The fact is that even in rural areas where health services are very, very good (and this is few rural areas), people die because the golden hour just isn’t a feasible rule when services are so far apart. And rural areas are a place where serious health risks are a common fact of life, too; they’re the place where children are injured on farms, where loggers acquire serious occupational injuries, where car accidents twist and snarl vehicles by the side of the road. To live in a rural community is often to be surrounded by dangerous things, with the knowledge that EMS are further away than they are in rural areas, and they are less able to help you.

As rural life is increasingly romanticised, one thing I worry about is how the rush of people to rural communities to take part in an idealised lifestyle will strain already stretched services and resources. The golden hour is already kind of a joke when it takes an hour from the time of an incident to even get to the ER, if you’re lucky, and how much worse will it get when there are more people without a corresponding increase in services, because it takes time and energy to implement infrastructure changes, and many newcomers are resistant to playing an active role in the communities they barge into?