April 24, 2019

The Golden Hour – The Problem, its Extent

Dear Visitors,

From today we would be publishing one Chapter of the Book The Golden Hour written by Dr. Arun Mohan (Advocate Supreme Court of India).

The book was published in 2014. The content is priceless. The Golden Hour throws light on:

  • Prevention,
  • Attention,
  • Compensation

Dr. Arun Mohan talks about Motor Accident Mediation Authority, an Institute that can look into the pending case and reduce burden on judiciary.

On behalf of Team NV, I thank Dr Arun Mohan for giving us permission to publish the content on our site.

Anil Kohli


The Golden Hour – The Problem, its extent.

T o p i c  9

The Golden Hour

  1. While every effort to prevent accidents and injury must be made, there is another equally important aspect which deserves consideration – immediate attention to the injured and Trauma Care at the earliest.
  1. To introduce the problem, of the 1,40,000 fatalities that occur in one year as statistics reveal, if proper attention – removal to hospital with trauma care – could be achieved within the first one hour, approximately 40,000 lives could be saved.
  1. Generally speaking, trauma can be defined as physical injury caused by events such as road accidents, workplace accidents, falls, explosions, burns, shootings, or stabbings. The expression ‘major trauma’ is used to describe multiple injuries involving different tissues and organ systems that are, or have the potential to be, life threatening.
  1. In an accident, not all die instantly; some may escape with minor injuries and some may get critically injured. Our focus here is on the latter. The critically injured, if not attended to immediately, may succumb to death for want of medical assistance. We read about it very often in the newspapers.
  1. Critical on this score is the time period – called the ‘Golden Hour’1 – or the first one hour in which prompt medical treatment may most likely prevent the fatality or other dire consequences of the injury.
  1. Major trauma requires immediate attention and treatment by experienced specialised personnel. A trauma centre is a special hospital facility


  1. Late Dr. R Adams Cowley is credited with promoting this concept, first in his capacity as a military surgeon and later as head of the University of Maryland Shock Trauma Center


The Golden Hour  Page 2

with the resources and medical specialists to handle the most severe injuries. It is staffed by a multi-disciplinary team of surgeons, X-ray

– CT-Scan specialists, physicians, anaesthetists, and specialist nurses.

A ‘hospital’ is very different from a ‘trauma centre’. The latter is a ‘hospital’ alright, but one staffed and equipped to provide comprehensive emergency medical services to the injured. Simply, what is expected to be available imme-diately at a trauma centre is very different from that at a regular hospital.

  1. Shortfall in the present availability and quality of trauma care apart, the more crucial aspect is the time gap between the accident and the victim being transported to the trauma centre and, after reaching there, given immediate medical attention of an adequate level, without having to wait for other formalities to be completed.
  1. The purpose of including this discussion as a separate topic is to high-light the importance, and more so in the context of the legal rules and formalities, as also administrative instructions, which, presently, far from facilitating, unintendedly stifle immediate transportation and proper medical attention.
  1. One is fully aware of the economic cost this provision will entail, but whatever resources are available, and feasible, should be expended on this cause as time is the essence in such cases of medical emergencies.

Saving of another’s life is probably one of the noblest actions that can be thought of and that alone can justify the cost incurred on the provision of emergency removal and trauma care. Saving of, say, 40,000 lives will mean, apart from saving on compensation, giving new lives to members of those many families whose bread earning members may be the ones so saved.

  1. The ‘right to life’, as enshrined in Article 21 of our Constitution, also entitles the injured to be given adequate transportation, and then medical attention, at the hands of the State in the Golden H
  1. Before we proceed further with the topic, a few words on the time periods or stages. Upon an accident resulting in a serious injury, it is:

.1 first 10 minutes – or the platinum 10 minutes – at the accident site, where medical aid is crucial to save the life;

.2 transportation to the trauma centre;

.3 (while transporting to the trauma centre) the next 50 minutes, preferably with onboard medical aid and reaching there within one hour of the accident;


The Golden Hour  Page 3

.4 (at the trauma centre) where the necessary medicare, including surgery, begins without delay in the first few hours;

.5 further attention till the patient can be removed from ICU;

.6 post-ICU care and post-recovery care at hospital in order to reduce the impairment / effects of the injury; and

.7 (after discharge from the trauma centre) back at home, recovery as also long term care to sustain.

It is ultimately at these seven time periods or stages that attention is required, but once again, until there is immediate removal (transportation) to a trauma centre, the injured may not survive to see the later stages.

  1. In order to facilitate reference in the later parts, it will also be apt to place a visual graphic of the timeline as below.


Golden Hour Dr. Arun Mohan 1


13. In order to be complete, this topic attends to all the stages, i.e., further delves into ‘attention’ beyond the Golden H There is no point in doing everything to transport an accident victim within the hour, if there are no proper or sufficient hospitals and / or trauma facilities available. It is for this reason this topic is structured the way it is, i.e., addressing trauma care first (sub-topics 5 & 6) and the transportation thereafter.

  1. The Problem, its extent

14. The first question is how many are actually able to reach the trauma centre in time. The second question is the kind of care they get when they do reach. By reason of deficiencies on this score, we lose 40,000 Moreover, a poor victim in our country is less likely to receive immediate medical attention, or he may even be refused the same.

15. Post-injury survival is greatly improved and impairment greatly reduced, if accident victims are attended to at a trauma centre where clinicians can maintain their skills by treating a sufficient number of trauma patients and have access to specialist resources and equipment.

4 The Golden Hour


  1. In Topic 6 (anatomy of an accident), an explanatory time chart has been given. A portion thereof is reiterated here to emphasise that injuries of Grade-3 to Grade-9 (Grade-10 is fatal on the spot) are where the need for trauma care and medical attention arises, and can make all the difference to the incidence of death, or the temporary or permanent degree of impairment.

Golden Hour Dr. Arun Mohan 2

  1. Approximately 3,00,000 injuries fall in this category, of which, may be, as stated earlier, 40,000 could be prevented from becoming fatal cases. For the remaining cases, immediate medical attention could substantially reduce the seriousness of the lasting injury.
  1. Trauma is ‘time sensitive’, and there is no time to waste. How early the victim is taken to the trauma centre and given medical help may determine his being dead or alive. Without an organised, time-based system of emergency medical care, it is easy to imagine how that Golden Hour could tick away to the detriment of the accident victim.
  1. Presently, at the site of impact, there is lack of awareness about the Emergency Medical Services (EMS), or simply, the importance of the Golden H Ambulance (transportation) facilities are lacking. Adequate numbers of ambulances are also not there and many of the ones in operation are inadequately equipped.
  1. Appropriate and sufficient trauma care services are not available within reasonable distances. Only sub-optimal quality care is provided at the existing facilities due to inadequately skilled manpower. Lack of standard operating procedures regarding the handling of a patient on his arrival at the trauma facility makes matters worse.
  1. There are also no standardised protocols and medical directives for EMS. At the same time, accountability and monitoring mechanisms are not in place to ensure timely and optimal care. There is absence of appropriate database for further evaluation and enhancement of the services being rendered. Post-trauma Rehabilitation Facilities for


The Golden Hour 5


the injured are deficient. Research into post-accident response and emergency care is also absent.

  1. Such being the ground reality, we cannot remain complacent. We have to find a solution and it is towards that as the goal, that this topic proceeds.

…to be continued (Next Topic – The Typical Public Response – and why ?)