Turning the tide on ‘Golden Hour’ Care

Time management is the key to reduce mortality in trauma patients. As per the annual report on ‘Road Accidents in India-2022’ published by the Ministry of Road Transport and Highways, a total of 461,312 road accidents have been reported by the States and Union Territories during the calendar year 2022, which claimed 168,491 lives and caused injuries to 443,366 persons. These numbers are steadily rising year on year.

The golden hour concept in emergency care refers to critically injured patients receiving definitive care within a time frame of one hour from the occurrence of injuries, after which mortality rate significantly rises. Dr Amit Gupta, Professor of Trauma Surgery and Critical Care at the All India Institute of Medical Sciences, New Delhi, was a speaker at the technical session on Challenges in Road Safety, held on Day 1 of Smart Mobility Conference 2024.

What are the most common challenges faced during the golden hour in traffic-related emergencies?

Traffic related emergencies in India have become a public health problem because they often result in injuries, and many of these injuries are serious in nature. The first challenge we face after an accident has occurred on the road is the access to first aid and/or ambulance services. The pre-hospital care in our country is still in its infancy. It is developed probably in bigger cities, but in the rural and semi-urban areas, the ambulance services are either unavailable or are underdeveloped. The second challenge is that access number for the ambulance services is not universal. In cities, it might be 108 for ambulance services but on the highways, there are multiple numbers provided by the various concessionaires and therefore it becomes difficult for anybody to contact the ambulance services. Ferrying accident victims to hospitals in time is a major hurdle as the pre-hospital care ambulances may not be well-equipped along with trained manpower.

Within the hospital, during the golden hour, there may be a lack of well-trained nurses, paramedics and doctors to efficiently take care of patients posing the third significant challenge. Training manpower in trauma care is a constant struggle.

How do you think the time of day or the weather conditions impact road accidents?

Most of the road traffic accident injuries are occurring after sundown and during late nights. There are issues with lighting and the weather conditions. Whenever it is overcast, visibility is low, which leads to an increase in road traffic accidents and injuries. We have noticed that many accidents after sundown are caused by driver drowsiness or intoxication. Strict enforcement during the evening and night hours would prove to be fruitful in reducing these emergencies.

What role do you think technology and data play in improving outcomes during the golden hour following traffic accidents?

I think the main issue is data. Including the data supplied by the police- the absolute data of mortality and the data available in the hospitals. How many patients have been brought to the hospital, what kind of injuries they presented, were they treated in the right manner during the golden hour and which are the hospitals they visited? All this data capture is essential, and therefore India needs to have what is known as a trauma registry.

The use of technology in terms of artificial intelligence can be helpful. I can foresee a future in which the roadside cameras, or the highway cameras can capture an accident and automatically report that accident to a nearby hospital or to the ambulance workers directly without any human interface. This would reduce the time of pre-hospital care and improve the outcomes for the trauma patients.

Are there specific protocols or guidelines that are effective during response to trauma care emergencies?

There are multiple policies and medical protocols. One of them is called Pre-hospital Care Protocol, or Pre-hospital Trauma Life Support Protocol. Then there are other protocols within the hospital. For example, triage protocols that offer a way to categorize the patients according to their need. In our own trauma centres, we have got a triage protocol which categorizes the patient into red, yellow and green, depending upon their severity of injury. There are treatment protocols within the emergency room such as Advanced Trauma Life Support (ATLS) protocol. With the help of such protocols, we can reduce the number of minutes taken to resuscitate a patient, and significantly lower the mortality and morbidity rates.

What kind of advancements and resources do you believe are necessary for first responders of traffic-related accident patients or victims?

It is critical to have good infrastructure of pre-hospital care which includes robust ambulances and communication systems from the ambulances to the hospital. Pre-hospital notification is crucial, and the hospital needs to know within a few minutes, how many patients are coming in, and within what time frame these patients will arrive at the hospital. Furthermore, within the hospital itself, the technology must be updated in India to reduce the time by providing necessary feedback to the doctor on whether his/her actions in the emergency room is right or futile.

Herein lies a multitude of pressing issues in the emergency care which need to be addressed to improve timely treatment of injured patients.

How does public awareness and education help?

Public education underscores twofold effects. The first is injury prevention, which educates the public of various aspects including the need to adhere to traffic rules, wear helmets, and avoid drink and drive. Such education will travel a long way in changing the behaviour of drivers and road users for accidents not to occur in the first place. The second is even if accidents do occur causing injuries, it is essential to train bystanders, or lay people in first aid and how to handle trauma victims, so when they encounter any accident victim on the road, they are already well-equipped with basic knowledge to take care of him/her, call the ambulance quickly, and do the needful to stop bleeding, or at least supply oxygen to the patient till the time the ambulance arrives and safely transports the patient.

Could you share one case that highlights effective timely intervention?

We at the AIIMS Trauma Centre, train police and people in basic first aid. In one such case for a patient lying on the road, the first call was made to the police dialling 100. The first responders on the scene were the police personnel. The police constable was trained in first aid and despite the fact that the victim was in cardiac arrest, he revived the patient on site, quickly transported the patient to the hospital and we were successfully able to save the patient in time. This demonstrates the power of bystander training, or a lay person training, which is highly significant during the first hour, or golden hour of saving injured patients.

Looking at the future, what are the exciting innovations aiding emergency care during the golden hour?

Utilization of artificial intelligence to detect the accident and inform the pre-hospital care workers is underway in the developed world. We should adopt the same in India. Another innovation is a computer generated decision making algorithm wherein the duty doctor is informed about the line of action for these patients. Apart from technological innovations, there are surgical innovations coming along thick and fast, like robotics and laparoscopic surgery that change the way we treat a trauma patient.