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Respecting the ‘Golden Hour

Dr. R. Adams Cowley coined the “Golden Hour” in the mid-1960s, and it refers to the concept that a critical trauma patient needs to be transported to a qualified trauma team within 60 minutes of injury or risk death from shock or its complications (Roy R. Banks, D.O., “Triangle of Death,” May 2002, JEMS).

Today, most would agree the critically injured will benefit more from early care intervention than not. This is a significant concern in rural settings where hospitals serve a larger area. With this in mind, how are we doing here in Canada? Are we getting our critically ill to a hospital inside the Golden Hour? The answer is, well, sometimes.

It takes quite a team to make this happen: paramedics, hospitals, health authorities, doctors and nurses, Transport Canada. I may have caught you by surprise here, but TC does have a role in ensuring critically ill patients arrive at a hospital in time to save their lives.

TC is the regulator that oversees heliport certification. Heliports must meet certain standards in order to be able to accept helicopter traffic. Heliport operators themselves have to satisfy TC that the heliport conforms to those standards. This is not new, and there’s no need to go into detail here. In fact, Blair Watson chronicled this very well in the Jan/Feb 2008 issue of Helicopters.

Heliport operators (hospitals, or perhaps more appropriately, regional health-care authorities) use TC standards when designing a heliport. They stick to these standards where they should, use the proper lighting, put up a windsock to attract helicopters. They do all that is required in the regulations. TC comes out, has a look, and classifies (non-instrument heliports) as H1, H2, or H3 depending on certain criteria relating to performance capabilities of the servicing helicopters.

The problem is once this happens, operators may believe they can receive any helicopter transporting a patient. But this is not the case. An H1 classification means the heliport can only be served by multi-engine helicopters capable of maintaining at least 4.5 metres (15 feet) above obstacles, in a “defined” area, with one engine inoperative. H2 classification is limited to multi-engine helicopters, while H3, oversimplified, means no obstacles in the “defined” area.

So, why is this so important? The question is, how many suitable patient-carrying helicopters are out there today that can meet H1 classification standards? The answer? Not many.

This is not simply a one-dimensional, helicopter performance issue. Some heliports were originally built to a H2 or H3 standard, only to have trees or new buildings intrude into the defined area. This came to light recently in British Columbia when a couple of hospital heliports were classified H1, and could no longer accept some helicopters the government had contracted medical services for. The result is some critically injured patients are being transported by helicopter or fixed-wing to an airport, then ground transported to or from the hospital — clearly falling outside the Golden Hour.

This caught the attention of the Truck Loggers Association (TLA), the official voice of independent forest contractors in B.C.’s coastal region. Don Bendickson, current past president of the TLA and a logging contractor out of Campbell River, is quite concerned. “We do not want to see a situation where regulations increase the time it would take for an injured logger to get treatment at a hospital,” he said. “Closing a hospital helipad to all but multi-engine helicopters would do just that.”

Michael Essery, Director, Airevac/Critical Care Transport Program for the British Columbia Ambulance Service, agrees. “We use helicopters to provide scene call response, and to transport critically unstable patients,” he said. “It will not help a patient if we have to drive 1/2 hour to an airport rather than transport them directly to the hospital. The situation is not ideal, but we are still safe, and feel we have always been safe.”

Given the new classification standards for heliports, it presents an interesting argument: are we doing all we can to assist the critically ill? I’m not so sure. Are we placing that group at risk to make another, the general public, safer? And is this not the same group? Maybe it’s time to get all members of the “team” together to work out the issues arising from heliport classification and how it affects the critical Golden Hour.

Neil MacDonald is a lawyer with Harper Grey LLP, practising in aviation law. He holds an ATPL-H, and flies as an air ambulance captain on helicopters in B.C.nmacdonald@harpergrey.com. This is not a legal opinion. Readers should not act on the basis of this article without first consulting a lawyer for analysis and advice on a specific matter.