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“Golden Hour” Policy Saved U.S. Lives in Afghanistan
By Patricia Kime, Staff Writer, Military Times
An Army flight medic and a helicopter crew chief help a Marine who was shot by a sniper as he is transported by a medevac helicopter in September 2010 near Marja, Afghanistan. Researchers say that more troops survived their battlefield wounds if they were transported within 60 minutes. (Photo by Scott Olson, Getty Images)
More U.S. troops survived life-threatening injuries in Afghanistan after Defense Secretary Robert Gates ordered evacuation helicopters to extract wounded personnel within 60 minutes, a period known in emergency medicine as the "golden hour."
In a study published Wednesday in JAMA Surgery, researchers found the number of wounded troops who died on the battlefield in Afghanistan dropped by more than 6 percentage points after the policy went into effect in 2009, while the case fatality rate — the proportion of total deaths among all wounded troops — declined as well.
According to the study, which reviewed the outcomes of 21,089 cases of battlefield wounds in Afghanistan from September 2001 to March 2014, 16 percent, or 386 of 2,411 severely injured troops, died on the battlefield before the mandate, while 9.9 percent, or 964 of 9,755 injured personnel, died afterward.
The case fatality rate also declined, from 13.7 before the mandate to 7.6 percent after.
Lead author and retired Army Col. Russ Kotwal said researchers initially examined the data to determine whether the services succeeded in adhering to Gates' mandate.
They found that the average air response time declined from 90 minutes to 43 minutes and the percentage of missions achieving pre-hospital helicopter transport within 60 minutes rose from nearly 25 percent to 75 percent.
Kotwal said that although the medical community generally agrees treating patients quickly after a severe trauma increases survival rates, there is little hard data to back up that presumption.
The study, a review of the data on Afghanistan in the Defense Department's Joint Trauma System "adds to the body of medical literature," he said.
"Time of transport certainly makes a difference. But so do treatment capabilities. It's not just the time getting to the hospital, it's about pushing out treatment capabilities."
The military medical community has been recognized for its advancements in increasing combat survivability in Iraq and Afghanistan over previous wars. According to the Army Institute of Surgical Research, the case fatality rate in World War II was 19.1; in Vietnam, 15.8; and in Iraq, 10.0.
Interestingly, the percentage of wounded troops who later died of their injuries beyond the "golden hour" remained relatively unchanged both before and after the mandate, roughly 4 percent of all wounded.
Kotwal said this was likely the result of a shift sparked by the policy change. Fewer wounded troops died on the battlefield as a result of their injuries, while some either survived, or at least survived beyond the battlefield long enough to later be counted as having died of their wounds. At the same time, after the mandate, some troops who previously would have died of their wounds survived.
Researchers estimated that the change in the policy likely means that 359 troops who would have died from their combat wounds prior to the policy change lived.
The "golden hour" is a term coined by Dr. R. Adams Cowley, a World War II Army veteran who developed the concept at Baltimore's Shock Trauma Center.
Cowley found that trauma patients receiving quality care sooner rather than later had a better chance of survival.
Kotwal credits faster response times as well as advancements in battlefield medicine for saving lives in Afghanistan and Iraq.
Improvements in blood replacement and transfusions immediately after injury and use of tourniquets — by medics, corpsmen or anyone responding to a casualty — contributed greatly to improving survival times, he said.
"It's been phenomenal," said Kotwal, who, as a 75th Ranger Regiment surgeon, led the effort in the late 1990s to train all regimental personnel in battlefield casualty care techniques. "It's all about performance achievement and equipment advances."
Developers of tactical combat casualty care techniques have pressed the Defense Department, the Defense Health Board and other research bodies to preserve lessons learned from the wars in Iraq and Afghanistan and maintain the skills acquired by medical personnel across 14 years of war.
Kotwal said there are challenges "going into the inter-war period in sustaining medical readiness."
"It's very important to have a trauma system in place," he said.
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This story was originally published on the Military Times website Sept.30. View the original article
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