It's About Time By Neal E. Flomenbaum, MD, Editor-in-Chief

In this issue of EMERGENCY MEDICINE, Michael Stern, MD, inaugurates a new series entitled “Case Studies in Geriatric Emergencies.” A key question raised by this first case is whether the signs and symptoms that emergency physicians depend on to diagnose significant injury are reliable in the elderly. Or do we require a different set of parameters to identify and treat geriatric trauma? In other words, is the “golden hour” applicable to the "golden years”?

The golden hour was first described by R. Adams Cowley, MD, as the maximum time allowable to get trauma patients to the operating room in order to optimize their chances of survival. Ironically, as this concept has undergone more rigorous scrutiny, it has been found somewhat lacking in defining a precise relationship with survival. It now appears that there is no clear cut-off time for trauma as there is for interventions with acute coronary syndromes, myocardial infarctions, and thrombotic strokes.

Until more precise time frames are established, it will be difficult if not impossible to determine how much shorter the interval may be for an elderly trauma victim. (However, now may be an excellent time to more precisely determine the window of opportunity for cardiac and cardiovascular interventions in the elderly.)

The dual issues of reliable diagnostic findings and appropriate treatment for the elderly occur repeatedly with every type of geriatric emergency. These considerations, in turn, raise the question of whether the time has come for our specialty to embrace a new area of concentration in geriatric emergency medicine.

Census data on the aging population and CDC data on the increasing percentage of emergency department visits by the elderly present strong arguments for anticipating the needs of this growing segment of the population. For those who question the rationale for devoting scarce health care resources to prolonging the lives of “a bunch of nursing home patients,” consider several newspaper articles that appeared just last month.

On December 16, 2006, The New York Times reported that “within 25 years or so elderly New Yorkers [over age 65] will outnumber school-age children for the first time.” The next day the Times noted that the U.S. Senate that had adjourned earlier in the month was the oldest ever, on average, and the one that would take office in January would break that record with an average age of 62. The oldest senator is now 89 years old, and both of Hawaii’s senators are 82.

When former President Gerald Ford died at the age of 93 less than two weeks later, several newspapers published his insightful observations on United States policy from interviews conducted when Mr. Ford was in his 90s.

There are, of course, other issues for emergency medicine to consider before it embraces yet another subspecialty. For example, would doing so further separate a large and important group of patients from the practice of the average emergency physician? Consider pediatric emergency medicine in this regard. Or would advanced expertise in managing geriatric emergencies help emergency physicians realize their full professional potential? Consider the current situation with respect to the inadmissibility of emergency medicine residency-trained critical care fellows to the critical care certifying exam.

The golden hour may not be what it used to be and the golden years for most people never were, but there may nevertheless be a “golden opportunity” for emergency medicine to begin dealing with these increasingly important issues now and avoid wasting time and energy trying to make up for lost time later.

Emerg Med 39(01):7, 2007