The Golden Hourglass By Neal E. Flomenbaum, MD, Editor-in-Chief

R Adams Cowley, MD, is widely credited with popularizing the concept that critically injured patients face a “golden hour” during which doctors can intervene to prevent irreversible shock-related processes that could ultimately prove fatal. Today, this concept may sound intuitive or simplistic and lacking in evidence-based precision, but in fact it represented a profound change in thinking about medical and surgical emergencies. And when it was first promulgated by Cowley in the early 1960s, it presaged the advent of emergency medicine as a specialty.

Consider everything required for the successful stabilization of a critically ill patient in just one hour: getting the patient from the scene to the emergency department, providing all necessary equipment and human resources on arrival, and ensuring that the patient is cared for by physicians and surgeons capable of operating both accurately and rapidly. In the late 1960s and early 1970s, there was nothing available to accomplish these necessary tasks—no organized EMS or medevac systems, no designated trauma centers, no properly trained physicians—only a shock and trauma wilderness, in which Cowley began his trailblazing work.

The specialty of emergency medicine is defined in large part by time limitations—a limited time to act, time-limited certification (one of the very first specialties to insist on this), and an hourglass as the symbol of the American Board of Emergency Medicine. Cowley was a talented cardiothoracic and trauma surgeon, but he was also one of the first “emergency physicians.” He used the idea of the golden hour to explain and popularize the need for both rapid systems and expert doctors to deal with trauma.

Later investigators who focused on smaller pieces of the deleterious and fatal effects of circulatory deprivation, such as acute coronary thrombosis and ischemic strokes, succeeded in more accurately defining windows of opportunity for intervention. But Cowley’s all-inclusive vision extended beyond pathophysiology—it also encompassed the belief that every critically ill or injured person had the “right to the best medical care, according to the state of the art and not according to location, severity of injury, or ability to pay,” as he once put it. Teamwork, too, was part of Cowley’s vision and included not just the physicians, surgeons, and nurses in the hospital, but also the EMTs and paramedics in the field, upon whom all subsequent success depended.

The current director and physician-in-chief at the University of Maryland’s R Adams Cowley Shock Trauma Center is Thomas M. Scalea, MD. I worked with Tom in Brooklyn in the late 1980s and 1990s when he was director of critical care and trauma at Kings County Hospital and then founding chair of the department of emergency medicine there and at State University of New York (Downstate) at Brooklyn. In 1997, Tom headed south to Baltimore as I headed north to Manhattan. When I think about those days I remember Tom’s New Year’s Day parties in Brooklyn Heights—almost always punctuated by Tom departing the scene like a shot out of a cannon to get to Kings County and operate to prevent a first-of-the-year homicide or motor vehicle fatality.

Tom is a talented investigator, a prolific writer, a dynamic educator, an excellent administrator, and one of the most skilled trauma surgeons operating today. Like Dr. Cowley, Tom has always believed in team efforts and in providing the best medical care to everyone. He is, and always has been, a friend of emergency medicine. In short, Tom is the embodiment of everything that R Adams Cowley stood for.

Tom will soon be joining the emergency medicine editorial board—and it is my pleasure to welcome him to our team.

Emerg Med 39(04):9, 2007