The golden hour evolved over more than a decade of conflict, but only recently has the concept been verified through a long-term study conducted by the United States Army Institute of Surgical Research, Uniformed Services University of the Health Sciences, Texas A&M Health Science Center College of Medicine and the Center for Translational Injury Research at The University of Texas Medical School at Houston. The study found that over the course of the conflict in Afghanistan, median transport time of traumatically injured patients improved from 90 to 43 minutes. The study also found that, because of this dedication to rapid transport, the fatality rate for traumatically injured troops went from 13.7 percent to 7.6 percent.

According to Brig. Gen. Kory Cornum, Air Mobility Command Surgeon of the Air Force and an orthopedic surgeon, the golden hour rules is one of a number of tools and medical practices developed during combat that have proven useful in and out of the war zone, throughout history.

During World War II, according to an analysis done by Dr. Kendall McNabney in 1981, it took roughly 10 hours to transport an injured soldier to definitive treatment. With each war, the time decreased.

McNabney credited use of helicopters as ambulances as well as better blood programs, staffing, facilities and organizational structure as factors contributing to the survival of injured troops in Vietnam.

According to the University of Maryland Medical Center, R. Adams Cowley was the first to popularize the term “golden hour.”

During the Vietnam War, the Army sponsored Cowley to study shock trauma in patients. Through his study, the idea of the golden hour became a theme in successfully treating trauma patients.

The Medical Center quoted Cowley as saying, “There is a golden hour between life and death. If you are critically injured you have less than 60 minutes to survive. You might not die right then; it may be three days or two weeks later — but something has happened in your body that is irreparable.”

According to Cornum, tourniquets and blood therapy are two other tools that started with the military but moved to civilian medicine.

According to Cornum, massive bleeding – known as hemorrhage – kills most people with traumatic injuries. However, tourniquets – used to limit blood flow to an injured and bleeding limb, for example – were not routinely used in civilian or military trauma centers until about two decades ago.

“Twenty-five years ago, we all were taught – in Girls Scouts and Boys Scouts and in first aid training in the military and you name it — that a tourniquet was only to be used as a last resort,” Cornum said.

Tourniquets were a last resort when medical transport was less efficient because applying a tourniquet for a long period means no blood, and with it oxygen, is being delivered to tissues below the tourniqut. This eventually kills all tissue below where it is applied; in the past, amputations were the result.

“Now everybody in their combat lifesaving kit…  there’s a couple of tourniquets in there,” Cornum said.

Even in 2008 the number of competed contracts for Air Force services was less than those of either the Navy or Army and has only fallen since.

The CSIS researchers suggested that policymakers determine whether the decline is caused by issues inside the Air Force or external forces.

“Given the strong emphasis on promoting effective competition in DOD contracting from DOD and congressional policymakers, as well as prominent officials within the Air Force, the real decline in competition for Air Force services contracts calls for increased attention and scrutiny,” the report said, calling it a “possible warning sign.”

The study used data from the Federal Procurement Data System to analyze why the Air Force continues losing ground in competition for contracts in this “period of significant policy focus on services acquisition.” Several compelling possible explanations for this fell short of explaining the situation. The study found that “shifts in the mix of services within the Air Force’s services contracting portfolio are not the primary driver of the decline in effective competition” and also that the Air Force’s enforcement of DOD plans to reduce obligations for service contracts did not explain the low numbers.

Of particular interest was an analysis of individual service categories within the Air Force’s portfolio of services. Of the various service categories, rates of effective competition for contracts management support services and equipment-related services declined the most sharply. The remaining categories, facilities-related services and construction, information and communications technology services and medical services were less affected.

Contracts management and equipment-related services are the two biggest service categories for the Air Force. Though tempting to assume that sharp declines in number of competed contracts in the largest categories could be indicative of infrastructural viability, the study found this not to be the case. Data actually showed increases in contract obligations awarded without effective competition for both of those types of services. The report considered category specific reasons that could contribute to this trend and found them insufficient as explanations. “Particularly for [equipment-related services], most maintenance and repair for major aircraft platforms and systems will end up being performed by the original developer/manufacturer, for reasons including ownership of technical data rights. With that said, even accounting for the limitation on competition for some services related to aircraft, the low and declining rate of effective competition for Air Force services is noteworthy,” the report stated. The Air Force spokesperson did not return requests for a comment.