The US military has been developing and evolving models to improve combat casualty care since the Civil War. However, over the past quarter century, military medicine dramatically improved combat survival by organizing care into a coordinated echelon system, where every role was clearly defined, rapid frontline response was prioritized, and clinical information moved quickly across a unified network.
Goldie applies that same “Golden Hour” logic to the opioid crisis by giving hospitals, peers, providers, community organizations, and civic agencies a secure, compliant platform to coordinate referrals, communicate in real time, close feedback loops, and operate as one synchronized system of health for people ready to pursue recovery.
This will take a little explanation, so bear with me.
And we will get to Goldie.
During the last Gulf War, the US Military Medical System exercised a tiered model of care that resulted in the lowest combat casualty fatality rate in history, despite the increased lethality of the wounds inflicted. In World War II, 30% of combat wounded U.S. soldiers died from their wounds. In Vietnam it was 24%. But in Iraq and Afghanistan (2001-2014), only 10% of those wounded succumbed. Ninety percent of combat wounded service members survived.
Much can be said about the improvements in personal protective equipment (e.g. Kevlar helmets, body army, ballistic glasses). But the biggest difference was the system.
During my military career, tiered levels of care (“Roles” or “Echelons of Care”) were clearly defined in the military medical system as were the standards for the definitive care delivered at each level, (table 1). I was assigned (part time) to a Medical Company of the 25th Infantry Division (Echelon II) and trained with them for six years in the 90’s before 9/11. Later, I deployed with the 8th Army Medical Brigade, responsible for care delivery in Operation Iraqi Freedom’s (OIF) Southern Theater, including Kuwait, Qatar as well as Afghanistan, (2004).
In our 8th Brigade footprint, we had an Air Force mobile behavioral health team and a Navy/Marine medical company (Echelon II), an Army preventive medicine team and a Navy hospital that included surgical capability (Echelon III). They all remained under the administrative control of their sending units and services, but they were operationally assigned to our Medical Brigade. We were one team under a single operational commander.
But even more importantly, the larger military combat care system “learned” through the course of that war, placing increasing stress on Dr. R. Adams Cowley’s “Golden Hour,” where life-saving care was delivered at or very close to the point of injury (e.g. tourniquets, blood transfusions) and prehospital transport to a higher level of care occurred ideally within 60 minutes of injury. The trauma mortality rate decreased rapidly through the first years of the conflict, and these ground-level (Echelon I and II) capabilities were associated with 44% of the decrease in mortality.
When I was the Chief Medical Officer at Walter Reed Army Medical Center (Echelon V, 2005-2008), stabilization and transport was so efficient that it was not unusual for a soldier to arrive at the medical center within 36-72 hours of being wounded. Biweekly video multi-disciplinary rounds were hosted by Walter Reed and included all the treatment/rehabilitation facilities in the US, the Echelon IV hospital in Germany and the combat hospitals in the theater of war. This patient care network has continued, and although a decade has passed since I retired from military service, I am confident that the system has continued to learn and evolve.
Several things are key to the system’s ongoing success. Emphasis remains on the front-line combat lifesavers. Every component of the system understands its role and place in the organizational hierarchy. Every component sees itself as a part of a system dedicated to the survival and recovery of the wounded, ill and injured service members. They are all aligned under a single command structure. And every component can communicate with the other components in the system, passing on clinical information, detecting and sharing critical data and lessons learned in near real time.
Fast forward to America 2026, where the opioid “syndemic” has raged for more than a quarter century at the cost of more than a million lives, to say nothing of lives disrupted and shortened for the more than six million adults and adolescents still suffering from opioid use disorder. Our city is like most American urban areas, with hundreds of focused, dedicated professionals and organizations, individually and collectively determined to decrease overdose deaths. While we recognize that the number of deaths is declining, any single death is one death too many.
Two years ago, our mayor established a cabinet level director and office to coordinate and synchronize the city’s efforts to improve outcomes for individuals with opioid use disorder and to decrease deaths from overdose. In collaboration across the city, the office is working to understand every organization’s role in the system and create a means to better integrate and coordinate care. I am increasingly convinced that borrowing from the military’s “echelons of care” model could be helpful.
It is paramount for us to begin to see ourselves as a single, synchronized “system of health” for this population of individuals, ideally with a centralized operational coordinating authority. Because of their addiction, the trauma that led to the addiction, the subsequent associated trauma, and their health-related social needs, these patients often fall through the cracks of the traditional health care models, unfortunately represented by a collection of dedicated but disparate “health systems.” This future system of health could mirror the military’s casualty care system. In many ways, the five echelons of care already exist, (table 2).
But we need a better way to efficiently communicate and exchange data.
Enter Goldie.
Goldie is a HIPAA and 42 CFR compliant platform that allows professionals across our city to enter patient information (after signed consent), to refer the patient to service providers, to address recovery and health-related social needs as well as ongoing treatment of associated medical complications. It can be used by hospital emergency room social workers, peers and providers as well as those working in community-based organizations and civic agencies dedicated to addressing the needs of this patient population.
Goldie creates a care network which allows for data sharing between disparate organizations using a novel framework to protect privacy and security. The network supports coordination, continuity and alignment of a range of different organizations that previously operated largely independent of each other.
Most importantly, Goldie is a secure way to communicate by chat or phone to others in the network as well as the clients themselves. It includes embedded resource access and points of contact with referrals made within the app and a closed feedback loop with the service provider. It allows us to connect the different pieces into a single, “system of health” and perhaps begin to see the benefits of city-wide synchronization and coordination, (figure).
Goldie is just one example. It is the tech platform we are piloting in our city. There are others and I suspect that the capability will continue to evolve. The name of the platform comes from the idea of the “Golden Hour,” when a person is ready to commit to recovery and the system must make it possible within that hour: by removing or eliminating the barriers that stand in the person’s way.
This should be the goal of all our efforts.
As is often the case, technology facilitates a new way of seeing ourselves and operating as a collective care community rather than as competitors. These are the kinds of adaptations that will allow us to mimic the success of the US military medical system in saving and improving lives in our battle against opioid addiction and the conditions that lead to it.
As the US health systems struggle to become a synchronized, coordinated system of health, this may well be our own Golden Hour.
Chuck Callahan Henry V 4.3 – Lead from the Front https://henryv43.com/
“The views expressed by Dr. Callahan are his own, and do not reflect the official policy or position of the BCORE project leadership, (“Baltimore’s Comprehensive Overdose Response to End the Epidemic”), the University of Maryland School of Medicine, the University of Maryland, Baltimore, or the Baltimore City, Maryland or U.S. Governments.”
On a clear, breezy summer Saturday morning in the Sandtown-Winchester neighborhood of Baltimore,