Once again I find myself taking a post length comment to an article on someone else’s blog and turning it into a post here.
Brooks Walsh over at Mill Hill Ave Command posted a new article called Gender, EMS, and STEMI – a new study
The indicated that women have longer on scene times then men when they are having a STEMI. The study drew no conclusions as to why, but Brooks brings up some good points. You should read his article, if not the original study.
I’ll add one more possible reason to his list. Women, especially elderly women, are often harder to get IVs in then men. Which would easily add another minute or two to the on scene time if you, as if sometimes the case, you need to do the IV before moving the patient.
Over the summer and fall I did a lot of reading on the subject of Women and MI. What I found is that this is well documented in the in hospital treatment setting. Not just in the US, but in many western nations.
The root of the problem is that many women do not present with what we have been taught over the years is “typical” chest pain. Women themselves, under appreciate the symptoms as they too have been taught “the classic” symptoms. Which were developed around the “typical” male, in his mid to late 50s.
Since women perceive pain differently and often don’t have “chest pain” per se, they don’t paint the picture that most of us have come to expect.
Did I mention that women tend to have NSTEMIs more than men?
Women also to have their first cardiac events at an older age than men. Sadly, their outcomes are often worse.
So, a lot of women with MIs get missed in the field, in the EDs, and in the units.
All of which is to say that the researchers are looking at the wrong things. The issue shouldn’t be why we have longer scene times, but are we as suspicious of ACS in women as we are in men. From my experience the answer is no and the studies on the subject suport that.
What to do?
Start by teaching that not all ACS events have chest pain and change protocols to reflect that.
I know of many cases where smarmy doctors condescendingly told paramedics that they shouldn’t have to given NTG because the patient didn’t have chest pain. Apparently the term “Anginal Equivalents” never came up at the mail order medical schools some EM physicians seem to have gone to. I guess they never covered that at the prestigious “Close Cover Before Striking” Medical School and Barbershop.
If you’re not looking for it, you’re not going to see it. If you’ve been told since about day seven of EMT school that all MI patients have substernal chest pain with radiation to the arm and jaw, you aren’t going to be looking for Acute Cardiac Syndrome symptoms in a 70 year old lady who tells you she just gets tired easily and wonders if she’s anemic.
Not that I’m advocating putting the monitor on every little old lady that calls for an ambulance. What I am advocating is listening to the story the lady tells you and pay heed to things like “I get tired climbing stairs”, “I got sweaty and started to throw up”, and my favorite “I just don’t have any energy to do the things I used to do”.
Any of those should make your spidey sense tell you that there might be more to the story than you initially.
Oh and one more clinical pearl before I shuffle off for a long winter’s nap.
If the lady has shortness of breath, but has never smoked, has never had Asthma or COPD, and isn’t on any medications for respiratory ailments, it’s unlikely that she suddenly developed Asthma as 0300 in the morning.
Think cardiac.
tooldtowork -
Thanks for the comments. Hope you don’t mind the “mini-post” over here!
This is a real interesting area, with a number of twists, but you emphasize the important point – EMS (and EM, and primary care…) needs to maintain a high level of suspicion for ACS in female patients, and indeed in ALL patients.
I have a slightly different take on the literature regarding how women vs men present with ACS. While the studies are of variable quality, in general they seem to indicate that a somewhat higher proportion of women deny any chest pain/discomfort with their initial presentation. Perhaps 37% of women present without chest pain, versus 27% of men, according to one summary by John Canto.** Importantly, this doesn’t take into account age, diabetes, or a variety of other complicating factors, but let’s just accept those numbers for the time being.
One way to look at those numbers, 27% versus 27%, is to say women don’t present “classically.” Another way to look at it is that the difference between men & women is less significant than the fact that a huge percentage of BOTH genders may present without “classic” symptoms.
Rather than emphasizing the 10% difference between men & women, perhaps we should be emphasizing the 27%-37% of patients we are missing by focusing solely on “chest pain.” Like you said “Start by teaching that not all ACS events have chest pain and change protocols to reflect that. ”
Frankly, I think it’s far more likely that we ignore some patients’ description of their symptoms (based on age, gender, language, etc.), than that women have a radically different physiology.
Brooks
**(http://www.femalepatient.com/Article.aspx?ArticleId=WQeGBqVYGUw=&FullText=1)
I agree. The literature that I’ve read contains a wide variation in the percentage of women that don’t experience chest pain, but no matter what you read, it’s significant. That women tend to be older than men, and thus have co morbid factors such as Diabetes and Hypertension just makes the picture all that much murkier. I’ve run into many patients whose presenting complaint was dsypnea and CHF. No chest pain at all.
You last line is telling. I think we all tend to, for any number of reasons, try to fit patients into boxes. Chest pain goes into the ACS box, no chest pain tends to go into some other box.
I blame the teaching. Doctors are taught the wrong things in medical school, and when they become medical directors or attending physicians, they teach residents and paramedics the wrong things.
We need to radically rethink how we teach people about ACS.
Cast a second vote for the teaching. For whatever reason, most EMS programs stress a ‘step 1, step 2, step 3′ approach to everything. Even so called ‘progressive’ training classes I have attended tend to try to make everything fit into specific boxes, as you put it.
I guess I was fortunate in that one of my paramedic teachers way back when highlighted how females have different presentations than males, and may not present with anything other than the s/s you speak of or just “I don’t feel well”.
As to scene time differences, I can only think back to my own anectdotal experiences, and recall that often, women typically downplay everything and take a bit more coaxing to actually go to an ED- they are worried about everyone else.
Even the one recently with a sudden onset of light headedness, pallor, diaphoresis, and what turned out to be a HR of 30 with wide complexes (we had to practically beg her to allow us an ECG, the 12-lead was even more coaxing), and a BP of 80/40. Twenty-four minute scene time, and eighteen between arrival and initiation of ECG. There was a bit of ‘splainin’ to do. But that is the way it is sometimes.
I came across an article that, if I remember correctly, found 33% of MI patients in a large registry did not have chest pain as a chief complaint, and this group was more likely to be female, black, and diabetic. This group took longer to be reperfused and their mortality rate was twice as high.
So my question is, how do these patients get paramedics in a tiered response system? Should one paramedic be sent on everything? Should EMT’s do ECG’s?
In my system, there is a fairly broad definition of cardiac symptoms, including dyspnea, tachycardia, syncope, and other non traditional symptoms. Partially that’s by design and partially it’s because of how the call takers process information. As a result we see a lot of patients and do a lot of 12 lead ECGs on patients that don’t really have cardiac symptoms. Sometimes we catch an atypical presentation. Telephone triage is incredibly imprecise, despite what it’s proponents will tell you. It’s very sensitive, but not very specific. So, you’re left with a decision to make as a system manager. Do you want to send paramedics to every call and end up with paramedics that do mostly BLS calls and don’t see many really sick patients? Or do you want a smaller cadre of well trained and experienced paramedics who see a higher percentage of sick patients and can handle them?
A lot of that will depend on the system design, the geography of the response area, the number of hospitals, and too many other variables to really identify.