How can we get heart patients past the E.R. gatekeepers?

15 Nov

by Carolyn Thomas  @HeartSisters

Sometimes, people in my women’s heart health presentation audiences ask me if I’ve ever gone back to confront the physician who had misdiagnosed me with indigestion and sent me home from the E.R. – despite my textbook heart attack symptoms of chest pain, nausea, sweating and pain radiating down my left arm.  No, my heart sisters, I never did. But what did happen was, I think, even more satisfyingly juicy.   

Months after surviving that heart attack, and freshly fortified with Mayo Clinic cred after graduating from their annual WomenHeart Science & Leadership training for women with heart disease, I received an invitation to share what I’d just learned at Mayo to local docs and nurses working in Emergency Medicine.  I was offered one whole hour on the agenda of their annual Staff Education Day to talk about my own fateful misdiagnosis - and how, according to the Mayo Women’s Heart Clinic, that scenario might be avoided for future female heart patients like me: women who present with clear cardiac symptoms but “normal” diagnostic tests. 

And as a patient advocate recently told physicians at a national symposium on integrated health care:

“The only way to heal a bad experience is to make it better for the next person.”  

Dr. Brian Goldman is an E.R. doctor and CBC radio broadcaster in Toronto who once observed to his White Coat, Black Art audience that the worst possible words E.R. docs could ever hear is:

“Remember that patient you sent home on Tuesday?” 

These words can be particularly fraught with menace when they refer to the heart patient who gets misdiagnosed and sent home from the E.R. instead of being appropriately admitted. 

I now believe that successfully navigating the gatekeepers working in Emergency Medicine (and thus being able to go immediately upstairs to Cardiology) may indeed be the most treacherous part of surviving a cardiac event – especially for women.

A woman attending one of my heart health presentations once told me of her recent trip to the Emergency Department of our local hospital, and an overheard conversation between the (male) doctor and the (male) patient in the bed next door beyond the curtain:

“Your blood tests came back fine, your EKG tests are fine – but we’re going to keep you for observation just to rule out a heart attack”.

A male patient is thus kept in hospital for observation in spite of ‘normal’ cardiac test results. But I and countless other females in mid-heart attack are being sent home from Emergency following ‘normal’ test results like his, and with misdiagnoses ranging from indigestion to anxiety or menopause.

We know that heart attack damage takes place gradually, as portions of the heart muscle are deprived of oxygen. Recent internal “door to balloon time” response awareness efforts underscore this heart attack maxim of doctors:

“Time is muscle.”

But the urgency to protect heart muscle actually starts long before we show up in hospital.

And, shockingly, we also know that first-responders like paramedics may be significantly less likely to provide standard levels of care to women who call 911 with cardiac symptoms compared to their male counterparts, according to the disturbing results of a University of Pennsylvania study reported by the Society for Academic Emergency Medicine.

Researchers found “significant differences in both aspirin and nitroglycerin therapy” offered to women vs men. The gender of the health care provider involved in each of the Pennsylvania cases studied did not appear to change the findings; female ambulance attendants were just as lax in providing appropriate care to their female patients as their male colleagues were. And even after the UPenn researchers adjusted for the possibility that age, race and baseline medical risk could have played a role in these apparent disparities, “the gender gaps in adherence to care protocols still remained”.

In fact, this study showed that of the women transported to hospital by ambulance who were subsequently diagnosed with heart attack, not one had been given aspirin by paramedics en route, as recommended treatment guidelines dictate.

Read that last line again.  NOT ONE had been given aspirin by paramedics.

This statement is critically important because early standard interventions like aspirin therapy – which helps to reduce clotting within coronary arteries that can block blood flow to the heart – can play an important role in preventing deadly damage to the heart muscle.

Here in British Columbia, I contacted Kelsie Carwithen at the provincial office of our BC Ambulance Service to find out what standard of care their BC Ambulance Treatment Guidelines specifically recommend for all ambulance attendants in our province when it comes to providing aspirin. She referred me to guidelines that do indeed clearly spell out a protocol for the use of aspirin (ASA) for all patients presenting with “Chest Pain Suggestive of Acute Coronary Syndrome”, a precursor to heart attack (myocardial infarction):

“ASA helps to prevent re-occlusion but will not open the artery. It has been shown to reduce mortality and is one of the most important early treatments the patient can receive.”

Interestingly, these same treatment guidelines suggest that nitroglycerin (the friend of all heart patients living with the chest pain of angina) has not been proven to improve heart attack outcomes:

“Nitroglycerin may relieve the pain of angina, but will not relieve the pain of myocardial infarction and may well worsen outcomes if it causes hypotension (low blood pressure).”

Note that even the otherwise sound BC Ambulance Treatment Guidelines for aspirin cited above include this protocol in a section called Chest Pain Suggestive of Acute Coronary Syndrome.” 

Read that one again: Chest Pain.

This begs the question, then, that even though the aspirin protocol is clearly recommended in writing as “the most important early treatment” for possible heart attack, will it actually be offered by paramedics if the patient riding in the back of the bus is among the 40% of women who experience no chest pain during a heart attack? The BCAS guidelines even warn:

“Women have ‘atypical’ pain complaints – or minimal complaints – more commonly.”

For example, what if our heart attack symptoms involve only vomiting, shortness of breath and crushing fatigue (as reported by many women in mid-heart attack)? Are the ambulance attendants who come to our aid even going to look up the page called Chest Pain Suggestive of Acute Coronary Syndrome” in their treatment manual if we have no chest pain?

These guidelines need to be corrected, and they need to be corrected now.  (* See Comments below for a response from the BC Ambulance Service).

For those Pennsylvania women in the UPenn study who survived the ambulance ride sans aspirin, they still had to get past the E.R. gatekeepers once they arrived at the hospital.

Unfortunately, they were met by both nurses and physicians working in Emergency Departments who reported to researchers a bias towards looking for women’s heart attack chest pain symptoms, even though a majority later acknowledged that they knew women often present with vague, non-chest-pain symptoms even during a serious cardiac event. (And remember that 40% of us will report no chest symptoms at all. None. Zero. Zilch.)

In the E.R., a raft of standard cardiac diagnostic tests will be ordered for us. Trouble is that tests that have been designed, researched and recommended for male patients have not turned out to be as accurate in appropriately identifying cardiovascular disease in females.  This may help to explain why women continue to be misdiagnosed in mid-cardiac event by physicians who send us home from the E.R. with what appear to be “normal” cardiac test results.

Cardiologist Dr. Sharonne Hayes, founder of the Mayo Women’s Heart Clinic in Rochester, Minnesota, offers this informed take on the problem with many cardiac diagnostic tests in women:

“Misconceptions about women’s heart disease grew roots decades ago. In the 1960s, erroneous assertions that heart disease was a man’s disease were widely spread to the medical community and to the public. This led to research almost exclusively focused on cardiovascular disease in men.

“Many clinical trials and research studies in the past excluded women or simply didn’t make an effort to enroll women in sufficient numbers to draw sex-based conclusions.”

This exclusionary practice in cardiac research has had grim ramifications ever since. A study on cardiac misdiagnoses reported in the New England Journal of Medicine, for example, looked at more than 10,000 patients (48% women) who went to their hospital Emergency Departments with chest pain or other heart attack symptoms. Women younger than 55 were seven times more likely to be misdiagnosed and sent home compared to their male counterparts.*

The consequences of misdiagnosis were enormous: being sent home from the hospital doubled the women’s chances of dying.

Dr. Hayes also believes that such misdiagnosis in women may be due to existing treatment protocols being ignored:

“Right now, guidelines help women get the care that has been shown to improve survival and long term outcomes in large groups of patients.

“Part of the problem now is that the guidelines are less likely to be applied to women compared to men. We know that when hospitals have systems in place to ensure they provide care according to the guidelines, women’s outcomes improve, even more than men’s.”

But my question to the UPenn academics (and all other cardiac researchers) is this: so now that you’ve undertaken this research, presented your findings at conferences, maybe even been published in a scientific journal (a considerable boost for your CV, no doubt), what real life changes have occurred as a direct and practical result of your study’s findings? 

Did you try to initiate or even recommend immediate retraining and monitoring of emergency medicine personnel, ambulance paramedics and all first-responders in order to ensure established clinical protocols for both male and female patients are being followed?

Or did your study end, as so many do, with just a CYA suggestion for further studies at some point by somebody else in the near or distant future?

Earth to cardiac researchers:  What we don’t need is yet another study saying: “Things are bad for women heart patients”.  Or as my irreverent cardiac survivor/heart sister Laura Haywood-Cory writes, women do not need to hear:

“Sucks to be female. Better luck next life!”

Many of us who have actually survived this deadly cardiac event despite being misdiagnosed – sometimes repeatedly – already know this from traumatic personal experience.  Yet emerging research continues to tell us over and over again what we already know.

As important as clinical research may be in developing new diagnostic tests or treatment protocols to address women’s heart disease, we know that, alarmingly, not all health care professionals are currently following even the minimum care guidelines that are already in place to help all patients – male or female – get the appropriate treatment we need.

What to do about this disturbing reality?

Women have to be willing to stand up for ourselves when we know something very wrong is happening. We would do this in a heartbeat if these symptoms were happening to our child or our sister or our mother, wouldn’t we? Why are we reluctant to demand good care for ourselves?

At a recent heart talk, one of the women in my audience asked what I might do differently if I now had to chance to replay that first visit to the E.R.

I told her that the most dangerous decision I had made back then was to believe that E.R. doctor while choosing to ignore my increasingly debilitating cardiac symptoms (because a man with the letters M.D. after his name had told me quite clearly: “It is NOT your heart!”

So instead of standing up for myself, I had just meekly left my E.R. gurney and the hospital, feeling very embarrassed and apologetic for having made a fuss “over nothing”.

What I should have done instead as soon as the symptoms returned (which they did – again and again and again!) was to immediately go back to that E.R. – and then to keep going back no matter how many times they tried to send me home. 

In fact, I made my entire audience that day chant along with me this practice demand:

“I don’t care what you say – SOMETHING is wrong with me!”

That’s also essentially what cardiologist Dr. Sharonne Hayes meant when she offered this advice for women seeking emergency help for heart attack symptoms:

“If you find yourself in an ambulance or Emergency Room, don’t be afraid to say to the paramedic or triage nurse:

‘I think I’m having a heart attack!’

“You want a proper diagnosis, and a straightforward blood test and EKG are the starting points. If the thought crossed your mind that you might be having a heart attack, you need to speak up.”  

Remember the patient advocate I quoted earlier here?  Here’s what she advised that Toronto conference audience of health care professionals:

“It’s not realistic to have patients drive change on our own. We are sick. We are exhausted. 

“YOU [referring to health care professionals] have to ask us. YOU have to listen.”

We do need this change to come from the top – including from E.R. department heads and ambulance managers who must train all staff in women’s unique heart disease presentation.

.

* Pope JH, Aufderheide TP, Ruthazer R, et al. Missed diagnoses of acute cardiac ischemia in the emergency department. N Engl J Med. 2000;342:1163-1170.

See also:

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19 Responses to “How can we get heart patients past the E.R. gatekeepers?”

  1. Ian March 30, 2014 at 7:46 am #

    I have been an Advanced Life Support Paramedic for 18 years and I am also a paramedic educator.

    Indeed the phenomenon of females being treated differently is well recognized. This is largely due to the fact that all of the “rules” regarding the symptoms of ischemic heart disease were written about men.

    Women can and do experience symptoms of acute coronary syndromes with a wide continuum of severity and specificity. They are statistically less likely to be having an acute coronary syndrome because women of child bearing age are “estrogen protected” from the disease processes that promote the development of ACS, but they are still candidates.

    However… I cannot speak for all jurisdictions, but the disparity between the regard paid to women and men presenting with symptoms, particularly subtle or atypical symptoms, has long since been corrected to a very large degree BECAUSE this phenomenon is well known and exhaustively taught in school and I know it is carefully regarded, at least certainly by paramedic practitioners.

    It is more likely to be a problem in facilities where general practitioners staff emergency departments rather than board-certified emergency physicians. Furthermore, I know of no North American Emergency Medical System (EMS) that either promotes or even ALLOWS paramedics and first responders to dissuade patients from seeking hospital attention.

    With many jurisdictions having developed highly-effective programs for identifying heart attacks outside of hospital and paramedics fast-tracking patients to angioplasty, the screening of an even broader range of patients for acute coronary syndromes is now routine.

    Like

    • Carolyn Thomas March 30, 2014 at 8:26 am #

      Thanks so much for taking the time to share your professional perspective, Ian. Indeed, I know of heart attack scenarios in which paramedics have actually argued with ER docs once they arrived at the hospital. One heart attack survivor, for example, wrote me: “The firefighters and paramedics knew right away that it was a heart attack when they saw my EKG. When we got to the ER, however, the doctor told the nurses to take the EKG leads off because I was just having a panic attack”.

      While it’s encouraging to know that your EMS training now appropriately emphasizes “routine” screening for all potential MIs regardless of gender, the reality still exists that women are being under-diagnosed (and under-treated even when appropriately diagnosed) compared to our male counterparts. Studies being published this month continue to confirm this reality. Another small local example: the reluctance of my own BC Ambulance Service to edit their current protocol guidelines beyond the “Chest Pain Suggestive of Acute Coronary Syndrome” section (as described in the comments below by Paul Leslie insisting that what’s written in the protocol – i.e. “chest pain = ACS” – is merely part of overall core paramedic training so doesn’t actually need to be edited).

      While I too would like to believe that gender disparity has “long since been corrected to a very large degree”, patients themselves know this is, sadly, still not true for everyone.

      Like

  2. Tony Maddox November 9, 2013 at 1:43 pm #

    If the patient is telling you they are having any sort of chest discomfort/pain/pressure or back discomfort/pain/pressure near the level of the heart you should be thinking heart attack and you treat as such.

    If the 12 lead ekg is normal then you run a 15 or 21 lead ekg to check the right side and back of the heart. It does not matter if the patient is male or female, black, white, short, tall, skinny, fat, straight, gay or what ever else.

    I have been in EMS for over 20 years, a paramedic for 12+, and an instructor and preceptor. There is NO EXCUSE for not listening to your patient and doing what is in the best interest of your patient!

    Liked by 1 person

    • Carolyn Thomas November 9, 2013 at 9:17 pm #

      Thanks so much, Tony. If only your advice were followed by all health care professionals. Alas, for women and particularly for those who present with vague or non-chest MI symptoms (that’s about 40% of us), we are too often sent home with misdiagnoses ranging from GERD to anxiety or menopause (a great all-purpose misdiagnosis).

      Wish I had a nickel for every heart attack patient who’s heard: “It can’t be your heart – you’re too young!”

      Like

  3. Bill Mapes September 8, 2013 at 8:06 am #

    Seldom does an article freeze me like this one did.

    As an experienced paramedic and EMS Educator, I am big enough to admit I may have been part of the problem. No more….it stops today.

    I have sent this to my staff and EMS education colleagues….and in our area, we will fix this.

    Thanks you for your passion, backed by data.

    Liked by 1 person

    • Carolyn Thomas September 8, 2013 at 8:50 am #

      Bill, you have just made my day! You have no idea what a response like yours means to those of us who need to get past the gatekeepers. Thank you so much and please continue to help spread this important message.
      regards,
      C.

      Like

  4. Jennifer January 9, 2013 at 8:11 am #

    Hello,
    I am 45, within the morbidly obese guideline, and went to emergency with “heart palpitations”. I was having long pauses, irregular beats, and these were accompanied by slight diaphoresis and vague nondescript feelings in my chest. I have a huge familial history of coronary artery disease on my father’s side, with his death of such at 52. I was kept less than 1 hour. A 12 lead was performed, but no labs, or anything. They are ordering a holter monitor only.
    Jen

    Like

    • Carolyn Thomas January 9, 2013 at 9:27 am #

      Hi Jennifer – sounds like they were not taking your symptoms seriously. Good news that you are getting a holter monitor, but if symptoms continue, do not hesitate to return to the E.R.

      Like

  5. * Carolyn Thomas November 21, 2012 at 10:40 am #

    ♥ On November 21, 2012, I received an email from the BC Ambulance Service in response to this post:

    “Hello Carolyn – Kelsie Carwithen of BCAS, who initially sent you the link to our treatment guidelines, provided me with your email address so that I could make a comment regarding your latest blog posting.

    “I’d like to commend you on your dedication to raising awareness about the very insidious atypical presentation of acute coronary syndrome often seen in female patients.

    “Women who call an ambulance and complain of very vague symptoms do present a real challenge to paramedics, nurses and physicians. A missed M.I. can be devastating.

    “In your recent posting, you referred to the BC Ambulance Service Treatment Guidelines. It’s important to note that treatment guidelines are supplemental to core paramedic training. Paramedics learn and practice principles of care, which, when combined with certification training and experience, are put into practice when paramedics are confronted with a patient whose complaints and assessment suggest the possibility of acute coronary syndrome.

    “Our treatment guidelines identify that only 30% of patients have a classical presentation of acute coronary syndrome. This reminds paramedics to be on the lookout for atypical presentations — particularly women and patients with diabetes. Paramedics on the very front line of the emergency medical care spectrum must rely on the patient’s story and assessment skills to sort out what is right for the patient at that moment in time.

    “Again, your attention to this issue is a great service to many. If you have any further questions, please don’t hesitate to contact me directly.

    Best regards,

    Paul R. Leslie
    Director,
    Professional Practice and Patient Care
    Medical Programs
    BCAS EHSC “

    Like

    • Carolyn Thomas November 21, 2012 at 11:00 am #

      Dear Paul,

      Thank you so much for taking the time to respond to my concerns about the BCAS Treatment Guidelines. I do of course understand that these guidelines cannot possibly include a comprehensive list of everything that’s already been covered in core training. But my concern remains that this particular section of the guidelines is still clearly titled “Chest Pain Suggestive of Acute Coronary Syndrome”. Chest pain. Paul, this makes little sense, given the widely accepted stats on women’s atypical non-chest pain presentation even in mid-M.I. as well as disturbing study results that continue to suggest that these women are still being under-diagnosed, and then under-treated even when appropriately diagnosed.

      Call me crazy, but I’m far less likely to make assumptions that because health care professionals are trained to look for XXX, they will necessarily be implementing care plans that do so. Consider, for example, the UPenn study on paramedics. Consider the E.R. doc who (despite his many years in medical school) did not follow established Emergency Medicine protocol in my own case – despite my presentation with textbook ‘Hollywood Heart Attack’ symptoms. (Even if he had Googled these symptoms, he and Dr. Google would have immediately come up with the correct diagnosis of myocardial infarction).

      So my request remains: please can we replace assumptions with some clear black and white edits to existing protocols? It would be a good start. Thanks again, Paul, for being willing to consider this step.
      regards,
      C.

      Like

  6. MentalMakeovers November 15, 2012 at 10:10 am #

    Excellent post Carolyn. “The only way to heal a bad experience is to make it better for the next person” is the most wonderful quote ever. I shall repost (of course!)

    Like

    • Carolyn Thomas November 15, 2012 at 2:44 pm #

      Hello JudyJudith – I too loved that quote. Isn’t it so true?

      Like

  7. Mary November 15, 2012 at 8:21 am #

    People should also know that the standard of care *SHOULD* be, TWO MINIMUM, NORMALLY THREE troponins drawn, 6-8 hours apart in the ER. Too often, it’s one set of troponins and out the door.

    When I found out that three was standard of care in most ERs (or for men?), I knew I had received cursory evaluation.

    One of the all time best posts, Carolyn!

    Like

    • Carolyn Thomas November 15, 2012 at 2:37 pm #

      Thanks so much, Mary. This issue of testing for cardiac enzymes is interesting, particularly for women.

      As a 2006 report in the Annals of Emergency Medicine recommends: “The serial measurements of the cardiac troponins over an 8 to 12 hour period of observation is supported by several studies as a reliable method of identifying and excluding acute myocardial infarction.” Testing for troponins is typically done every 3-4 hours during that period, so 2-3 blood tests while in the E.R. appear to be the bare minimum of appropriate care. (In reality, I was sent home from the E.R. less than five hours after the onset of my heart attack symptoms with two back-to-back “normal” cardiac enzyme blood tests; the E.R. doc told me confidently following the first one on admission: “Your first blood test came back fine. We’re going to do another blood test – and THAT WILL BE FINE, TOO!”).

      One set of blood tests!? Simply not good emergency medicine.

      Like

  8. Laurie November 15, 2012 at 6:56 am #

    I was very fortunate in that the paramedics came to the conclusion that I could be having a heart attack before I did; I received several doses of nitro as well as aspirin on my way to the hospital. I don’t know if this is a function of training or luck, but I know I am blessed to have had caretakers who saw what was unfolding and took it seriously. I wish all women had this experience, but posts like this will hopefully make everyone more aware of the need to advocate for ourselves!

    Like

    • Carolyn Thomas November 15, 2012 at 1:45 pm #

      You were fortunate indeed, Laurie, to have your symptoms taken very seriously, likely thanks to both training and luck! BTW, note that the evidence suggests that while aspirin is recommended, nitro is apparently not: “Nitroglycerin has not been proven to improve outcomes.”

      Like

  9. Dee Madscientist November 15, 2012 at 6:11 am #

    Your experience was my experience, and even after being a survivor for 9 years, it is still happening!

    Like

    • Carolyn Thomas November 15, 2012 at 1:34 pm #

      I know! Would somebody please explain to me why this is so!?

      Like

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  1. DxWatch - July 19, 2013

    [...] Information on this topic: myheartsisters.org/2012/11/15/getting-heart-patients-past-gatekeepers-of-emergency-medicine/ [...]

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