I sometimes think that, during the years I’ve been writing about women’s heart disease research, diagnostics, treatment or outcomes, I’ve heard it all when it comes to women being under-diagnosed and under-treated (yes, sometimes under-treated even when appropriately diagnosed!) I thought I was unshockable by now. But a study published in the journal, Women’s Health Issues (WHI) was indeed a shocker.(1) .
Researchers compared the pre-hospital care of both male and female heart patients over the age of 40 who had been transported to hospital after calling 911 for help.
It wasn’t only the WHI study’s findings that women being transported to hospital were less likely than men to receive recommended treatments (including even the minimal basics such as aspirin or cardiac monitoring) that shocked me. That appalling reality has been reported by cardiac researchers so many times that’s it’s at risk of being considered tired old news by now (for example, Blomkalns et al., 2005; Jneid et al., 2008; Dey et al., 2009; Meizel et al., 2010; Balady et al., 2011; Poon et al., 2012; Koopman et al., 2013, etc. etc. etc.) See also: The Sad Reality of Women’s Heart Disease Hits Home
Researchers continue to describe this under-treatment as what’s known as the cardiology gender gap, often blamed on the implicit bias against women among many medical professionals. The same professionals may blame women themselves, perhaps because of our tendency to delay seeking emergency care, or because of the way we communicate our cardiac symptoms to physicians.
It’s also why we are often forced to conclude, in the immortal words of Laura Haywood-Cory (who survived her own heart attack at age 40):
“Sucks to be female. Better luck next life!”
The study in WHI analyzed the National Emergency Medical Services Information System database (which collects EMS patient care reports from 46 American states) over a three-year period. Data included 2.4 million patients with chest pain transported by ambulance to a hospital (over 280,000 were diagnosed with out-of-hospital cardiac arrest) But the part of this study that seemed to cause the most excitement was this conclusion, as the WHI researchers wrote:
“When transporting women with cardiac symptoms from the scene to the hospital, Emergency Medical Services (EMS) personnel were significantly less likely to use lights and sirens compared with men being transported.”
This isn’t even the first study to arrive at the same distressing conclusion; at least two other studies conducted in Norway and in Australia also found that women diagnosed at the hospital with acute myocardial infarction (heart attack) were less likely to have been transported there by ambulances with flashing lights and loud sirens compared with male heart attack patients (Melberg et al; Coventry et al).
Findings like these seem particularly shocking because of our assumption that the decision to employ lights and sirens indicates urgency in safely getting that patient to the hospital as fast as possible.
So when an ambulance driver decides to turn on the lights and sirens if the patient lying in the back is a male, but not so much if she’s a female experiencing the same symptoms, it does indeed send a disturbing message.
As longtime former paramedic-turned EMS attorney Douglas Wolfberg says, lights and sirens do work:
- – to clear traffic and warn drivers, pedestrians and others that an ambulance is approaching in emergency mode
- – by showing the public that we are treating their emergency calls seriously
- – to show our public officials that we are meeting their response time expectations and being accountable
But even though lights and sirens “work” for those purposes, Wolfberg says that there’s a larger question here, and that is all about patient benefit.
So here’s another shocker (putting the serious issue of cardiac gender bias aside for a moment): consider that the use of flashing red lights and loud sirens has become a controversial issue in the field of Emergency Medical Services.
In fact, there seems to be a movement among emergency responders to actually reduce the overall use of lights and sirens. Emergency physician, professor of emergency medicine and paramedic Dr. Douglas Kupas listed some of the arguments for this change in his U.S. Office of Emergency Medical Services report:
- – studies suggest that EMS response times generally make much less of a difference than the public believes
- – response times are driven by public perception of quality service
- – some patients decide to drive themselves to the ER because of concern or embarrassment associated with an ambulance “running hot” down their street. See also: Too Embarrassed to Call 911 During a Heart Attack?
- – siren noise can cause distress to some patients being transported.
- – EMS personnel are at risk of hearing impairment/loss from high decibel siren noise (a risk that can be mitigated by limiting siren response or using hearing protection)
- – reducing use of red lights and ambulance sirens reduces the risks of a crash and collision-related liability (for example, when Salt Lake City emergency medical dispatch prioritized medical calls in 1983, the lights and siren response decreased by 50%, and there was a 78% reduction in emergency vehicle collisions in the same year).
- – fewer than 5% of 911 calls are true time-sensitive emergencies, so many EMS agencies should be able to safely reduce their lights and sirens use during response to less than 50% of their 911 calls
By now, you might be wondering which 911 responses do warrant flashing red lights and loud sirens?
As outlined in the report by Dr. Kupas, these five categories are the true time-sensitive emergencies (e.g. a one- to five-minute response required):
- 1. cardiac or respiratory arrest
- 2. airway problems
- 3. unconsciousness
- 4. severe trauma
- 5. true obstetrical emergencies
Since cardiac arrest is ranked Number One on this priority list, let’s go back to those findings published in the journal Women’s Health Issues. In three years of data from the National Emergency Medical Services Information System, activations of more than 280,000 patients with out-of-hospital cardiac arrest were also analyzed. Over 108,000 of those patients were women.
According to the priority list from Dr. Kupas, every one of those cardiac arrest cases would have been considered a true time-sensitive emergency requiring red lights flashing and loud sirens screaming all the way to the hospital – for both men AND women. Yet the study found that paramedics were not only less likely to provide aspirin/cardiac monitoring and employ lights and sirens en route if their patients were women, but women in cardiac arrest were also significantly less likely than men to be resuscitated.
1. Lewis, Jannet F. et al. “Gender Differences in the Quality of EMS Care Nationwide for Chest Pain and Out-of-Hospital Cardiac Arrest.” Women’s Health Issues, December 10, 2018.
Q: Were you transported by ambulance to the ER with or without lights and sirens?
NOTE FROM CAROLYN: I wrote much more about differences between how men and women are researched, diagnosed and treated in my book, “A Woman’s Guide to Living with Heart Disease” . You can ask for it at your local bookshop, or order it online (paperback, hardcover or e-book) at Amazon, or order it directly from Johns Hopkins University Press (and use the code HTWN to save 30% off the list price when you order).