Pre-hospital care: can paramedics influence your cardiac future?

by Carolyn Thomas    ♥   @HeartSisters

Helen A. (pictured here) is a longtime Heart Sisters reader from North Carolina. (My other regular readers may remember Helen’s heart patient story a few years ago in The Handlebar-Gripping Cardiac Symptom). Helen asked me recently if I’d ever written about the influence of paramedics on subsequent medical care. Here’s how she started her message:

“We called 911 because I was having heart attack symptoms, but by the time we arrived at the hospital, the paramedic had decided nothing really serious was going on, and he made me get out of the ambulance and walk into the Emergency Department.” 

Unfortunately for Helen, however, something “really serious” was in fact going on.

And after the paramedic had already dismissed her symptoms as being non-cardiac, Helen was told to join the waiting queue in the Emergency Department at the major medical/trauma centre she’d just walked into, until she finally became frightened that she might die waiting in line:

“I made my husband drive me to a satellite hospital, where I was taken in immediately and told I was indeed having a heart attack.

“People are advised to call for an ambulance when they experience symptoms consistent with heart attack. That’s fine, but it occurs to me that the ambulance attendant really has quite a bit of influence in determining how seriously a particular patient is considered.

“In my case, now about a year ago, it still makes me angry. I don’t know what would have happened had I not insisted on going to the satellite hospital. I think the paramedic had quite a bit of influence on how things unfolded.”

We can’t know for sure how much that particular paramedic influenced Helen’s waiting time in Emergency, but hers is not the first report I’ve observed on this topic – surprisingly, in both positive or negative ways.  For example, I’ve met many women who shared Helen’s narrative (e.g. first responders who did not believe them – see below for specific distressing research results) but I’ve also met women who told me it was a paramedic who not only believed them, but went to bat for them with dismissive Emerg staff.

I know that my paramedic friends have a hugely challenging job to do. Every day, they deal with horrific traumatic injuries, family tragedies, overflowing Emergency Departments, offload delays, ambulance diversion, staffing shortages, extreme stress and so much more.(1) 

And the work of paramedics has also become more complex due to increased emergency calls, demographic changes and new healthcare technologies which can affect pre-hospital care.

In fact, a Scandinavian study appears to confirm Helen’s gut feeling that paramedics can influence our outcomes, according to researchers who concluded that “a preliminary diagnosis made by a paramedic has an essential role in directing subsequent care.”(2)

Let’s also consider the disturbing image of a woman with cardiac symptoms who is told by a paramedic, as Helen was, to get out of his ambulance and walk into the Emergency Department. Would he have told a male patient with Helen’s cardiac symptoms to walk?

There’s an old rule among first responders: ABC (‘Ambulate Before Carry”). And as one paramedic explained to me:

“Many patients can walk (with a broken wrist in a sling, for example). But anyone whose condition could be made worse by walking (e.g. experiencing a heart attack or difficulty breathing) should NOT be exerting themselves.”

Make no mistake: being able to walk to or from the ambulance doesn’t mean that a person is not having a heart attack.

Before I was misdiagnosed with acid reflux in mid-heart attack, for example, I’d walked into the Emergency Department on my own steam. (I’d been out for a brisk early morning walk when my symptoms struck out of the blue that day).

And not only was I able to walk, I went to work, I drove my car, and I flew to Ottawa for my mother’s 80th birthday weekend celebrations – all while forcing down non-stop Tums and Gaviscon for my worsening come-and-go symptoms of central chest pain, nausea, sweating and pain down my left arm.

Cardiologists like to say “Time is muscle” when it comes to delayed treatment-seeking behavior. The longer heart muscle is deprived of blood flow by a blocked coronary artery, the more permanent damage can happen to that heart muscle. So the urgency to protect the heart actually starts at the first onset of early symptoms, long before we show up at the hospital – and ideally when an ambulance arrives at our home.

But many studies have found that first-responders like paramedics are significantly less likely to provide standard levels of care to women who call 911 with cardiac symptoms compared to our male counterparts, according to the disturbing results of a landmark University of Pennsylvania study published by the Society for Academic Emergency Medicine.(3)  

Researchers found “significant differences in both aspirin and nitroglycerin therapy” offered by paramedics to women vs. men. And even after the UPenn researchers adjusted for the possibility that the patients’ age, race or baseline medical risk could have played a role in these apparent disparities, “the gender gaps in adherence to care protocols still remained”.

For example, the Pennsylvania study showed that of the women transported to hospital by ambulance who were subsequently diagnosed with acute heart attack, not one had been given aspirin by paramedics en route, as recommended guidelines dictate for cardiac symptoms.

And later research published in the journal Women’s Health Issues reported essentially identical conclusions.(4)  For even more shocking results, see also: “Fewer Flashing Lights/Sirens When a Woman Heart Patient is in the Ambulance“

The care protocols mentioned by researchers are those official treatment guidelines that recommend best practices to all healthcare professionals tasked with assessing and treating any person reporting cardiac symptoms.

So here’s my question: why would there be gender gaps in following guideline-based care protocols unless paramedics were exhibiting implicit bias against female heart patients? The word “implicit” means that individuals are not even aware of their own bias, as many emerging studies on women’s health care  continue to confirm.

This is critically important because early standard interventions like giving patients aspirin – which helps to reduce clotting within coronary arteries  – can play an important role in preventing deadly damage to the heart muscle.

Accurate cardiac diagnosis involves administering an ECG (EKG) test. Here are two key factors to know about your diagnostic ECG:

1. the electrodes must be correctly placed on the patient’s body (in an estimated 10 per cent of ECGs, they are NOT), and
2. the ECG test results must be correctly interpreted (only half of all ECGs are interpreted accurately(5) 

As heart patients, we have no clue if our cardiac diagnostic tests are being appropriately interpreted or if current care protocols are being followed. We simply trust doctors, nurses, paramedics and other healthcare professionals to help us. Yet the Scandinavian study  which compared the preliminary diagnoses of paramedics with the confirmed diagnoses of the same patients admitted to hospital found that the overall accuracy of the preliminary paramedic diagnoses was 70 per cent, which has also been reported in previous studies.(2)  That seems like a pretty solid average – except when you’re in that 30 per cent group.

Sometimes, like Helen, we may experience a strong gut feeling that we’re not being taken seriously. And as Maya Dusenbery advises healthcare professionals in Doing Harm, her compelling book on the history of women’s health care:

“Listen to women. Trust us when we say we’re sick.”

Helen’s final observation about her own ambulance experience was this:

“I just remember thinking that I’m having a heart attack and this guy is making me walk into the ER!  Fortunately, I listened to that inner voice and decided the only way I wasn’t going to collapse on the floor was to go to that other hospital.”

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1. Phillips, W. J. et al. “Ambulance ramping predicts poor mental health of paramedics.” Psychological Trauma: Theory, Research, Practice, and Policy. 2022.

2. Koivulahti, O et al. “The Accuracy of Preliminary Diagnoses Made by Paramedics – a cross-sectional comparative study.” Scandinavian Journal of Trauma, Resuscitation, and Emergency Medicine 28, 70, 2020.

3.  Meisel Z et al. “Influence of Sex on the Out-of-Hospital Management of Chest Pain.” Academic Emergency Medicine. Volume 17, Issue 1, 4 January 2010). 

4. 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.

5. Cook DA et al. “Accuracy of Physicians’ Electrocardiogram Interpretations”. JAMA Internal Medicine, 2020; 180(11):1461–14

 

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Q:   Have you shared Helen’s experience of listening to that ‘inner voice’ in order to get the medical help you needed?

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NOTE FROM CAROLYN:  I wrote more about differences between how male and female heart patients 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 their code HTWN to save 30% off the list price when you order).