How many heart patients get to the hospital by ambulance?

by Carolyn Thomas   ❤️   Heart Sisters (on Blue Sky)

In 2010, Australia’s National Heart Foundation launched what they called a “hard-hitting” Heart Attack Warning Signs awareness campaign. Physicians and cardiac researchers were concerned that too many Australians did not know the common warning signs of a heart attack. They hoped that such an awareness campaign would encourage high-risk patients to quickly call an ambulance if they were having cardiac symptoms. Their Warning Signs campaign explained why this is so critically important: 

“When having a heart attack, every minute counts. The longer you wait, the more your heart muscle is damaged. Knowing the warning signs and acting quickly could save your life, or the life of someone close to you.” 

Yet Australian researchers(1) reported that during the three years of the campaign, less than half of the patients who had been diagnosed with acute coronary syndrome (sudden and dangerously reduced blood flow to the heart muscle) had called an ambulance to get themselves to the Emergency Department. Interestingly, heart patients’ awareness of the heart attack Warning Signs campaign was “not associated with ambulance use.”

Although those researchers reported  cardiac symptom awareness was “high or increased” during the 3-year awareness-raising campaign period, there was a significant downward trend in each year following the campaign for most cardiac symptoms.

And worse, the inability to name any heart attack symptom increased in each year following the campaign. The alarming and discouraging conclusion of the study was this:

“Awareness of heart attack symptoms has decreased in the years since the Warning Signs campaign in Australia, with 1 in 5 adults currently unable to name a single heart attack symptom.”

Those shocking results are comparable to the equally shocking  results of the American Heart Association’s annual National Survey on Women’s Awareness of Heart Disease, which found women’s awareness was significantly worse than 10 years earlier, despite extensive and expensive Go Red For Women awareness campaigns.  Over half of the women surveyed, for example, could not name chest pain as a heart attack symptom. See also: “Women’s Heart Disease: Is it Time To Hang Up The Red Dress?”

Meanwhile, Irish researchers(2)  undertook a large study of over 1,900 heart patients also diagnosed with acute coronary syndrome, and reported these outcomes:

• only one-quarter of those heart patients had called an ambulance
• over half had gone initially to their GP’s office to get their symptoms assessed
• just over half of the GP patients continued from their GP’s office to Emergency by self-transport rather than by ambulance (which makes us wonder if the decision NOT to call an ambulance was made by the patient or the GP the patient had just seen)
  
• 17 per cent arrived directly at the Emergency Department on their own

The strongest predictors in deciding to call for an ambulance included:

• having already survived a previous heart attack (about 1.5 times higher likelihood of calling an ambulance)
• severity of symptoms (patients suffering a cardiac arrest, for example, were 21 times more likely to call an ambulance than non-cardiac arrest patients)
• being a smoker

There are also strong predictors in deciding NOT to call an ambulance, according to Seattle researchers who learned that the delay between the first onset of cardiac symptoms and seeking appropriate help averages about two hours of waiting.(3)  That’s a remarkably long time to wait for heart muscle cells to die off.

Some common reasons for that dangerous delay may include:

-because the patient thought that the symptoms would go away

-because the symptoms did not seem severe enough

-because the patient thought that the symptoms were caused by another illness

–because the patient did not even think of calling 911

-because the patient thought that driving their own car to Emergency would be faster

-because the patient had a very busy day planned

-because the patient did not want to be embarrassed by making a fuss in front of Emergency doctors “in case it’s nothing and I would feel like a fool”

Some researchers who specifically study women living with pain also suggest that many of these patients have learned to tolerate a lifetime of different forms of severe pain (from pain that’s unique to women like menstrual cramps, childbirth, endometriosis – or diagnoses that are significantly seen more often in women compared to men – e.g. irritable bowel syndrome,  rheumatoid arthritis, osteoarthritis, temporomandibular joint disorder (TMJ), chronic pelvic pain, migraine headaches and more).

This unique tolerance to ongoing severe pain is called habituation.  

Professor Tali Sharot (at MIT) and Cass Sunstein (at Harvard)  explain habituation in their fascinating book Look Again:  The Power of Noticing What Was Always There:

“Habituation is the tendency of neurons in the brain to fire less and less in response to things that are constant.”

This reality of habituated pain helps to explain why, after an Emergency Department physician sent me home in mid-heart attack with an acid reflux misdiagnosis, I felt so embarrassed about making a fuss over nothing that my brain began to shrug off my neurons’ alarm signals – and I immediately went back to work.

After that humiliating experience, I attributed all of my severe symptoms to simple indigestion – because a man with the letters M.D. after his name had confidently told me to do so. It took me two full weeks – until the debilitating central chest pain, nausea, sweating and pain down my left arm became so unbearable that I forced myself back to that same Emergency Department. Different doc this time, different (and correct) diagnosis this time:  the “widowmaker” heart attack.

And we also know that women, despite having more pain, are less likely to have their pain taken seriously, which in turn can causes extreme reluctance to seek medical care to “make a fuss over nothing”.  

Take painful menstrual cramps, for example. Globally, 45-95 per cent of all women of reproductive age suffer from what doctors call “dysmenorrhea”. This particular pain is the leading cause of lost working hours and school absences in females. And when researchers asked women in their studies why they had not sought help for severe period pain (either from their GP or by going to an Emergency Department), their answers ranged from “didn’t think providers would offer help” to “considered symptoms to be tolerable.”(4)  

Until women learn to consider extreme pain as neither normal nor tolerable, and until healthcare providers learn to believe women who tell them we’re suffering, researchers will continue to publish studies asking the same questions (and getting the same answers).

No wonder women with cardiac pain wait significantly longer than our male counterparts to seek medical help – including calling for an ambulance.

Finally, there’s another possible barrier to picking up the phone in mid-heart attack and calling 911, and that might be the cost of the ambulance ride.

For example, where I live (on Canada’s beautiful west coast), if I or person nearby calls 911 to take me to the nearest hospital, I will later be sent a bill for $80 from the B.C. Ambulance Service for that trip. My generous extended workplace health insurance benefits don’t cover ambulance transport. And if somebody else calls 911 for me, but I refuse to get into that ambulance, I will be billed $50. This fee discourages people from making frivolous crank 911 calls (and yes, our local 911 dispatch staff do publish a list every January of the year’s stupidest reasons that idiots use to call 911 inappropriately while wasting valuable dispatcher time and paramedic resources (e.g. my neighbour’s wearing too much perfume, or where’s the closest 24-hour pharmacy?)  Seriously.

But when you do suspect that your symptoms are genuinely heart-related. please don’t hesitate to call 911.

You know your body. And you know when something is “just not right”. 

Remember that chest pain is the most common heart attack sign in both male and female patients (although women often use words like pressure or fullness instead of PAIN). Also remember that cardiac symptoms in women can often come, and then go away, and then come back. As cardiac researcher Dr. Sharon O’Donnell  explained, that slow-onset myocardial infarction (MI) is the gradual onset of relatively mild heart attack symptoms, while fast-onset MI describes the immediate onset of sudden, continuous, and severe heart attack symptoms, particularly chest pain.(5)

Other common warning signs include the following:

Do not drive yourself to the hospital, and do not let anybody else drive you (unless it’s an extreme emergency (e.g. a blinding blizzard and your cousin next door is a professional snow plow driver). Every paramedic I know has told me that they’d much rather show up and discover the crisis is not a crisis after all, instead of NOT being called and missing out on treating a serious medical issue that could be fatal.

And please please please don’t be like the woman in one of my Heart-Smart Women presentation audiences who told me that she had taken the bus to our Emergency Department in mid-heart attack!

1. Lavery T et al. “Factors Influencing Choice of Pre-Hospital Transportation of Patients with Potential Acute Coronary Syndrome. Emerg Med Australas. 2017 Apr;29(2):210-216. 

2. S. Ahern et al. “Factors Influencing Ambulance Usage in Acute Coronary Syndrome”. Irish Medical Journal. February 17, 2022. Vol. 155. #2. P.539.
   

3. Meischke H et al. “Reasons Patients with Chest Pain Delay or Do Not Call 911.” Ann Emerg Med. 1995 Feb;25(2):193-7

4. Chen CX et al. “Reasons Women Do Not Seek Health Care for Dysmenorrhea. J Clin Nurs. 2018 Jan;27(1-2):e301-e308.

5. O’Donnell, S. et al.  “Slow-Onset Myocardial Infarction and Its Influence on Help-Seeking Behaviors.” Journal of Cardiovascular Nursing, August 2012. Volume 27  Number 4. Pages 334-344.

♥

NOTE FROM CAROLYN: I wrote more about treatment-seeking delay behaviour in my book, “A Woman’s Guide to Living with Heart Disease”  (Johns Hopkins University Press).You can ask for it at your local library or bookshop (please support your favourite independent neighbourhood booksellers) or order it online (paperback, hardcover or e-book) at Amazon – or order it directly from my publisher, Johns Hopkins University Press (use their code HTWN to save 30% off the list price).

 

See also: Fewer lights/sirens when a woman heart patient is in the ambulance