Virginia EMS Symposium: Not Just Boobs and Tubes

Medicine has long been practiced based on what’s proven most beneficial to white men, as research has largely been conducted by white males, for white males. This has resulted in applying a one-size-fits-all approach to all of our patients, with little regard to the possibility that when it comes to medicine, we might need different strokes for different folks.

“We’ve been using one model to treat all patients, but we need to start thinking of different ways for sex, gender, race, and ethnicity,” said Valerie Quick, MSN, RN, EMT-I, NCEE, in her Virginia EMS Symposium session, “Not Just Boobs and Tubes: What Makes Women Different to Assess and Treat?” on Nov. 8 in Norfolk, Va. 

Historically, men have dominated academic medicine and research, Quick said. The way we study medications and understand disease processes has largely been based on research done on  young, healthy men in the military (such as trauma care with blood supply, TXA, and tourniquets). Quick said it’s important that we protect our research dollars to be used for studies that are more inclusive of women—the original school of thought has been medication outcomes would be different in women because of fluctuating hormones, but guess what? Men have these, too!

"This is about making things better for all individuals, not just one group,” Quick said.

In many EMT textbooks, there is little discussion of the differences in men’s and women’s physiology or acknowledgement of nontraditional gender roles. For example, despite the fact that both men and women contract STDs, these diseases were only mentioned in the OB/GYN section until recently, when they should have been categorized under infectious diseases. Though vaginal bleeding and pregnancy-related conditions are thoroughly covered, there is no mention of male genital medical emergencies—Quick wondered aloud if we should simply have a section of urogenital emergencies to encompass both sexes. And although women account for 51% of the population, we deem their Acute Coronary Syndrome symptoms as “atypical” presentations. 

Quick also pointed out that the discussion of providing care for victims of sexual assault excludes men even though they, too, can be victims. And pediatric chapters always credit moms as the reliable resources of what baby’s normal presentation is, even though many dads today are the primary caregivers. So instead of thinking ‘Mom knows best,’ while rolling up to a scene for a pediatric call, we should think ‘caregiver knows best.’

Quick provided an overview of important physiological differences to take note of when treating your female patients:

Hormones

• Differing levels of estrogen, testosterone, and progesterone create legitimate differences in how men and women think and act
• Four key points to remember in pharmacokinetics:
  • Absorption:
    • Ask women the date of their last menstrual period
      • While women have less acid in their stomachs and slower emptying times, their absorption rates increase during menstruation, so drug metabolism rates will be very different preceding this period
    • Women can overdose on smaller amounts of fentanyl than men might
    • They absorb alcohol differently because they only have 1/5 of alcohol dehydrogenase, the enzyme that breaks down alcohol
       
  • Distribution:
    • Drug dosing for women is generally lower due to higher percentage of body fat, which helps guard the uterus during pregnancy
    • Ask if they’re taking any oral contraceptives, which compete against some drugs such as antibiotics—this makes the birth control less effective
    • Oral contraceptives make women more prone to conditions like brittle bones, deep vein thrombosis (DVT), and pulmonary embolism (PE)
    • Women who smoke and take oral contraceptives are 60 times more likely to develop PEs and DVT
       
  • Metabolism:
    • Biotransformation and drug metabolism mostly take place in the liver (though during pregnancy, biotransformation may occur in the fetal tissues and placenta)
    • Seizures are more frequent prior to menstruation due to changes in hormones
       
  • Elimination:
    • Mostly happens in the kidneys but also through the skin and lungs, where elimination can occur more quickly for women
    • Hormonal-based medications like antibiotics, benzodiazepines, and steroids may impact rate of elimination

The Brain

• Both men and women repair tissues and organs with estrogen which also protects the brain and maintains its plasticity
• Because women’s estrogen decreases over time, especially after menopause, their ability to restore weakens; e.g. More aggressive treatment may be needed for elderly women for sepsis, hemorrhage, and kidney injury
• Strokes
  • Occur more frequently among men but are more fatal in women, who are more likely to delay seeking treatment
  • Worse neurological outcomes lead to higher suicide rates after strokes

Lungs

• COPD is more common; women respond well to early oxygen during periods of exacerbation
• Asthma attacks are more likely during menstruation
• Smaller lungs = less reserve
• Lower hemoglobin levels = less oxygen
• Lung cancer is the #1 cancer killer among women

GI Tract

• Moves more slowly than in men until menstruation, at which point it speeds up
• Increased need for glucose while prepping for pregnancy creates a breeding ground for infections and other breakdowns, causing a predisposition to Type 2 diabetes

Esophagus (shorter)

• GERD is more common
• Persistent cough shouldn’t be thought of as just a respiratory issue—antacid is a good treatment

Trauma

• Despite having increased inflammatory responses because of their hormones, women get under-triaged
• Young, healthy males get different treatment—women are often observed for less time
• Women handle and express pain differently than men

Heart

• For women over the age of 65, taking aspirin daily is more likely to cause bleeds than provide protection from heart disease
• Higher heart rates and lower cardiac outputs
• Testosterone shortens Q-Tc = more likely to develop early or premature beats and arrhythmias

Coronary Artery Disease

• #1 killer of American women
• Symptoms are different and often ignored
  • 20% of women experience upper abdominal pain, back pain, shortness of breath, nausea, sweating
• Having diabetes increases risk of CAD by 4-6 times in women vs. 2-3 times in men
  • Women have a higher death rate and worse prognosis after AMI
  • Kidney disease hits harder in women than in men due to less elimination and fluid challenges so responses to medications are poorer

 Assessments in Women

• Keep differential diagnoses broad
  • “Believe their symptoms and understand you may have to advocate for them at the hospital,” said Quick.
• Have higher suspicions about underlying causes of their condition
• “Denial ain’t just a river in Egypt.” Just because they deny it, it doesn’t mean it’s not happening