seX & whY Episode 14, Part 1: COVID-19 Through a Gender-Based Lens

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Show Notes for Episode Fourteen of seX & whY: COVID-19 Through a Gender Based Lens Part 1

This is a discussion on how gender-associated norms impact disease process.

Host: Jeannette Wolfe
Guests: Dr Gary Barker CEO of Promundo- an organization that promotes healthy masculinity and gender equality

Dr Stephen Burrell Assistant Professor in the Dept of Sociology at Durham University- who’s area of focus in on engaging men and boys in the prevention of violence against women.

Today’s podcast features the first part of our discussion which focuses on how “gender” roles and norms impact general health and the COVID-19 pandemic. Both of our guests are experts on how societal perceptions and stereotypes surrounding “masculinity” influence the health and well-being of both men and women. Through Promundo, Dr Barker has done significant amounts of work in Brazil where toxic masculinity has been associated with the early deaths of millions of young men and Dr Burrell recently wrote the article: Coronavirus reveals just how deep macho stereotypes run through society.

Our discussion focuses on:

  • The intentionality required to engage diverse groups of people to actually talk about how gender and masculinity associated issues significantly impact health outcomes.
  • Research from Promundo which suggests that of the about overall 5 year mortality difference between men and women, that about 20% of that gap is due to genetics and about 50% is associated with the following three factors:
    • diet
    • smoking
    • substance abuse
  • The recognition that more men than women are dying of Covid-19 and that we need to go beyond binomial data to look at “which” men and “which” women are at highest risk for death which leads us to the intersection of biological sex and other sociocultural influences.
  • How the words different countries use to describe the pandemic often appear to reflect that country’s approach in how they are addressing it.
  • The importance of intentionally creating neuro and cultural diversity amongst teams tasked to solve complicated problems.
Special thanks to Doug Deems who helped edit this podcast.

seX & whY Episode 13, Part 3: LGTBQI Health-related Issues

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Show Notes for Episode Thirteen of seX & whY: LGTBQI Health-related Issues Part 3

How best to support students and colleagues in the LGBTQ community

This is a very special podcast and I want to deeply thank Shana Zucker, Ellie Ragone and Mike Gisondi for sharing their very personal experiences.

Host: Jeannette Wolfe
Guests:

Shana Zucker, MS

  • Shana is a rising 4th year medical student at Tulane in the MD/PhD program
  • When she was a first-year medical student at Tulane she helped to create The Queericulum, an educational program geared at helping medical students become more culturally competent surrounding LGTBQ health related issues and patient interactions
  • Since its creation, it has now become a mandatory course for all first-year Tulane medical students and she is currently working to expand the program to other medical schools
  • In addition, she and Mike are creating (with another MD/PhD student at Stanford) an online educational program to help medical educators teach medical students about LGTBQ health
  • Here is Shana’s talk at Feminem’s Fix conference in NYC

Ellie Ragone DO

  • Is a first-year emergency medical resident at UMMS-Baystate
  • Ellie is a transwoman and has graciously shared her personal experiences about transitioning as a medical student
  • One of her largest concerns about transitioning was being able to successfully identify a primary care provider who was both competent and comfortable with LGTBQ patients and their health-related needs

Michael Gisondi

  • Vice chair of education at the Dept of EM at Stanford
  • Mike shares how his identity formation was actually quite different at different points of his own life
  • He reflects on the generational differences of LGBTQ physicians

Tips offered by the group

  • If you have a trans colleague and you misgender them, besides apologizing in real-time consider sending them an email or text later on to let them know you have reflected upon the mistake and appreciate the challenges they are routinely facing and that you want to support them.
  • When you are looking at a program or job, be authentic and find the program who accepts you for who you are versus trying to be the image of the person you think the program wants.
  • Let medical students and residents lead. They often are much more on point about what does and doesn’t work than most senior educators

Accountability buddy article

https://www.aliem.com/peer-accountability-strategy-maintaining-commitment/

Special thanks to Doug Deems who helped me edit this podcast

 

seX & whY Episode 13, Part 2: LGTBQI Health-related Issues

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Show Notes for Episode Thirteen of seX & whY: LGTBQI Health-related Issues Part 2

How to take better care of transgender patients when they seek medical care

Host: Jeannette Wolfe
Guests:

  • Dr Elizabeth Samuels Assistant Professor of Emergency Medicine Warren Alpert School of Medicine at Brown University
  • Dr Michelle Forcier Professor of Pediatrics at Warren Alpert School of Medicine at Brown University and Director of Gender and Sexual Health Services

Quotes used are from Dr Samuel and her team’s paper: “Sometimes You Feel Like the Freak Show”: A Qualitative Assessment of Emergency Care Experiences Among Transgender and Gender-Nonconforming Patients Ann Emerg Med 2018

Here are 10 take-home points

  1. Delivering Intentional habits to care for our transgender patients actually helps us deliver better care to our cisgender patients too.
  2. Appreciate that many trans and gender non-conforming patients are incredibly reluctant to seek out medical care due to previous discriminatory treatment,
  3. Don’t assume a trans patient is out to the other people in the room and offer to speak with them privately
  4. Ask their name, if different than expected ask them if they have a different legal name, then confirm how they would like to be addressed and what pronouns they use.
  5. Respectfully update other team members about this information so that the patient doesn’t need to unnecessarily repeat themselves. Importantly how we model this message to our staff can set the tone for how these patients will be treated, so take this responsibility seriously.
  6. When asking about past medical history, surgical histories and current medication make sure that you are clear as to why you are asking and how it relates to their current medical problem.
  7. In trans patients that present with abdominal pain, don’t assume because they physically look like their asserted sex that they lack organs from their biological one such as ovaries or a prostate. Remember to ask.
  8. When admitting a trans patient, if a private room is unavailable they should be roomed with patients of their asserted gender.
  9. If not already doing so, encourage your hospital to use software that allows an individual’s sexual orientation and gender identity to be included in a separate field of their medical record
  10. If you are a medical educator, look for ways to include an issue

seX & whY Episode 13, Part 1: LGTBQI Health-related Issues

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Show Notes for Episode Thirteen of seX & whY: LGTBQI Health-related Issues Part 1

Host: Jeannette Wolfe
Guests:

  • Dr Elizabeth Samuels Assistant Professor of Emergency Medicine Warren Alpert School of Medicine at Brown University
  • Dr Michelle Forcier Professor of Pediatrics at Warren Alpert School of Medicine at Brown University and Director of Gender and Sexual Health Services

This is the first of a three-part series that will cover LGTBQI health related issues. This podcast focuses on some basic definitions and general principles surrounding the care of gender non-conforming children and adolescents. It also discusses some of the gender affirming hormonal and surgical options available to patients.

Resources that we discussed

The link to USCF’s Center of Excellence for Transgender Health

The link to the American Academy of Pediatrics statement on transgender and gender diverse children.

The link to the Gender Unicorn

Basic definitions

Biological Sex

  • This is related to our innate sex chromosomes and hormones

Gender

  • Influenced by biological sex and sociocultural constructs

Gender Identity

  • How an individual internally perceives themselves within the norms and expectations of society in which they live

Gender Expression

  • How an individual presents their gender publicly via mannerisms, appearance and clothing, etc

Gender Asserting

  • How an individual perceives themselves and desires to be viewed by the world

Gender Affirming

  • Hormones, procedures or clothing that align with asserted gender

Gender Dysphoria

  • The distress a person may experience when their gender identity is not aligned with their assigned sex

Hormones commonly used

  • To stall puberty
    • Gonadotropin-releasing hormone (GnRH) analogues
  • Transmen
    • Testosterone
  • Transwomen
    • Estradiol (and possible spironolactone or finasteride)

Gender affirming surgeries

Transwomen

  • breast augmentation
  • orchiectomy
  • feminizing vaginoplasty
  • reduction thyrochondroplasty
  • voice surgery

Transmen

  • hysterectomy
  • oophorectomy
  • vaginectomy
  • metoidioplasty (clitoral release and enlargement)
  • phalloplasty/scrotoplasty
  • masculinizing chest surgery (“top surgery”)

Gender non-conforming health related issues that can occur in transgender and gender non-conforming patients

  • Tucking of scrotum and penis that can lead to trauma/inflammation, infection, reflux
  • Estradiol related thrombosis
  • Testosterone related uterine bleeding
  • Infection or emboli from body sculpting injections

Take home points

  • When someone identifies themselves as transgender that simple means that their gender identity does not align with their assigned sex. It doesn’t mean that they have necessarily had specific surgeries or that they are taking certain hormones.
  • Gender identity is distinct from an individual’s sexual preference.
  • Some younger kids can experience their gender identity in a more fluid manner. This can often make it more difficult to predict what their gender identities will be later on as adults. Supporting and respecting these kids for where they are, and understanding that their gender identity may or may not later change, is important for their social and psychological development.
  • As kids reach puberty their gender identity is generally less fluid and more permanent, for kids and their families who our struggling with gender identity, puberty blockers are an option to give people more time to process information and make decisions
  • Currently there are multiple gender affirming treatments available to trans-individuals, including hormonal treatments and different types of surgeries some of which may become important when a transgender individual becomes a patient in our emergency department

Next month we will focus on how we can deliver better care to transgender and gender non-conforming patients in our emergency departments.

seX & whY Episode 12, Part 3: Sex and Gender Differences in CPR

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Show Notes for Episode Twelve of seX & whY: Sex and Gender Differences in CPR Part 3

Host: Jeannette Wolfe
Guest: Dr Justin Morgenstern

Here is a link to Justin Morgenstern’s awesome First10EM blog site where you can find an excellent review of the two papers that we discussed today: Perman’s DNR paper and Huded’s Cleveland Clinic Study on gender gaps in 30 day survival after ST elevation myocardial infarctions.

Here are some take home points for this podcast:

  • We don’t know what we don’t study and when we don’t consider sex and gender as legitimate variables, we can inadvertently miss opportunities to improve the health of all of our patients.
  • There appears to be lots of sex-based differences in cardiac electrophysiology
    • females are more prone to AV nodal re-entrant arrhythmias, sick sinus syndrome, prolonged QTc and postural orthostatic tachycardia syndrome
    • males are more prone to AV block, early repolarization, Brugada’s syndrome, accessory pathway-mediated arrythmias, idiopathy ventricular arrhythmias and dangerous arrythmias associated with arrhythmogenic right ventricular cardiomyopathies
  • In many ways, biological sex represents a much “cleaner” variable to study in that most of us have a sex specific chromosomal pairing and hormonal cocktail that allows us to be more easily placed into a binary male or female category.
  • Biological sex differences are often detected and treated by tweaking technology- adjusting the results of a blood test or using a different type of imaging modality to account for sex based physiologically differences.
    • Biological sex is akin to the variable of age- its importance is related to context. Although a 15 year and 50-year-old may get the same evaluation for an ankle sprain they should not get the same evaluation for chest pain. Similarly, how females and males react to any particular treatment may or may not be associated with a clinically important difference.
    • As the science of earnestly studying males and females side by side is still so new, we are just beginning to understand where differences actually exist and in what contexts they are clinically relevant.
  • As the influence of gender can be quite subtle and often involves many touchpoints, recognizing and fixing gender-based differences can be challenging. For example, here is how an individual’s gender might influence what happens to them if they have a heart attack.
    • Whether they live alone
    • If and when they call an ambulance
    • If they come in by car, how quickly they are triaged
    • Where they are geographically placed in the department
    • How they describe their symptoms
    • How their symptoms are perceived by providers (which in turn may be confounded by provider gender)
    • How quickly an EKG is done
    • How comfortable they are with procedural consent
    • How quickly they go to the cath lab
    • When and what type of medications they are prescribed
    • Who they are referred to for follow up
    • Whether they are compliant with their new meds or appointments
    • Whether they are referred to and participate in cardiac rehab
  • Currently, I suspect that most of us in medicine would likely acknowledge that there are some legitimate examples out there of gender and race- based health inequities. The next step, however, requires an acknowledgement that those inequities are not just happening somewhere else, but that they have also likely creeped into our own practices. This can be difficult because it directly threatens our explicit belief that we deliver “the same” excellent care to all of our patients.
  • Recognizing and mitigating gender disparities, especially those related to implicit bias, requires deep self-reflection along with an individual and organizational commitment to actually want things to change.
  • Solutions include wide-spread “no-blame” educational forums and the development of technical safeguards to help reduce unintentional bias. For example, the creation of default “opt in” disease specific order sets and operational checklists.

Here is a table that shows outcome data from Bosson’s JAHA paper from LA County data base that we briefly mentioned on the podcast.

Men Women
CPR 41% 39%
shockable 35% 22%
STEMI 32% 23%
Cath 25% 11%
TTM 40% 33%
Survival/CPC 1-2 24% 16%

 

Other studies discussed.

European study that examined sex-differences in atrial fibrillation study

Danish study on cardiac arrests in people less than 35 with 2 to one ratio of men to women

Korean eunuch study suggesting that a historical lineage of castrated males outlived several socioeconomically matched peers, supporting the concept of a disposable soma theory.

Cleveland Clinic informational sheet on arrhythmias in women

Study that suggests more women than men die or go to hospice after an intracranial hemorrhage and brings up idea of gender-based differences in “social capital” contributing to this difference

EOL choices in advanced cancer patients showing gender differences in palliative care and DNR preferences

seX & whY Episode 12, Part 2: Sex and Gender Differences in CPR

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Show Notes for Episode Twelve of seX & whY: Sex and Gender Differences in CPR Part 1 & 2

Host: Jeannette Wolfe
Guest: Dr Justin Morgenstern

Two big databases surrounding cardiac arrest

  • Cares- Cardiac Arrest Registry to Enhance Survival which is based on information from national EMS data input via the NEMSIS national EMS information system
  • ROC- Resuscitation Outcomes Consortium (ROC) 2011-2015. The ROC is a network of National Institutes of Health -funded clinical trial network evaluating out of hospital cardiac arrests that collects data from 11 different sites around the United States

Here are two great articles that cover this material in depth

What we know

  • Over 350,000 people will have a cardiac arrest this year
  • Men account for about 2/3 of OHCA
  • About 20-25% will occur in public place
    • Men are proportionately more likely to collapse in public place than women (19% versus 8.4% in one study)
  • About half of cardiac arrests are witnessed (about 37% by layperson and 12% by EMS)

(46% vs 52%  in one study)

  • Bystander CPR doubles to triples rates of survival
  • Rates of bystander CPR are highly variable and depend heavily upon where you live and its demographics with CPR being less likely to be started in predominately minority and lower socioeconomic communities. Overall, it appears that about 35-40% or cardiac arrests will get bystander CPR
  • Where you live is also dramatically associated with your rates of leaving the hospital neurologically intact.
    • One study that examined 132 different counties showed, depending upon the county,  functional recovery rates ranging from 0.8%-20% (which again, is likely heavily influenced by  variations in CPR and AED use.)
  • CARES data bank stats suggest that out of hospital cardiac arrest (OHCA)
    • 28% live to hospital
    • 8% leave neurologically intact
  • Usually less than 20% of initial rhythms of OHCA are shockable
    • though sex difference here also

(one study 29% men vs women 16% with initial shockable rhythm)

  • Per one survey  about 2/3 of people has some type of CPR training with 20% being currently trained
    • CPR training noted to be lower amongst Hispanics, elderly, lower income, less formally educated
  • Of those trained in CPR only about 1/3 of people will actually step up and do it when indicated

First study

Gender disparities among adult recipients of bystander cardiopulmonary resuscitations in the Public from Audrey Blewer in Cir Cardiovasc Qual Outcomes 2018

Primary study question- is there an association between an individual’s biological sex and the likelihood they will receive bystander CPR

Resuscitation Outcomes Consortium (ROC) 2011-2015

This was a retrospective analysis of data collected in a prospectively for several clinical trials in out of hospital cardiac arrests from 7 of these sites.

Exclusion:

Traumatic arrest

Occurs in a residential institution or hospital

Less than 18

CPR initiated by someone who was not a layperson (police EMS doc)

The variable they used in logistic regression modeling included whether event was witnessed, location, layperson CPR, time of event, and basic demographics including age, race, gender

Nontraumatic out of hospital cardiac arrests

19331 events

Mean age 64

63% male

17% public location (3297)

82% private (15788)

Overall 37% received CPR (38% of men and 35% of women)

If collapse occurred in public place

  • 45% of men and 39% of women

If collapse occurred in private place

  • 36% of men and 35% of women received CPR

Overall: Males had 29% increased odds of survival

Bottom line: If you have a OHCA in public you are about 6% more likely to receive CPR if you are a man than a woman

This is not the only study showing gender differences in CPR here is a   Netherland study and an avatar study which also highlight these differences.

There are also studies suggesting subtle gender differences in EMS treatment of chest pain/cardiac arrest:

Ok so why is that happening?

So first let’s talk about some general barriers to stepping up and doing CPR in public-

A 2008 study by Swor in Annals of EM interviewed almost 700 bystanders to an OHCA. Although about ½ of the bystanders had previous CPR training only about 20% actually started doing CPR.

Cited barriers to doing CPR included:

– feeling of panic (reported by about 38% )

– concern of doing it incorrectly (9%)

– concern they could cause harm (1%)

– reluctance to do mouth to mouth (1%)

In another study which surveyed community members from areas in which there were low rates of bystander CPR to understand why the rates were so low, answers included:

– fear of getting sued

– emotional overtones of the situation

– lack of knowledge

– situational concerns

A different study suggested that disagreeable physical characteristics– read dentures and vomit-  might hamper CPR initiation.

Overall you are more likely to step up and do CPR if

  • CPR training within last 5 years (OR 6.6)
  • in public (OR 3.1)
  • see them collapse (OR 2.3);
  • bystander has greater than a high school education (OR 2.0)

So the next question is, are these the reasons why there is a gender difference in who gets bystander CPR or are there additional factors to consider.

Second study

Public Perceptions on Why Women Receive Less Bystander Cardiopulmonary Resuscitation than Men in Out of Hospital Cardiac Arrest

Perman Circulation 2019

Primary Question- what are the public perceptions as to why women are less likely to get bystander CPR?

Methods- Electric survey via Amazon’s crowdsourcing platform- Mechanical Turk. Participants were English, >18 and familiar with CPR principles

Mechanical Turk- have “master users” people achieve this rate by apparently having a history of completing other surveys out appropriately in the past (essentially successfully answering planted “attention” surveys which suggests that they are actually reading the surveys)

Participants were asked 11 multiple choice questions and one free text- “ Do you have any ideas on why women may be less likely to receive CPR than men when they collapse in public?” Free text responses were coded and major themes were identified by using an inductive qualitative method.

548 subjects

542 completed surveys

average age 38

equal number of males and females about 1% of participants were transgender

81% White 7% Black 6% Asian 3% Hispanic

45% college diploma

½ were trained at some time in CPR (top reasons for training were cited a work or volunteer related requirement)

24 had actually done CPR on a collapsed person-

Three major themes evolving:

1) Sexualization of woman’s bodies (40% of men mentioned versus 29% of women)

– fear of making incidental contact with a woman’s breast

“I think that people are afraid to touch the breast region, so hesitate to administer CPR”

– fear of being wrongfully accused of sexual abuse

“Bystanders, especially male bystanders, may be afraid to touch women especially in the chest area… anxious that their help my be unnecessary and therefore touching may be misconstrued”

“Men are afraid of seeming like perverts”

2) Perception that women are weaker and frailer and thus at greater risk for injury if CPR was not really needed

“People might be afraid of hurting them since women tend to be smaller and more fragile looking than men

3)  Misperception of what actual distress looks like in females

”They are not known to have as many heart attacks in public, they are known to be healthier”

 “ Maybe people assume they are being dramatic and overreacting so CPR isn’t needed”

Interestingly in the open- ended responses it was frequently implied by use of pronouns that the bystander initiating CPR would be a man. Along these lines, this European paper hints that gender related issues may also influence who steps up to start CPR.

My (liberal) summary of paper:

“Look I’m not super thrilled about the idea of touching a woman’s breast and quite frankly I’m a little scared about being accused of sexual assault.  And also, if I’m honest, I’m a little suspicious that the woman might be collapsing from something less serious, because most cardiac arrests seem to happen in guys. Finally, if I do start CPR on a woman and they really didn’t need it, I’m afraid I might accidentally physically hurt her.

Five take home points

  • As more than 60% of cardiac arrests do not get bystander CPR, please consider sending out these CPR videos from the American Heart Association and The British Heart Foundation to friends or family members to teach and/or reinforce basic CPR principles as good CPR doubles to triples survival rates.
  • There are innate biological sex differences associated with out of hospital cardiac arrests including: 2/3 of cardiac arrest occur in men who collapse on average collapse about 7-10 years earlier than women. Men are also more likely to have an initial shockable rhythm.
  • Gender related issues, which can notoriously sneak under the radar if we don’t intentionally look for them, can also impact cardiac arrests. The study we talked about today suggested about a 5-6% absolute differences in public bystander CPR rates with men receiving more CPR. Concerningly there is similar research suggesting gender based inequities of both the EMS and hospital management level of cardiac arrest and we will continue this discussion in part 2 of our series. Although more deductive research is needed, there are hints that some of these gender related CPR differences are rooted in concerns surrounding sexuality, perceptions about fragility and misconceptions that collapsing women are unlikely to be having a cardiac arrest.
  • The first step to gender- based gaps in cardiac arrest is to simply validate they exist. If you teach CPR, recognize and normalize that for some learners, invading someone’s personal space can feel totally awkward and then encourage them to mentally rehearse different scenarios in which they visualize themselves successfully starting CPR.  Using tools like the womanikin can help.
  • As it appears that only about 30% of people who already know CPR, will actually step up to do it, we must work on ways to close this gap. Considering the introduction of stress inoculation and introducing things like Mike Lauria’s breath, talk, see and focus technique holds promise.

Other references

High Sensitivity Troponin and Gender Differences in treatment after ACS

North Carolina’s Heart Rescue Intervention

Article about CPR and Good Samaritan laws

seX & whY Episode 12, Part 1: Sex and Gender Differences in CPR

Jeannette WolfePodcast EpisodesLeave a Comment

Show Notes for Episode Twelve of seX & whY: Sex and Gender Differences in CPR Part 1 & 2

Host: Jeannette Wolfe
Guest: Dr Justin Morgenstern

Two big databases surrounding cardiac arrest

  • Cares- Cardiac Arrest Registry to Enhance Survival which is based on information from national EMS data input via the NEMSIS national EMS information system
  • ROC- Resuscitation Outcomes Consortium (ROC) 2011-2015. The ROC is a network of National Institutes of Health -funded clinical trial network evaluating out of hospital cardiac arrests that collects data from 11 different sites around the United States

Here are two great articles that cover this material in depth

What we know

  • Over 350,000 people will have a cardiac arrest this year
  • Men account for about 2/3 of OHCA
  • About 20-25% will occur in public place
    • Men are proportionately more likely to collapse in public place than women (19% versus 8.4% in one study)
  • About half of cardiac arrests are witnessed (about 37% by layperson and 12% by EMS)

(46% vs 52%  in one study)

  • Bystander CPR doubles to triples rates of survival
  • Rates of bystander CPR are highly variable and depend heavily upon where you live and its demographics with CPR being less likely to be started in predominately minority and lower socioeconomic communities. Overall, it appears that about 35-40% or cardiac arrests will get bystander CPR
  • Where you live is also dramatically associated with your rates of leaving the hospital neurologically intact.
    • One study that examined 132 different counties showed, depending upon the county,  functional recovery rates ranging from 0.8%-20% (which again, is likely heavily influenced by  variations in CPR and AED use.)
  • CARES data bank stats suggest that out of hospital cardiac arrest (OHCA)
    • 28% live to hospital
    • 8% leave neurologically intact
  • Usually less than 20% of initial rhythms of OHCA are shockable
    • though sex difference here also

(one study 29% men vs women 16% with initial shockable rhythm)

  • Per one survey  about 2/3 of people has some type of CPR training with 20% being currently trained
    • CPR training noted to be lower amongst Hispanics, elderly, lower income, less formally educated
  • Of those trained in CPR only about 1/3 of people will actually step up and do it when indicated

First study

Gender disparities among adult recipients of bystander cardiopulmonary resuscitations in the Public from Audrey Blewer in Cir Cardiovasc Qual Outcomes 2018

Primary study question- is there an association between an individual’s biological sex and the likelihood they will receive bystander CPR

Resuscitation Outcomes Consortium (ROC) 2011-2015

This was a retrospective analysis of data collected in a prospectively for several clinical trials in out of hospital cardiac arrests from 7 of these sites.

Exclusion:

Traumatic arrest

Occurs in a residential institution or hospital

Less than 18

CPR initiated by someone who was not a layperson (police EMS doc)

The variable they used in logistic regression modeling included whether event was witnessed, location, layperson CPR, time of event, and basic demographics including age, race, gender

Nontraumatic out of hospital cardiac arrests

19331 events

Mean age 64

63% male

17% public location (3297)

82% private (15788)

Overall 37% received CPR (38% of men and 35% of women)

If collapse occurred in public place

  • 45% of men and 39% of women

If collapse occurred in private place

  • 36% of men and 35% of women received CPR

Overall: Males had 29% increased odds of survival

Bottom line: If you have a OHCA in public you are about 6% more likely to receive CPR if you are a man than a woman

This is not the only study showing gender differences in CPR here is a   Netherland study and an avatar study which also highlight these differences.

There are also studies suggesting subtle gender differences in EMS treatment of chest pain/cardiac arrest:

Ok so why is that happening?

So first let’s talk about some general barriers to stepping up and doing CPR in public-

A 2008 study by Swor in Annals of EM interviewed almost 700 bystanders to an OHCA. Although about ½ of the bystanders had previous CPR training only about 20% actually started doing CPR.

Cited barriers to doing CPR included:

– feeling of panic (reported by about 38% )

– concern of doing it incorrectly (9%)

– concern they could cause harm (1%)

– reluctance to do mouth to mouth (1%)

In another study which surveyed community members from areas in which there were low rates of bystander CPR to understand why the rates were so low, answers included:

– fear of getting sued

– emotional overtones of the situation

– lack of knowledge

– situational concerns

A different study suggested that disagreeable physical characteristics– read dentures and vomit-  might hamper CPR initiation.

Overall you are more likely to step up and do CPR if

  • CPR training within last 5 years (OR 6.6)
  • in public (OR 3.1)
  • see them collapse (OR 2.3);
  • bystander has greater than a high school education (OR 2.0)

So the next question is, are these the reasons why there is a gender difference in who gets bystander CPR or are there additional factors to consider.

Second study

Public Perceptions on Why Women Receive Less Bystander Cardiopulmonary Resuscitation than Men in Out of Hospital Cardiac Arrest

Perman Circulation 2019

Primary Question- what are the public perceptions as to why women are less likely to get bystander CPR?

Methods- Electric survey via Amazon’s crowdsourcing platform- Mechanical Turk. Participants were English, >18 and familiar with CPR principles

Mechanical Turk- have “master users” people achieve this rate by apparently having a history of completing other surveys out appropriately in the past (essentially successfully answering planted “attention” surveys which suggests that they are actually reading the surveys)

Participants were asked 11 multiple choice questions and one free text- “ Do you have any ideas on why women may be less likely to receive CPR than men when they collapse in public?” Free text responses were coded and major themes were identified by using an inductive qualitative method.

548 subjects

542 completed surveys

average age 38

equal number of males and females about 1% of participants were transgender

81% White 7% Black 6% Asian 3% Hispanic

45% college diploma

½ were trained at some time in CPR (top reasons for training were cited a work or volunteer related requirement)

24 had actually done CPR on a collapsed person-

Three major themes evolving:

1) Sexualization of woman’s bodies (40% of men mentioned versus 29% of women)

– fear of making incidental contact with a woman’s breast

“I think that people are afraid to touch the breast region, so hesitate to administer CPR”

– fear of being wrongfully accused of sexual abuse

“Bystanders, especially male bystanders, may be afraid to touch women especially in the chest area… anxious that their help my be unnecessary and therefore touching may be misconstrued”

“Men are afraid of seeming like perverts”

2) Perception that women are weaker and frailer and thus at greater risk for injury if CPR was not really needed

“People might be afraid of hurting them since women tend to be smaller and more fragile looking than men

3)  Misperception of what actual distress looks like in females

”They are not known to have as many heart attacks in public, they are known to be healthier”

 “ Maybe people assume they are being dramatic and overreacting so CPR isn’t needed”

Interestingly in the open- ended responses it was frequently implied by use of pronouns that the bystander initiating CPR would be a man. Along these lines, this European paper hints that gender related issues may also influence who steps up to start CPR.

My (liberal) summary of paper:

“Look I’m not super thrilled about the idea of touching a woman’s breast and quite frankly I’m a little scared about being accused of sexual assault.  And also, if I’m honest, I’m a little suspicious that the woman might be collapsing from something less serious, because most cardiac arrests seem to happen in guys. Finally, if I do start CPR on a woman and they really didn’t need it, I’m afraid I might accidentally physically hurt her.

Five take home points

  • As more than 60% of cardiac arrests do not get bystander CPR, please consider sending out these CPR videos from the American Heart Association and The British Heart Foundation to friends or family members to teach and/or reinforce basic CPR principles as good CPR doubles to triples survival rates.
  • There are innate biological sex differences associated with out of hospital cardiac arrests including: 2/3 of cardiac arrest occur in men who collapse on average collapse about 7-10 years earlier than women. Men are also more likely to have an initial shockable rhythm.
  • Gender related issues, which can notoriously sneak under the radar if we don’t intentionally look for them, can also impact cardiac arrests. The study we talked about today suggested about a 5-6% absolute differences in public bystander CPR rates with men receiving more CPR. Concerningly there is similar research suggesting gender based inequities of both the EMS and hospital management level of cardiac arrest and we will continue this discussion in part 2 of our series. Although more deductive research is needed, there are hints that some of these gender related CPR differences are rooted in concerns surrounding sexuality, perceptions about fragility and misconceptions that collapsing women are unlikely to be having a cardiac arrest.
  • The first step to gender- based gaps in cardiac arrest is to simply validate they exist. If you teach CPR, recognize and normalize that for some learners, invading someone’s personal space can feel totally awkward and then encourage them to mentally rehearse different scenarios in which they visualize themselves successfully starting CPR.  Using tools like the womanikin can help.
  • As it appears that only about 30% of people who already know CPR, will actually step up to do it, we must work on ways to close this gap. Considering the introduction of stress inoculation and introducing things like Mike Lauria’s breath, talk, see and focus technique holds promise.

Other references

High Sensitivity Troponin and Gender Differences in treatment after ACS

North Carolina’s Heart Rescue Intervention

Article about CPR and Good Samaritan laws

seX & whY Episode 11 Part 2: Interview with Dr. Cara Tannenbaum

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Show Notes for Podcast Eleven, Part 2 of seX & whY

Host: Jeannette Wolfe

This is a continuation of my interview with Dr. Cara Tannenbaum, Professor in the Faculties of Medicine and Pharmacy at the Université de Montréal in Canada, and Scientific Director of the Institute of Gender and Health of the Canadian Institutes of Health Research

Our discussion and the following table is centered around this recent review article by Dr. Tannenbaum found in Pharmacology Research 2017

Type of experiment Traditional way Better way
                 Stem cells -Male cells

-Unknown sex of stem cells

-Problems: in immortal cell lines the integrity of in vivo sex chromosomes diminishes over time and can complicate the identification of sex- based differences.

Similarly, although normal female cells have two X chromosomes- one from the mother and one from the father- one of those chromosomes is usually turned “off”. With Stem cells however, after multiple reproductive cycles there can get something called “X skewing” in which instead of some cells turning off the maternal chromosome and others the paternal one, there is overrepresentation of one line.

Conversely in “X escape”, the second X chromosome is no longer getting inactivated and this can cause trouble because too much X gene is getting expressed (for example this could lead to significant autoimmune problems)

Use and record results of both male and female cell lines

Know sex & of donor

–       Include cell lines with finite life spans

–       Add sex hormones to XX and XY cell

–       X chromosomes house genes that influence: cellular growth, metabolism and immunity

–       Y chromosomes contain genes beyond SRY (which makes testosterone), and if loss Y chromosome increased risk of Alzheimers and certain cancers

Gendered Innovations group in Korea has actually labeled sex of commercial cell lines

 

 

Lab animal Standard use of male animals

80% of traditional research done on males

-Females felt to be too variable due to estrous cycle* (average of 4 days)

Inclusion of female animals**

-analyze data by sex

-include factorial designs that allow for the identification of age or hormonal influence in outcome

-Consideration of housing conditions that can lead to hormonal fluctuations

Phase trials

 

Change began with The NIH Revitalization
Phase 1 and 2 Currently it is believed that women still make up less than 25% of Phase 1 Include sex and age as independent variables

 

Further query if discovered sex differences are due to sex-based differences in pharmacokinetics (how our body’s characteristics like our weight or liver function influence the drug) or pharmacodynamics (how the drug influences our body)

Phase 3 trials As it was believed that outside the reproductive organs that males and females were physiologically the same,  most studies focused on males and thus side effects in females were often missed or underappreciated

 

 

Report and analyze data by sex and age

 

Use updated statistical models to calculate appropriate sample sizes prior to starting study so that any identified differences are likely to represent valid findings

 

Further explore hormonal states of study participants. For example, if they are pre or post menopausal, pregnant, or if they are taking hormones such as estrogen or testosterone.

 

56% of participants in drug trials submitted to FDA in 2018 were women

Phase 4 As this is further analysis of a drug after it hits the market, it can take a long time to pick up sex-based differences.

Poster child of this is Ambien in which dosing adjustment for women took 20 years

Analyze results from “real world” use of drug and its side effects by sex and age

 

Go back to lab to identify etiology of discovered sex or age differences

 

Adjust dosing when important differences are discovered

Click here for a paper that nicely summarizes the reasons behind why females were underrepresented in scientific research during the 20th century.

Other points

  • Important variables to consider when talking about biological sex
    • Sex chromosomes
      • X chromosome contains 1669 genes
      • Y chromosome contains 426 genes
    • Sex hormones
      • We all have testosterone, progesterone and estrogen it is the ratios that differ between men and women
      • Hormones influence us in two ways
        • The cocktail of hormones our brain is exposed to during prenatal and pubertal development leads to permanent wiring changes in the brain.
        • The fluctuating blips of hormones caused by multiple different triggers (like the estrous cycle or dominance posing) can lead to transient wiring changes.
        • Depending upon specific context organizational and activational hormones can potentially influence outcome data
        • There are new study designs that can help identify potential hormonal based differences that do not require an excessive sample size or budget
      • Age
      • Gender

What we do (and what society allows us to do) influences our epigenetics and future gene expression.

For example, our gendered professions- men work more in coal mines and women in nail salons- can influence stuff we are exposed to which in turn can influence are future gene expression.  This is further complicated by males and females having potentially different DNA modifications after exposure to the same insult. Ultimately this can make it tricky to sometimes distinguish what is a sex- based difference versus a gender one.

  • The X chromosome has 1669 known genes on it and the Y chromosome 426 genes

Miscellaneous

2017 Tetris study on decreasing PTSD intrusive thoughts after C-section.

seX & whY Episode 11 Part 1: Interview with Dr. Cara Tannenbaum

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Show Notes for Podcast Eleven of seX & whY

Host: Jeannette Wolfe

Interview with Dr. Cara Tannenbaum, Professor in the Faculties of Medicine and Pharmacy at the Université de Montréal in Canada, and Scientific Director of the Institute of Gender and Health of the Canadian Institutes of Health Research

Definitions

Biological Sex- chromosomes, hormones, reproductive anatomy, usually binary

Gender- social and cultural construct- falls on a spectrum

Historical factors that limited the inclusion of women in clinical trials.

  • Belief that outside of reproductive zones, males and females were the same
  • Dogma that the female estrous cycle screwed up data and that male animals produced “cleaner” results
    • Two interesting facts
      • Many female rodents’ entire estrous cycle is only 4 days!
      • We now know that male animals also have significant hormonal fluxes and that overall they are actually just as variable as females- see review
    • Concern after the worldwide thalidomide nightmare* and the public backlash from the discovery of several unethical government sponsored clinical trials, that fetuses (along with prisoners and children) needed extra protection from the potential of unnecessary harm by participation in a research trial. This led to regulatory protection via the Common Rule. As any women of child-bearing age could theoretically become pregnant, they (and ultimately by cultural proxy all women) were essentially excluded from most human trials and early clinical phase drug trials from 1970’s to the mid 1990’s.
      • To read and an inspiring story as to why most of American was saved from the limb-shortening horrors of thalidomide, read here. (Essentially, FDA scientist Dr. Oldham Kelsey refused to sign off on its application, even amidst considerable pressure from the drug company, due to concern of inadequate evidence.)

Interesting sex and gender differences in car crashes

  • Crash dummy 101
    • Historically crash dummy is Hybrid III which is 5’9’’ 170 pounds representing an average male
    • Hybrid III female model- 5’ 110 pounds
    • Other models- used by NHTSA
    • Why injury patterns may be different between men and women
      • Differences in baseline anthropometric measures (like height)
      • Biomechanical differences
        • Women more prone to whiplash due to differences in neck muscular
      • Mechanical design
        • smaller adults
          • sit closer to steering wheel
            • increase risk of lower extremity injury
          • are more vulnerable to side impact (more of their head is in front of window)
        • NASS CDS data
          • Weight annual sample of US 5000 police reported tow away crashes
          • Collects data on
            • Occupant demographics
              • Age, sex, weight, BMI
              • Restraint use
              • Injuries obtained (via medical records and interviews)
                • Standardized into an abbreviated injury scale (AIS)
                  • Examines fatality
                  • Whole body and regional injuries
                    • On 1-6 scale of severity
                  • Vehicle properties
                    • Type
                    • Model year
                  • Crash conditions
                    • Estimated speed
                    • Mechanism of impact

What we know from NHTSA data and Insurance Institute for Highway Safety

  • Overall, males represent about 70% of overall fatalities for crashes
    • Greatest gender differences is in 20-29 age group
    • Men more likely to have alcohol involved in accident
  • On average men drive about 5000-6000 miles/yr more than women
    • Women more likely to work closer to home
      • Crashes more likely to be low speed and to occur in more congested areas
    • If a man and a woman are both in car
      • Males more likely to be driver
    • Summary of Bose study Vulnerability of female drivers involved in motor vehicle crashes: An analysis of US population at risk.
      • Question they asked- for a comparable crash do male and female drivers sustain similar rates of injuries.
        • Examined injury outcomes in men and women using 1998-2008 NASS CDS data set
        • For a comparable crash, women had 47% percent greater chance of being severely injured than men
          • Had a higher risk of chest and spine injuries
        • Of note the researchers controlled for weight and BMI

Other evidence that the clinical relevance of studying different sized and biomechanical models in crashes is important is shown by data obtained in 2011 after the NHTSA changed their safety star ratings to include testing of a female sized dummy in the front passenger seat. Many cars found their ratings go down, for example the 2011 Sienna minivan saw its ratings for passenger frontal crashes go from 5 star to 2 after it was shown that at 35mph that 20-40% of female dummies were killed or seriously injured compared to the industry average of 15%.

Underscoring the “literal” blind spots that can occur if you don’t consider factors associated with diversity in study design, a recent study from Georgia Tech suggested that some of the visual recognitions systems used that are critical for self-driving car safety may not adequately recognize dark skinned faces showing a 5% increased chance of error in recognition compared to that of fair skinned faces. Of note, there is a significant lack of gender and racial diversity in the self-driving car technology teams and in artificial intelligence/tech research overall.

Who makes up the team influences what gets studied, click here for a recent Lancet article and here for a Nature Human Behavior one both  showing that sex-related outcomes are far more likely to be reported in medical research consisting of diverse teams.

Take home points

  • Including the variables of biological sex and gender in research results in better science and has led to the discovery of huge knowledge gaps that need to be closed if we want to optimize the care of all of our patients
  • Our historical medical research model has been predominately based on the study of male animals. There are multiple reasons for this including a true belief that: outside our reproductive zones that men are women are exactly the same; using males animal produces cleaner data; and including women of child bearing age in clinical research trials exposes women to unnecessary risks without significant benefit. We now know that all these reasons are fundamentally flawed. Every cell has a sex and the differences between men and women outside their reproductive zones are often quite clinically important. Studying males and females side by side helps us to optimize the care of both sexes. In women it allows us to double check that therapies that were originally developed in men actually work in women and have the same benefit/side effects profiles. And for men, in instances when it is discovered that women have more favorably outcomes, it allows us to go back to the lab, figure out why there is a difference and then to use that knowledge to develop new therapies to help men.
  • To move the scientific community and its deeply ingrained culture to a new model that incorporates the variables of sex and gender will require a comprehensive multi-targeted approach. Key considerations include- engagement, education, skill building around research methodology and analysis, mentoring and funding incentivization. Of note Institutional review boards, journal editors, grant reviewers and conferences directors have great power to jump start this transition by including an expectation of sex and/or gender inclusion in submission requirements.
  • As we live in an ever increasingly complex world, now more than ever, it is essential that we pay attention to who is actually doing the research and developing new technologies. A diverse world requires diverse teams.

Next month we will look at the science pipeline from bench to bedside to identify opportunities to do better science.

seX & whY Episode 10: How to Give Better Feedback

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Show Notes for Podcast Ten of seX & whY

Host: Jeannette Wolfe

Guests: Adam Kellogg, Associate residency directory and medical education fellowship director UMMS – Baystate and Mike Gisondi, Vice-chair of education at Stanford

Topic: How to Give Better Feedback

What is bad feedback –

  • Vague
  • Nonactionable
  • Feedback on non-malleable attributes – like gender, age
  • Sandwich model
  • Done in public place in front of peers

Know what role you are playing (from Thanks for the Feedback)

  • Cheerleading: encouragement
  • Coach: real time pointers
  • Evaluator: comparison of performance to peers or expected benchmark

We are most effective giving and receiving feedback if expectation of roles match up – ie a novice putting in their first central line needs a coach not an evaluator.

Radical Candor- Develop as a Leader and Empower your Team by Kim Scott

  • Caring personally
  • Challenging directly

Feedback formula by Lisa Stefanar KSE leadership

  • Ask permission
  • State intention (be a better doctor)
  • State behavior
  • Describe impact
  • Inquire about learner experience
  • Identify desired change

General tips

  • Feedback is also received best if the learner has a sense of belonging and a believe that you recognize their potential
  • Is it the right time (asking them helps)
  • Praise in public, give tough feedback in private
  • Label it – as in “I’d like to give you feedback, is now a good time?”
  • If you anticipate that you might get emotional during feedback, prepare and practice a response. For example, “I obviously have a powerful response to this information could we please take a 5 min break and regroup”
    • Emphasize your desire to hear feedback
    • If needed ask for clarification
  • If you are giving feedback and the other person becomes emotional
    • Consider using “Name and Tame strategy
      • “Last time I gave you feedback, I noticed that you did…….. and I have to tell you, honestly now I’m a little more hesitant. As I want you to be the best doc you can be, is there a particular way that would work best for you to receive feedback?”
    • Switch-tasking- many times conversations can change
      • Recognize which conversation you are going to tackle
        • The one about a specific behavior
        • The one about an emotional tag

Suggested books

Thanks for the Feedback- Douglas Stone Sheila Heen

Radical Candor by Kim Scott

Articles by Mike Gisondi and Lisa Stefanac and the Feedback Formula

https://icenetblog.royalcollege.ca/2018/10/02/the-feedback-formula-part-1-giving-feedback/

https://icenetblog.royalcollege.ca/2018/10/23/the-feedback-formula-part-2-receiving-feedback/

Wise feedback intervention: https://www.apa.org/pubs/journals/releases/xge-a0033906.pdf

Harvard Business School article on gender differences in receiving feedback https://hbr.org/2016/04/research-vague-feedback-is-holding-women-back

Harvard Business School article with deals with managing emotional response to feedback

https://hbr.org/2016/09/how-to-give-feedback-to-people-who-cry-yell-or-get-defensive