Preprint Females are less likely to receive bystander cardiopulmonary resuscitation in witnessed out-of-hospital cardiac arrest, 2023, Munot et al.

[SNT Gatchaman]

Females are less likely to receive bystander cardiopulmonary resuscitation in witnessed out-of-hospital cardiac arrest: An Australian perspective.
Sonali Munot; Janet E Bray; Julie Redfern; Adrian Bauman; Simone Marschner; Christopher Semsarian; Robert Denniss; Andrew Coggins; Paul M Middleton; Garry L. R. Jennings; Blake Angell; Saurabh Kumar; Pramesh Kovoor; Matthew Vukasovic; Jason C. Bendall; Thomas Evens; Clara K Chow

Background
Bystander cardiopulmonary resuscitation (CPR) plays a significant role in survival from out-of-hospital cardiac arrest (OHCA). This study aimed to assess whether bystander CPR differed by patient sex among bystander-witnessed arrests.

Methods
Data on all OHCAs attended by New South Wales (NSW) paramedics between January 2017 and December 2019 was obtained from the NSW Public Health Risks and Outcomes Registry (PHROR). This observational study was restricted to bystander-witnessed cases with presumed medical aetiology. OHCA from arrests in aged care, medical facilities, and cases with an advance care directive (do-not-resuscitate) were excluded. Multivariate logistic regression was used to examine the association of patient sex with bystander CPR. Secondary outcomes were OHCA recognition, bystander AED applied, initial shockable rhythm, and survival outcomes.

Results
Among the 4,491 bystander-witnessed cases, females were less likely to receive bystander CPR in both private residential (Adjusted Odds ratio [AOR]: 0.82, 95%CI: 0.70-0.95) and public locations (AOR: 0.58, 95%CI:0.39-0.88). Recognition of OHCA in the emergency call was lower for females, particularly in those who arrested in public locations (84.6% vs 91.6%-males, p=0.002) and it partially explained the association of sex with bystander CPR (~44%). There was no significant difference in OHCA recognition by sex for arrests in private residential locations (p=0.2). Females had lower rates of bystander AED use (4.8% vs 9.6%, p<0.001) however, after adjustment for arrest location and other covariates, this relationship was attenuated and no longer significant (AOR: 0.83, 95%CI: 0.60-1.12). Females were significantly less likely to record an initial shockable rhythm (AOR: 0.52, 95%CI: 0.44-0.61). Although females had greater odds of event survival (AOR: 1.34, 95%CI: 1.15 ? 1.56), there was no sex difference in survival to hospital discharge (AOR: 0.96, 95%CI: 0.77-1.19).

Conclusions
OHCA recognition and bystander CPR provision differs by patient sex in NSW. Given their importance to patient outcomes, research is needed to understand why this difference occurs and to raise awareness of this issue to the public.


Link | PDF (Preprint: MedRxiv)

 

[SNT Gatchaman]

OHCA recognition and bystander CPR provision differs by patient sex in NSW. Given their importance to patient outcomes, research is needed to understand why this difference occurs and to raise awareness of this issue to the public.

It's a mystery.

 

[Sid]

No surprise there. Previous research has shown that females having a heart attack are more likely than males to be diagnosed with anxiety by emergency room. The same beliefs extend to the general public as we see here.

 

[Jonathan Edwards]

I don't see anything in the abstract about age. I would expect females having cardiac arrests to be older. Maybe that is covered by the logistic regression but it should be said.

This is of course Australia and most of the Australians I know left Australia for the UK because of the perception of sexism in Oz society!

It also says that more women survived so maybe they are doing it right?

 

[Arnie Pye]

I thought that women didn't get CPR from bystanders because those bystanders are worried about touching the boobs of women they don't know in public.

 

[Mij]

Women survive a heart attack more often when their doctor is female, study finds

 

[Mij]

I thought that women didn't get CPR from bystanders because those bystanders are worried about touching the boobs of women they don't know in public.

So basically flat chested women have a higher chance of survival

 

[Arnie Pye]

So basically flat chested women have a higher chance of survival

Probably!

 

[Creekside]

Arnie's comment was my first thought too. Men are taught to not touch breasts without permission, so that's a mental hurdle to overcome. There's also the fear of being charged with groping or whatever. I wouldn't know for sure if CPR was the correct response for the situation, whether it's a man or a woman. I also don't have any CPR training, so I'm not sure what I'd do in such a situation. I think if fear of impropriety was a concern (witnesses around), I'd clearly state that I was going to attempt CPR.

Someone should study deeper to see if the numbers do correlate with flat-chested vs well-endowed, or witnesses vs no witnesses.

CPR--and other first aid--taught in high or elementary schools would be a lot more useful than memorizing the name of the prime minister of somewhere sometime.

 

[Mij]

I had to dig further . . .

When it comes to CPR, you gotta get grabbed.

That’s why a new product, the Womanikin, is putting boobs on CPR mannequins. They’re not just for show: The altered model aims to combat the disparity between genders receiving CPR from bystanders.

https://nypost.com/2019/06/06/cpr-mannequins-are-getting-breasts-to-save-womens-lives/

 

[SNT Gatchaman]

I don't see anything in the abstract about age. I would expect females having cardiac arrests to be older. Maybe that is covered by the logistic regression but it should be said.

Yes.

Of the bystander-witnessed cohort (n=4491), 30% were female. Most arrests occurred in private residential locations, although this was significantly higher in females (84.6% females vs 70.7% males, p<0.001). Females were also older (median age: 71 vs 68 years, p<0.001), and less likely to have a presumed cardiac cause than males (54.0% females vs 61.9% males, p<0.001).

I thought that women didn't get CPR from bystanders because those bystanders are worried about touching the boobs of women they don't know in public.

Several studies have found differences in provision of bystander CPR by sex with most indicating lower rates in females and some suggesting the observed differences vary by arrest location or patient age. For example in the United States, males had higher odds of receiving bystander CPR in public locations, but not in private residential locations. Similar observations were made across Asian countries where an analysis of 56,192 OHCA cases found females had lower rates of bystander CPR in public locations, but in private locations there were higher rates of CPR for females compared to males. Such observations have been explained as potentially due to the bystander knowing or being related to the patient in private locations versus a discomfort of touching the chest of an unknown female in public locations. Indeed, one study form the U.S. suggests it may be less socially acceptable to perform CPR in women with hesitancy in touching females suggested as a factor in a public survey conducted in the United States. In our cohort, majority of bystanders were related with patients in private residential locations, less so in public locations. Despite this we observed a disadvantage in CPR provision for females in private residences.

Researchers have pointed to sex-related differences in warning symptoms prior to cardiac arrest noting that while chest pain was more commonly experienced by men, women more typically had shortness of breath.

Females also had a lower likelihood of presenting in a shockable initial rhythm irrespective of age and location. This could be related to differences in arrest aetiology and mechanisms of cardiac arrest. However, a lack of or a delay in CPR provision could also play a role, given that over time shockable rhythms degenerate to non-shockable rhythms without chest compressions. As reported in other studies, females were more likely to survive to hospital, but there was no difference in survival to hospital discharge. Several studies have examined the differences in aetiology and comorbidities among women. However, it is uncertain whether a real difference in survival exists after accounting for known patient, prehospital and treatment factors that could explain disparities.

 

[Wits_End]

It's quite well-known that the "typical" symptoms of a heart attack are those found in men: in women, they are often quite different, and not nearly as recognisable, because we've all been taught to be aware of male-type symptoms only.

 

[Mij]

@SNT Gatchaman

Thanks for starting this thread. I truly had no idea that this was an issue. I was of the impression that bystanders would be more focused on starting CPR and saving a life.

 

[Arnie Pye]

I had to dig further . . .

When it comes to CPR, you gotta get grabbed.

That’s why a new product, the Womanikin, is putting boobs on CPR mannequins. They’re not just for show: The altered model aims to combat the disparity between genders receiving CPR from bystanders.

https://nypost.com/2019/06/06/cpr-mannequins-are-getting-breasts-to-save-womens-lives/

I don't think I've (knowingly) ever met a woman with boobs as far apart as that mannikin with boob attachment.

 

[Creekside]

Breasts also vary with how they're positioned along the vertical axis, which could make a difference in where/how to apply pressure. The Womanikin needs to be adjustable to get responders used to non-standard configurations.

As for the difference in numbers, it might be some factor such as "women are more likely to be in situations with x characteristics (ie. bystanders are busy and ignoring surroundings", or they are more likely to have a heart attack at a certain time of day, which affects how people respond.

I think Wit's End's response might be right. I wasn't aware of differing signs of heart attack by gender, so maybe on women it looks more like "fainting" or some sort of emotional outburst (that men don't want to deal with).

 

[Jonathan Edwards]

I wasn't aware of differing signs of heart attack by gender, so maybe on women it looks more like "fainting" or some sort of emotional outburst (that men don't want to deal with).

There is literature on different symptoms of myocardial infarction with gender. I suspect that may in part relate to difference in pathology. Men might be more likely to infarct large segments of heart at once from focal stenoses with thrombus where for women the event may be part of a diffuse ageing process.

But the is about cardiac arrest - which occurs in a minority of cases because the infarct causes an irregular rhythm (or loss of rhythm). The signs are the same in men and women as I can attest to having seen them scores of times in the middle of the night on duty in A/E. The person suddenly becomes limp, goes blue and may have a minor convulsion. They stop breathing completely. It is usually very obvious, for both men and women, that they are no longer keeping themselves alive. Fortunately, in most of the cases I have seen we have managed to restore heart function.

 

[Creekside]

The person suddenly becomes limp, goes blue and may have a minor convulsion.

At one time, wouldn't it have been common to view that as "female hysteria", "having the vapours", or some such dismissal? Eventually, they'd realize "Oh, she's dead." A manly man clutching his chest and keeling over would be accepted as a heart attack ... and probably given some ineffectual treatment, such as loosening his tie, or "fetch a brandy!"

 

[Jonathan Edwards]

At one time, wouldn't it have been common to view that as "female hysteria",

You may not have met many people suddenly going dead. It doesn't look the least bit like having the vapours. You go dark blue, make strange noises with your lips and often wet yourself. It still terrifies me to see it after fifty years - most recently a friend on the ski slopes.

Men do not clutch their chests and keel over that often. The cardiac arrest event tends to occur either without warning symptoms or some considerable time after pain starts.

 

[SNT Gatchaman]

There used to also be delay to compressions for both males and females, as bystanders and sometimes HCWs were often unsure if actual cardiac arrest and were worried about injuring the heart or breaking ribs.

So pulse check has gone, which wasted time even if you were trained to evaluate carotid or femoral pulse. Now as Jo says, unresponsive with abnormal breathing -> immediate compressions. There's no meaningful downside even if the problem is actually a cerebral haemorrhage.

Also doing chest compressions is now much more of a priority than mouth-to-mouth ventilation in the out-of-hospital scenario. Continuous compressions are prioritised as circulating hypoxic blood is still better than non-circulating less hypoxic blood, and there is a delay to re-establishing physiologically effective rescue circulation when compressions are paused for ventilation or rhythm check / shock.

Early defibrillation is critical though for survival out-of-hospital. So a pwME well enough to be in the community and witnessing an arrest could make themselves very useful even when completely unable to assist in physical resuscitation. In many ways they are in a better position to help manage the event hands-off (which is the ideal management in the well-resourced, professional/in-hospital scenario).

Call emergency services and say "cardiac arrest" as your first words. It doesn't matter if you're wrong. In major cities, that will often task a fast responder, eg motorbike, in addition to ambulance. Get on your phone and locate the nearest AED (there are apps in most countries for this) and instruct another (fit) bystander to run for it. The aim is rapid return of spontaneous circulation out of a shockable rhythm. Time = neurons.

 

[Sid]

20+ years ago an elderly woman clearing snow with a shovel (what possessed her to do this, I will never know) fell down dead beside me of cardiac arrest. It was extremely sudden with no warning, she just went blue and nonresponsive. Back in those days there were no mobile phones or defibrillators around. The ambulance came very quickly but it made no difference.