I’LL NEVER FORGET THE DAY that a thirty-two-year-old woman almost walked out of my emergency department while having a heart attack.
In emergency medicine, there are many algorithms by which we evaluate risk factors and stratify incoming patients. Not everyone who walks through the doors of the emergency department is on death’s door, so we treat the most urgent cases first. For example, someone who’s asphyxiating or suffering from a stab wound will be regarded as a higher priority than someone suffering from nonspecific pain or who “just doesn’t feel quite right.”
Does this risk assessment makes sense?
This risk assessment makes sense theoretically and works fairly well in practice too. But once the obvious cases have been dealt with, we’re navigating a large gray area. Unfortunately, the subtle (and often subjective) strata by which we prioritize patients who don’t appear to be at immediate risk are far from perfect—particularly when those patients are women.
Women are different from men in more ways than merely the obvious—and nowhere is this more apparent than in the halls of the hospital where I work and teach every day.
For example, the research upon which our stratification procedures are based cites things like the “estrogen-protective effect” (meaning, the way in which blood estrogen levels appear to reduce or modify traditional risk factors like oxidative stress, arrhythmia, and fibrosis in premenopausal women) and the supposedly low statistical likelihood of premenopausal women presenting with acute heart conditions. In other words, even if a young woman were to come into the ED and say, “I think I’m having a heart attack,” unless she displayed blatant and very specific symptoms, most doctors would immediately look for another explanation.
Julie, the young woman I met that day, had visited her primary care doctor several times prior to coming to the emergency department and had also seen at least two other physicians in the previous forty-eight hours. She was experiencing discomfort in the region of her chest and shortness of breath that worsened markedly the more agitated she became.
I was working in the critical care area when she came in. Immediately, I thought to myself, This woman doesn’t look good. I had a gut feeling that something was really wrong.
Her other doctors had attributed Julie’s symptoms to a combination of anxiety and stress to her heart due to her obesity. The vagueness of her descriptions when she talked about her symptoms, combined with her age and the fact that she had been clinically diagnosed with anxiety several years before, made her current discomfort seem like a no-brainer for her doctors. She was having panic attacks, and her weight was compounding the issue. End of story.
However, as a specialist in sex and gender medicine, I knew that during myocardial infarction (MI)—aka, a heart attack—and other cardiovascular events, women often present much differently than men. In fact, women’s cardiac symptoms are often described as “atypical” and “unusual” in medical literature. While men might experience pain radiating down the left arm, chest heaviness, or other stereotypical signs of a heart attack, women often present with only mild pain and discomfort, possibly combined with fatigue, shortness of breath, and a strong feeling that “something isn’t right.”
Julie was very pleasant, but I could tell she was scared. I calmly explained that, while her current issue might be exactly as other doctors had described, I would be more comfortable if we ordered an electrocardiogram (EKG) and blood work to make sure things looked normal.
When we got the results, I caught my breath. There was something very wrong here. This could actually be a myocardial infarction, I thought.
I immediately called our attending cardiologist. “I believe this woman is having an MI and needs to go to the cath lab,” I told him. The cath lab is the medical suite where a procedure to fix blocked arteries is performed.
“A thirty-two-year-old woman?” There was a slight pause, then a sigh. “Oh, all right. I’ll send someone down to take a look.”
Like Julie’s previous doctors, the cardiologist’s assessment was that she was displaying symptoms of assessment was that she was displaying symptoms of anxiety. But her EKG was slightly abnormal, so he finally agreed to take her to the cath lab.
About an hour later, I got a call from the cardiologist. “Dr. McGregor,” the attending cardiologist began, sounding a bit astounded, “I wanted to let you know that your patient, Julie, had a 95-percent occlusion of her main coronary artery. We placed a stent to restore blood flow to her heart.”
Modern Medicine Is Male-centric!!
An occlusion of the main coronary artery, in a man, is often called a “widow maker.” We see it all the time in men over fifty and in a number of postmenopausal women. And yet, here was sweet, thirty-two-year-old Julie presenting with a condition that was likely to kill her in weeks, if not days, if left untreated—and no one had thought to look for it because her symptoms and risk factors weren’t consistent with the classic male model of a heart attack.
Thankfully, Julie pulled through the procedure and recovered. I didn’t see her in the ED again, but her story has stayed with me. Sometimes, I wonder how many other women like her walk out the doors of other emergency departments every day without receiving the lifesaving treatment they need and deserve for their health and wellness. Even one is too many—but I have a feeling the number is much, much higher than that.