The bad news is that female trauma patients are substantially less likely to receive it. In fact, the data shows that women are less than half as likely to receive TXA as men “regardless of their risk of death from bleeding (BATT score) or the severity of their injuries.”
Naturally, I’m still fine.
The data also showed that while women were less likely than men to receive TXA treatment in every age category, the disparity increased as patients got older. This is bad because injured women admitted to hospital tend to be older than injured men, and “the risk of death due to bleeding increases with age.”
The sex disparity in treatment begins with how long it takes to get to hospital in the first place, with the mean time being 126min for female patients versus 106min for males. Then there’s where you get taken, with women and older patients (who are disproportionately female) being “less likely to be transferred to a major trauma centre and less likely to receive whole-body CT in the setting of major trauma.” Which is, of course, still totally fine.
GFPs would at this point be forgiven for asking what the f is going on here. Well, we don’t exactly know, although as the study authors point out this finding isn’t exactly unprecedented:
Women with chest pain are less likely to receive aspirin and nitro-glycerine and are less likely to be conveyed to hospital by an ambulance using lights and sirens. Women are less likely to be resuscitated for out of hospital cardiac arrest. Injured women are less likely to receive opioid analgesia.
The authors do suggest that part of the problem may lie in the patient group directions (PGD) legal framework through which paramedics administer TXA, which provides legally binding inclusion and exclusion criteria for giving TXA. According to the study authors, these exclusion criteria are overly narrow, and exclude “thousands of patients” who would likely benefit from receiving TXA, and, they add, “it is likely that those excluded are disproportionately women.”
So probably update the PGDs, PDQ, eh?
Still though, since the sex disparity in TXA treatment occurs “in both the prehospital and hospital settings,” this won’t be the full answer, and further research is needed to understand why it is that doctors seem to think female trauma patients with the same level of trauma as male patients are somehow less deserving of life-saving treatment. It’s a real head-scratcher that one, but there’s this book called Invisible Women, you may have heard of it, and there’s a passage in there that this finding made me think of:
…failing to listen to female expressions of pain runs deep, and it starts early. A 2016 study from the University of Sussex played a series of cries to parents (twenty-five fathers and twenty-seven mothers) of three- month-old babies. They found that although babies’ cries aren’t differentiated by sex (sex-based pitch differences don’t occur until puberty) lower cries were perceived as male and higher cries perceived as female. They also found that when male parents were told that a lower-pitched cry belonged to a boy, they rated the baby as in more discomfort than when the cry was labelled female.
Women’s physical pain is far more likely to be dismissed as ‘emotional’ or ‘psychosomatic’. The Swedish study which found that men are more likely to report depression also found that women who have not reported depression are twice as likely as men to be prescribed antidepressants. This chimes with studies from the 1980s and 90s which found that while men who reported pain tended to receive pain medication, women were more likely to receive sedatives or antidepressants. A 2014 study which required healthcare providers to make treatment recommendations for hypothetical patients with lower back pain similarly found that female patients were significantly more likely to be prescribed anti- depressants than men.
Could it be that women aren’t being prescribed life-saving TXA because female patients are perceived as somehow being at less risk when they are in fact at equal risk as their male counterparts? Perhaps there’s a touch of my least favourite syndrome, our old friend Yentl Syndrome (IW, p.217) going on here, and female patients who are at risk of death from bleeding present differently to our default male chums?
Either way, I prescribe these under-prescribing doctors a full dose of Invisible Women, STAT.