Invisible Women: female medics insisting on having female hands
Invisible Women: female medics insisting on having female hands
Well hello there my dear GFPs! I hope you all misbehaved while I was away last week. As you can see, I put the time to good use...
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And if you want to know what on earth any of that was about, make sure you tune into the podcast when it launches later this month which is FINE we are TOTALLY READY and NOT AT ALL PANICKED ABOUT THAT IMPENDING DEADLINE 🤠
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Gender data gap of the week
Following on from last week's overall-not-that-surprising revelation that women are nearly twice as likely as men to become trapped in a car following a crash, the same group of researchers have released another study which analyses sex differences. They are ON FIRE, GFPs.
This second study looked at sex differences related to tranexamic acid (TXA), a drug that is given to trauma patients to stop excessive blood loss:
Each year, world-wide, more than four million people die from injury. Most injury deaths are from exsanguination or traumatic brain injury. The CRASH-2 (20,211 patients) and CRASH-3 (12,737 patients) trials showed that timely treatment with the antifibrinolytic drug tranexamic acid (TXA) reduces deaths on the day of the injury in polytrauma patients and in patients with isolated traumatic brain injury by about 20%.
The CRASH trials reported in June 2010 and October 2019. And this 2022 paper is the FIRST sex-disaggregated analysis of that data that has been done. Which is fine.
As far as who was included in the analysis, the study authors explained that
Patients randomised more than 3 hours after injury in both trials were [...] excluded as the explanatory analysis of the CRASH-2 trial showed that TXA has no beneficial effect beyond this time.
...which feels very relevant given what we found out in last week's newsletter about women being almost twice as likely as men to become trapped in their car following a crash. So bear that in mind as you read the rest of this section.
Anyway, the good news is that we can now confirm that TXA is as effective in women as it is in men. Hooray! Totally cool that it only took twelve years for anyone to look into that!!!
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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.
Default male of the week
As a medical trainee pursuing general surgery at Vanderbilt University Medical Center in Nashville, Jaime Bohl, MD, struggled to operate equipment the way her male attending physicians taught her.
Her hands were too small to drive the endoscope into the colon and easily adjust it because of the position of the buttons.
It wasn’t until the chair of her fellowship program, a female surgeon, showed her how to adjust her pinky to free up her other fingers that she was able to make the instrument's use less cumbersome.
GFPs I know we talked about this article last newsletter but I only covered the PPE bits and this week I want to talk specifically about surgical tools, which are ALSO not designed for the female body. And, as with PPE, this really matters. Medicine -- and in particular, surgery -- is a precision occupation. You don't want your doctor to be struggling with the equipment when they're cutting you open. And yet, this is exactly what many female medics have reported to me over the years.
When the surgical bed doesn’t go low enough, Bohl must stand on steps that limit her balance and compromise her ergonomics.
[...]
One small 2014 study found that surgeons who were women were more likely to receive medical treatment on their hands and report shoulder, neck, and back pain than their male counterparts, which the study authors suggested could be remedied by redesigning laparoscopic equipment and bed heights to be more ergonomic for smaller surgeons.
Or, you know, we could just carry on shouting at female medics for having female hands:
Meanwhile, surgery remains a highly male-dominated profession: in the US only 22% of general surgeons are female; in the UK 86% of consultant surgeons are male. What is particularly interesting/disheartening about the UK data is that women in fact make up 41% of early stage surgeons, so something is going wrong to end up with only 14% female consultants: could part of the problem that the instruments literally don't fit their hands?
And this is not just bad for the female surgeons: it's bad for patients, especially of the female variety. Research from earlier this year found that female patients are 32% more likely to die if their surgery is carried out by a male surgeon than if it's carried out by a female surgeon. They are also more likely to experience complications and to be readmitted to hospital. Men, meanwhile, have similar outcomes whether their surgery is carried out by a male or a female surgeon.
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Toilet...something...of the week
Homework
Two bits of homework! First up:
I'm sure there are GFPs to whom this applies -- and if not, that you know fellow GFPs who would be interested in submitting a paper!
And second, final call for telling NHTSA to get their act together. As a reminder:
The US regulator (NHTSA) is requesting comments on the question of updates to 5 star safety – these are the consumer tests, and they currently do not require a female dummy in the driver seat. When they do use a female dummy, in the passenger seat, they are using the very old scaled-down-male Hybrid III 5th percentile female dummy. This is weird because there is a more advanced 5th percentile female dummy available, the THOR 5F – and the tests have introduced the more advanced THOR average male dummy. So why are women stuck in the 1980s?
GFPs, here is your mission, should you choose to accept it:
1) submit your comment on NHTSA’s website, explaining why you want better representation for women in car safety tests. You can find loads of useful resources/info on VERITY NOW’s website to help you craft your message and they’ve also created this useful toolkit.
2) Tweet @SecretaryPete, the US Secretary of Transportation, and ask him to tell @NHTSAgov to put the advanced female dummy in the driving seat for 5 star safety tests. If you aren'y sure what to say, VERITY NOW have put together some handy examples for you:
Example 1
#DYK women are 17% more likely to die in a vehicle crash than men? Why? NCAP tests do not require the use of female crash test dummies. @SecretaryPete we need #equality in all vehicle safety tests to protect women’s lives. #VERITYNOW
Example 2
Vehicles and vehicle safety tests are designed by men, for men. Female crash test dummies are simply scaled-down versions of male dummies. This bias in design disproportionally affects women’s lives. @SecretaryPete, it’s time to #BreakTheBias in vehicle safety. #VERITYNOW
That’s it! Go forth, my GFPs, and help literally save women’s lives
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Poppy pic of the week
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That's it! Until next time my dear GFPs....xoxoxo