Let me tell you something. There’s one of these doctors in Atlanta that’s taken a knife and cut the human heart-the human heart,” he repeated leaning forward, “out of a man’s chest and held it in his hand.” and he held his hand out, palm up as if it were slightly weighted with the human heart…{and} he doesn’t know more about it than you or me.”
– Flannery O’ Connor, “ The Life You Save May Be Your Own”
The human heart is the most vital organ in the human body, its steady beat, the ultimate proof of life. Consequently, any failure in its functioning can be deadly especially when this failure occurs suddenly, without any prior warning signs and symptoms, outside of a hospital or medical clinic. In medical terms, this phenomenon is known as Sudden Cardiac Death (SCD). An SCD is the most commonly caused due to the occurrence of a cardiac arrest in an individual.
Cardiac arrest (also known as cardiopulmonary arrest or circulatory arrest) is the cessation of normal circulation of the blood due to failure of the heart to contract effectively. Cardiac arrest is a medical emergency that, in certain situations, is potentially reversible if treated early. Unexpected cardiac arrest sometimes leads to death almost immediately, this is called sudden cardiac death[1]. Recent data indicates that SCD’s are an unfortunate reality of modern society. SCD is the leading cause of death globally, with the global incidence of out-of-hospital cardiac arrest (OHCA) being 62/10,000[2]. While not much data is available on the prevalence of OHCA’s in India, here too the prevalence rate is believed to be on the rise.
At the same time, it has been shown that if victims of OHCA can receive immediate and appropriate treatment, they have a 30%–70% chance of survival[3]. In fact, the management of OHCA is presently the only area of prehospital emergency care where there is clear evidence that appropriate intervention leads to improved survival[4]. The appropriate intervention as indicated by the American Heart Association is cardiopulmonary resuscitation (CPR). Troublingly, a contemporary study has substantiated that there is a clear gender divide in the percentage of women who successfully survive an OHCA with a lower percentage of women being successfully resuscitated compared to men.
The reasons for the above phenomenon need to be closely examined. Is the fairer sex, currently the endangered one? Is it a fluke of nature or are there legitimate reasons for the same? A population-based cohort study published in the European Heart Journal in 2019 provides us with some solid answers. The results of this study show women with OHCA were less likely than men to receive a resuscitation attempt by a bystander (67.9% vs. 72.7%; p < 0.001), even when OHCA was witnessed (69.2% vs. 73.9%; p< 0.001)[5]. Another study showed that this is due to fear among the general public regarding inappropriate touching, accusations of sexual assault, and fear of causing injury in women[6]. Qualitative feedback given by male participants in the study included statements such as:
“Touching the chest area in women is forbidden in many societies. Nowadays, you could be accused of sexual assault, whether it is being given by a man or a woman to a woman”
–Male, age 40.
“Women tend to be smaller than men, and chest compressions can be very forceful. It might be assumed that giving CPR to a woman might cause further injury if the woman is particularly small in stature”
–Male, age 27
“The perception that the illness is more serious in men”
–Male, age 29.
Such concerns while justifiable and understandable may be the difference between survival or death in a woman suffering from an out of hospital cardiac arrest. Public awareness programs organised by the government in order to educate the public on the value of bystander administered CPR is the need of the hour. CPR training programmes should not be reserved for doctors or health care workers/professionals alone. As part of their Corporate Social Responsibility policies, CPR training programmes should be organised by the Human Resources team for all corporate employees. Schools and colleges too can have these programmes for their students, teachers and administrative staff.
While the above-mentioned studies relate the psychological reasons why women are less likely to survive an OHCA. There are also some physiological reasons for the same. Women suffering from an OHCA are often older (69.4 vs. 67.1 years; p< 0.001) compared to men. They also suffer an OHCA less often at a public location (15.2% vs. 32.1%; P< 0.001) and had less often witnessed OHCA (70.8% vs. 74.7%; p< 0.001)[5].
Also, in the case of a cardiac arrest followed by CPR, survival also depends on the patient having a ‘Shockable initial Rhythm’ (SIR) when emergency services arrive on location and connect the patient to an automated external defibrillator. The initial rhythm recorded by manual defibrillator or AED is categorized as shockable (ventricular tachycardia, ventricular fibrillation) or non-shockable (asystole, pulseless electrical activity).
The 2019 study by Blom et al showed that women were less likely to have SIR than men (33.7% vs. 52.7%; p < 0.001). Presence/absence of SIR (dependent variable) was associated with sex, age, and all resuscitation characteristics, in both univariable and multivariable analyses. Even when OHCA occurred at a public location, women were less likely to have SIR than men (59.2% vs. 72.0%; p< 0.001). Thus, female sex was independently associated with lower odds of SIR after adjustment of age and all resuscitation characteristics (OR 0.55; 95% CI 0.49–0.63; p < 0.001) )[5].
While these physiological gender differences may be out of our control, what needs to be targeted is the training of the general public in administering CPR and encouraging them to administer CPR to a patient irrespective of gender. Especially in a country like India where it is believed that 98% of the country’s population is not trained in the basic CPR according to a survey conducted by Lybrate, an online consultation platform.
To sum it up, don’t let gender hold you back in learning CPR or administering it!
Take some time to learn first aid and CPR.
It saves lives and it works.
-Bobby Sherman
References:
1 Jameson JN, Dennis LK, Harrison TR, Braunwald E, Fauci AS, Hauser SL, et al. Harrison's Principles of
Internal Medicine. New York: McGraw-Hill Medical Publishing Division; 2005
2 Rao BH, Sastry BK, Chugh SS, Kalavakolanu S, Christopher J, Shangula D, et al. Contribution of sudden
cardiac death to total mortality in India – A population based study. Int J Cardiol 2012;154:163-7.
3 Larson MP, Eisenberg MS, Cummins RO, Hallstrom AP. Predicting survival from out-of-hospital cardiac
arrest. Ann Emerg Med 1993;22:1652-8.
4 Guidelines for cardiopulmonary resuscitation and emergency cardiac care. Emergency cardiac care committee
and subcommittees, American Heart Association. Part I. Introduction. JAMA 1992;268:2171-83.
5 Blom MT, Oving I, Berdowski J, van Valkengoed IGM, Bardai A, Tan HL. Women have lower chances than
men to be resuscitated and survive out-of-hospital cardiac arrest. Eur Heart J
2019; doi:10.1093/eurheartj/ehz297.
6 Perman SM, Shelton SK, Knoepke C. Public perceptions on why women receive less bystander
cardiopulmonary resuscitation than men in out-of-hospital cardiac arrest. Circulation. 2019;139:1060e1068.
