Anne Montera is the featured keynote speaker at EMS World Expo, Oct. 29–Nov. 2 in Nashville. This three-part series follows her journey, building to its unexpected conclusion.
You are called for a 37-year-old female, chief complaint “abdominal pain.” It is coded low-priority.
Sigh. Yes, your preplanning and differentials contain a host of life threats, but experience tells you a sizable percentage of these calls are nonurgent.
The suburban home is well kept, in a quiet neighborhood. A teenage girl opens the door and says her mother is in the kitchen. Your patient is sitting at the kitchen table. She is petite, quiet, and composed, holding her head in her hand.
Your internal monologue sighs again, but you don’t let it reach the polite expression of concern on your face.
She straightens and smiles apologetically as you walk in. You can see she has good color and is breathing normally. There are no signs of injury, and she is not doubled over.
There is no evidence of vomiting, although there is a wastebasket tucked discreetly next to the chair. There are a few prescription bottles lined up neatly on the table. You introduce yourself and ask her what’s bothering her today, and in a calm voice she says, “I am in excruciating pain.”
You nod agreeably, but your skepticism begins to leak through. Your differentials move away from life threats and toward possible behavioral issues—nothing in her presentation screams distress. Despite your growing doubts, you stay the course with your assessment.
Your partner attaches her to the monitor and cycles the blood pressure: 190/116. Raising an eyebrow, he repeats the pressure manually and confirms the reading. You turn back to the patient and ask if she has a known history of high blood pressure. She shakes her head and in the same quiet voice says, “I told you, I am in excruciating pain.”
This time she’s the one who sighs.
Pain and Gender
As providers, as people, we struggle with the concept of pain. It is uniquely personal and not tangible—a nebulous, purely subjective experience no two people will identify quite the same way. As we are discovering, no two genders feel it the same way either, and medicine is only now beginning to learn about the collateral damage that has resulted in when it comes to the treatment of pain.
For EMS providers pain control is not a straightforward subject with a clearly defined history. In the early days of EMS, you frequently did not treat for pain unless it was extreme and the doctor on the radio said you could. Our job was to come up with creative stall tactics to help get patients through the ride: “Hang in there, buddy, just a few more minutes.” If they had a closed head injury, it was even worse: The receiving physicians would rail against the crews because their sedatives or analgesics made a preliminary neuro exam impossible.
The concept of palliative care as a facet of prehospital care was difficult to develop. The idea implies a much longer-term relationship with patients than the average prehospital emergency allows. Our function is in an “emergent” span of interaction and gives rise to the argument that there are other priorities. We don’t have time to treat something non-life-threatening like pain. Even as the impact of “patient satisfaction” on reimbursement began spurring radical changes in treatment guidelines in the clinical setting, as a field we remained steadfast—tough it out, kid.
As much as we’d like to claim we’re healers of the people, no person operates purely without judgment or bias—it’s part of the human condition. One unique bias within the medical community at large has to do directly with gender: Women are treated differently, especially when it comes to pain. The reasons behind it are complex and heavily influenced by cultural and societal norms and assumptions, but the result is the same. Women in pain are frequently undertreated—or, worse, their symptoms are dismissed or devalued, resulting in years of unnecessary agony, misdiagnosis, and even death.
It’s not solely your fault as the provider. Women are taught to express themselves differently, to understate and not inconvenience. As natural caregivers they will deflect and defer their own discomfort in self-sacrifice to care for others. There is an inherent trust in the healthcare system, accompanied by the fact that nobody taught them how to advocate for their bodies. “Not just on the side of the medical establishment—where female pain might be perceived as constructed or exaggerated—but on the side of the woman herself: My friend has been reckoning in a sustained way about her own fears about coming across as melodramatic.”1 So they try not to burden others, preferring instead to try to function, until they cannot. By the time they ask for help, they are filled with self-doubt and become more willing to accept delays in testing or treatment.
When your suffering patient sighs, it is in acceptance of the fact that you do not believe she is in pain and she must explain away the rest of her assessment first. You are one more person in an extensive line of medical professionals she’s had to convince her illness is not some psychologically created phantom menace but a genuine experience that is disrupting her life and indicates systemic damage or dysfunction. The process even has a name, “Yentl syndrome,” wherein women are generally found to be treated less aggressively within the healthcare system until they “prove they are as sick as male patients.”2
In the United States women wait an average of 65 minutes for analgesia in response to acute abdominal pain, compared to 49 minutes for men. One study even showed women who received coronary bypass surgery were only half as likely to be prescribed painkillers as men who had undergone the same procedures.3 Half, for having their sternum sawed open.
This isn’t the promotion of politics but simple biology. It is not a reach to consider that the internal structure and anatomy differs based on gender. We adapt dosing and treatment to age and weight; why is considering gender such a stretch?
“Women have hormonal cycles, smaller organs, higher body fat composition—all of which are thought to play a role in how drugs affect our bodies,” noted health and science writer Laurie Edwards. “We also have basic differences in gene expression, which can make differences in the way we metabolize drugs. For example, men metabolize caffeine more quickly, while women metabolize certain antibiotics and anxiety medications more quickly. In some cases drugs work less effectively depending on sex; women are less responsive to anesthesia and ibuprofen, for instance. In other cases women are at more risk for adverse—even lethal—side effects.”4
A Nurse’s Story
Anne Montera is an animated, articulate woman with a cheerful voice and bright personality. The cadence of her speech is ardent, sincere, and optimistic. When you have her attention, there is no doubt she is listening to you. It makes her story difficult to hear, because for a long time nobody was truly listening to her, and it almost killed her.
Those who work in healthcare are frequently the least likely to seek its help. Not so in Anne’s case: A newly graduated nurse, fresh from college, her introduction into adulthood came with crippling pain. She began to experience “hard periods,” episodes of extensive pain that would twist her into knots and impact her everyday life. Active in sports, she’d had orthopedic surgeries on a knee and an ankle, and even being cut open was nothing compared to what her insides would do to her every few weeks. Her doctors began looking for causes, and when they scoped her gallbladder, they discovered she had significant endometriosis. She was full of scarring already.
They moved her case quickly from GI over to gynecology, and just five months before she was to marry, she was told that the scarring was so bad that she probably would not be able to conceive.
This was not acceptable to Montera, but sometimes the medicine can be worse than the illness. She spent months receiving shots and taking fertility treatments, medications that triggered crippling migraines like clockwork. Though she closely followed all her doctor’s instructions, very little was done to address her pain or help her manage what she was physically experiencing.
Through all of this Montera kept working as a nurse, coming up with ways to cope that would still allow her to function. While this tenacity is not limited to gender, it is consistent with women and chronic pain. One of the major facets of pain management comes from learning how to assess and measure it. One of the many gender differences discovered was how men and women perceive their pain. In the frequently cited study “The Girl Who Cried Pain: A Bias Against Women in the Treatment of Pain,” researchers pointed out that “Psychological factors influencing the pain response include cognitive appraisal of pain (i.e., meaning-making), behavioral coping mechanisms, and cultural influences.”2
This means women and men view the experience of pain from perspectives unique to their gender experience. Women describe pain with context, with a primary concern of how it impacts their relationships and ability to function in their cultural roles (like child care). Men relate pain to loss, a threat to their livelihood. When pain impacts their ability to physically work, they will more aggressively complain about it.
Montera continued to work and push through a daily routine because to reach her professional goals, or personal ones like childbirth, she simply had to.
Pain also catches men by surprise. Women have a range of “normal” pain that comes from just being biologically a woman, menses being the best example. So they sort any other pain differently, on an alternative scale and with a range of what is bearable vs. not. Men generally do not have to sort it, just react to it.
Not in Their Heads
After the birth of her first child, Montera’s body rebelled even harder, and she refers to her experience with her “daily dose of pain.” Though she knew this was not normal, her doctors fell back on the simplest answer: They told her she had ovarian cysts and recommended more rounds of hormone treatments. Yes, she had ovarian pain, but there was more—and it was impacting her daily life. Sharp, shooting pains in her pelvic floor made it difficult to stand, walk, or drive. Her pelvic bones would ache; she could identify her anatomy just based on the pain. Doctors did not pursue any other avenues.
Studies demonstrate that physicians generally have difficulty accurately diagnosing or treating women with complex gynecological issues. Women with acute abdomen complaints are often assumed to have gynecological issues instead, making for delays in proper testing.
Additionally, when it comes to chronic pain, 70% of the people it impacts are women. “And yet, 80% of pain studies are conducted on male mice or human men,” found feminist writer Laura Kiesel. “One of the few studies to research gender differences in the experience of pain found that women tend to feel it more of the time and more intensely than men.”3 Biology and hormones are thought to play a major role. It’s not in their heads—they really do feel things differently.
But that level and duration of pain is difficult to fathom, and outsiders struggle to remain empathetic. Montera’s friends and family began to question the entire existence of her pain. They suggested she was just in it for the medications. Pain was her daily companion, its complex origin making it impossible to easily relate or explain, so it was better to say nothing at all. She was becoming isolated, unable to relate to her family, her husband, struggling with a new baby and a career she loved.
As the months went on with no change, she began to do her own research. In her rural area specialized resources were difficult to find. Fortunately she came across one of the few pelvic pain specialists in the country, just three hours away.
She met with John Slocumb, MD, at the University of Colorado, without any other options. He listened without judgment, and not only did he actually hear what she was saying, he recognized her symptoms and gave her a diagnosis nobody else had considered. He told her she had interstitial cystitis and he would help her.
It only took three years.
Anne Montera’s journey didn’t end with a diagnosis. Next month we will talk about just how complex the body’s response to pain can be and what happens when medical providers fail to properly manage patients with chronic pain.
1. Fassler J. How Doctors Take Women’s Pain Less Seriously. The Atlantic, 2015 Oct 15.
2. Hoffman DE, Tarzian AJ. The girl who cried pain: A bias against women in the treatment of pain. J Law Med Ethics, 2001 Spring; 29(1): 13–27.
3. Kiesel L. Women and pain: Disparities in experience and treatment. Harvard Health Publishing, 2017 Oct 9.
4. Edwards L. The Gender Gap in Pain. New York Times, 2013 Mar 16.
Tracey Loscar, NRP, FP-C, is chief of operations for Matanuska-Susitna (Mat-Su) Borough EMS in Wasilla, Alaska. She is a member of the EMS World editorial advisory board. Contact her at email@example.com or www.taloscar.com.