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Implications of systemic racism in emergency medical services: On prehospital bias and complicity

2022; Elsevier BV; Volume: 50; Linguagem: Inglês

10.1016/j.eclinm.2022.101525

2589-5370

Christian Ventura, Edward E Denton, Benjamin R. Asack,

Healthcare professionals’ stress and burnout

Public health research has increasingly proven racial disparities within emergency medicine, as exemplified by the fallibility of pulse oximeters resulting in unreliable detection of respiratory compromise, to implicitly biased clinical perception of pain in Black and Brown patients.1Bickler PE Feiner JR Severinghaus JW. Effects of skin pigmentation on pulse oximeter accuracy at low saturation.Anesthesiology. 2005; 102: 715-719https://doi.org/10.1097/00000542-200504000-00004Crossref PubMed Scopus (173) Google Scholar There is a lack of literature detailing the complicity of Emergency Medical Services (EMS) clinicians who sit among a nation with an inequitable healthcare system. In this piece, we aim to shed light on how disparities in prehospital emergency medical care harm patients of color. Informed by Black, Indigenous, and People of Color (BIPOC) accounts, our experiences as prehospital clinicians, and available literature, we discuss pressing concerns with actionable implications. We argue that patients of color, and particularly Black and Brown patients, are disproportionately subject to faulty clinical assessment and treatment by EMS largely due to provider implicit bias and institutionally-embedded racism inherent within the American healthcare system. EMS clinicians are trained to conduct a holistic assessment encompassing subjective complaints, quantitative values, physiological indicators, and intuitive-based discretion. But how do we account for the realization that we often fail to teach and remind clinicians that cyanosis, a late indicator of respiratory failure, does not typically present as blue-tinted skin in Black patients, but rather gray or white? How do we advise clinicians to employ pulse oximetry as a reliable tool for assessing a patient's respiratory status, when we know oximetry readings are more likely to be inaccurate in Black hypoxic patients1Bickler PE Feiner JR Severinghaus JW. Effects of skin pigmentation on pulse oximeter accuracy at low saturation.Anesthesiology. 2005; 102: 715-719https://doi.org/10.1097/00000542-200504000-00004Crossref PubMed Scopus (173) Google Scholar? These concerns have become increasingly urgent due to the rising opioid epidemic that disproportionately affects Black and Brown communities, which the COVID-19 pandemic has only exacerbated.2Price-Haywood EG Burton J Fort D Seoane L. Hospitalization and mortality among black patients and white patients with Covid-19.N Engl J Med. 2020; 382: 2534-2543https://doi.org/10.1056/NEJMsa2011686Crossref PubMed Scopus (948) Google Scholar A 2014 study in a journal published by the American Psychological Association suggests that Black boys are often perceived as less innocent and older than their White counterparts.3Goff PA Jackson MC Di Leone BA Culotta CM DiTomasso NA. The essence of innocence: consequences of dehumanizing black children.J Pers Soc Psychol. 2014; 106: 526-545https://doi.org/10.1037/a0035663Crossref PubMed Scopus (505) Google Scholar Similar phenomena have been well-studied among medical professionals, where they have reported inaccurate beliefs regarding biological differences between Black and White patients, as well as significant disparities in pain assessment and treatment of Black patients rooted in racial bias.4Hoffman KM Trawalter S Axt JR Oliver MN. Racial bias in pain assessment and treatment recommendations, and false beliefs about biological differences between blacks and whites.Proc Natl Acad Sci USA. 2016; 113: 4296-4301https://doi.org/10.1073/pnas.1516047113Crossref PubMed Scopus (831) Google Scholar In this same study, medical students and residents had endorsed beliefs such as “Blacks’ nerve endings are less sensitive than whites,’” “Black people's blood coagulates more quickly than whites',” and “Blacks’ skin is thicker than whites’” A 2019 study of EMS agencies in Oregon found that racial minorities were less likely to receive pain assessments and pain medication in the 911 setting.5Kennel J Withers E Parsons N Woo H. Racial/ethnic disparities in pain treatment: evidence from oregon emergency medical services agencies.Med Care. 2019 Dec; 57 (PMID: 31730566): 924-929https://doi.org/10.1097/MLR.0000000000001208Crossref PubMed Scopus (24) Google Scholar The death of 23-year-old Elijah McClain on August 30, 2019 sparked global discussion of EMS involvement in police-related deaths of Black individuals. When a stop-and-frisk of a Black man escalated to a stranglehold, EMS was requested on scene and paramedics subsequently administered ketamine, an intervention approved by Aurora EMS protocols to treat excited delirium.6Smith J, Costello M, Villaseñor R. Investigation Report and Recommendations. City of Aurora, Colorado, 22 February 2021. https://p1cdn4static.civiclive.com/UserFiles/Servers/Server_1881137/File/News%20Items/Investigation%20Report%20and%20Recommendations%20(FINAL).pdfGoogle Scholar While much has been made of the role of ketamine, has EMS adequately discussed the role of racial bias at the initial steps of patient assessment? Prior to injection, McClain received no clinical assessment, was already physically restrained by police, sustained a carotid chokehold and briefly became unconscious. Immediately on scene, EMS is trained to assess the ABCs – airway, breathing, and circulation. In police footage, McClain is heard repeatedly saying he cannot breathe, a critical observation for clinicians if administering ketamine. Did racial bias impede their review of the five rights of drug administration? Further, the medical community has continued to question the validity of excited delirium as a legitimate medical diagnosis.7Rimmer A. Excited delirium: what's the evidence for its use in medicine? BMJ. 2021;373:n1156. Published 2021 May 5. https://doi.org/10.1136/bmj.n1156Google Scholar While systemic racism is not unique to EMS, it is worth investigating its industry-specific impact. As we continue to build knowledge of disparities in prehospital care, there are actions we can take that are proven effective. At the systemic level, we invoke National EMS Education Standards to mandate adequate training in implicit bias, clinical assessment and treatment variances for patients of color, and for state and local EMS authorities to follow suit. We believe that this competency should also be assessed by the national registry EMT exam. In addition, we call for radical efforts to diversify the profession by campaigns to train and employ racial minorities, as approximately 70% of EMTs and paramedics are White.8Crowe RP Krebs W Cash RE Rivard MK Lincoln EW Panchal AR. Females and minority racial/ethnic groups remain underrepresented in emergency medical services: a ten-year assessment, 2008–2017.Prehosp Emerg Care. 2020; 24: 180-187https://doi.org/10.1080/10903127.2019.1634167Crossref PubMed Scopus (19) Google Scholar While we acknowledge that racial injustice in EMS manifests itself beyond solely clinical care, these critical actions have tremendous potential to move the industry forward towards evidence-based care for everyone. All authors commented critically in the manuscript, revisions were made, and the final draft was prepared and submitted. The work is not funded by any specific source.