Twenty-five participants ranging in age from 18–65 years (33.5 ± 14.9) participated in the study (see Table 1). The sample was predominantly women (72%) with greater than a high school education (88%). Over half the sample were employed full- or part-time outside of the home, whereas 32% were students. Participants were from four Canadian provinces (British Columbia, Alberta, Ontario, and Quebec).
The participants described various factors influencing the decision-making process about whether to call EMS following a syncopal event, which were categorized into four common themes (Fig. 1, Table 2). Overall, participants reported concerns about judgement as a critical consideration in their EMS utilization decisions (Core category; Fig. 1, Table 2).
Theme 1: Previous Healthcare Experiences
Participants frequently described previous interactions with EMS that influenced their decisions to seek (or not seek) assistance after fainting. Two participants reported positive experiences with EMS, however most indicated past negative interactions were salient when considering not to seek care.
I think the main factor that affects [the decision to call EMS] is your history with medical services…If your experience is negative, you’re much less likely to pursue help when you need it, which has certainly been my history, and that of my family. (Nicole, 35, woman)
Feeling Dismissed
Most participants described experiences where they interpreted their syncope symptoms as being dismissed by EMS and other medical personnel:
… I've been dismissed enough by doctors that unless something drastic has happened in relation to my medical condition, I don't want to go [to the ED] anymore. Sometimes that's at a risk to myself, but the experience of dismissal has happened so often…. (Ben, 30, man)
Nicole, a 35-year old woman, said “the doctors didn't really care, [that] was [a] big problem. They just sort of dismissed it.” Jane, also 35, stated: “I have a very negative image of paramedics. When they come to pick you up, they'll just dismiss you."
Participants speculated about potential reasons for ‘being dismissed’, including the
common experience that their syncope symptoms often resolve prior to EMS arrival. For example, Amy (19) said “it (syncope) has to be more or less, caught in the act, for notice to be taken of it, or for you to be taken seriously by doctors.” Participants reported the experience of their symptoms being downplayed, describing their treatment by EMS as ‘disrespectful’.
(He) goes, ‘Oh, it's just fainting. Oh, just throw a little water in her face. Oh, does somebody have an onion? Haha.’ So yeah, it's not something I would go into ER for or to a medical professional for because sometimes they're not the nicest people. (Jane, 35, woman)
Further, several women participants endorsed beliefs that women who faint are more likely to be dismissed than men. Participants attributed this to a perceived bias among EMS/physicians that syncope is typically a symptom of benign, feminine conditions (e.g., menstruation, menopause, or pregnancy).
I think we still are stuck in that 1800s view of a woman fainting like… It's not something serious…“Oh, she's going through menopause. Oh, she's got her period.” They brush it off. (Megan, 30, woman)
Theme 2: Individual Factors
Patient-level factors such as age, medical history, and medical comorbidities were frequently provided as important practical considerations when deciding to seek medical care for oneself or others who faint.
Age
In general, participants reported that they would call an ambulance for a senior who fainted, due to the increased risk of serious medical concerns among older people.
…Older people fainting is much more serious because you break your hip, you break something…So the care and concern that is given to them, I feel, is much more than a 30 year old fainting. (Jane, 35, woman)
In contrast, being “younger” was associated with a perception that fainting should not require EMS care.
Fainting just seems like a silly thing to complain about. At my age at least. (Kayla, 21, woman)
Medical History
Participants considered their own medical history, and fainting history in particular, when deciding whether to contact EMS. Individuals who fainted repeatedly/frequently considered fainting to be a ‘normal’ experience, not worthy of medical attention. For example, Holly (19, woman) indicated “I've fainted enough times that it doesn't really strike me as being a big deal.” Kayla (21, woman) further explained: “I just wake up [after fainting] and dust myself off, carry on my day, like ‘oh I have class in ten minutes.’”
In contrast, when asked what would prompt them to call EMS if someone else fainted, nearly everyone indicated they would call if they were not familiar with that person’s medical history.
Patient Comorbidities
Participants indicated that they would be inclined to call EMS for another person who fainted if they believed there was a more serious underlying medical condition.
I think certainly (I would call EMS) if they have been diagnosed with some major medical condition and if they have a medic alert bracelet saying so. (Luke, 35, man)
Theme 3: Attitudes And Beliefs
Participants frequently endorsed personal attitudes and beliefs about the use of healthcare resources, and about syncope in general, that influenced decision-making.
Burdening The System
Numerous participants believed that accessing EMS was tantamount to “being a burden” on others and, in particular, the healthcare system. Participants wanted to avoid wasting hospital resources, and simply disliked the experience of ‘needing help’ from others.
[I] didn't want to be a burden on the medical system for something that wasn't an emergency… (Sarah, 60, woman)
Beliefs about Syncope
Many participants expressed beliefs about fainting that seemed to influence their EMS utilization decisions. Syncope was often described as “not a big deal”, and therefore not worthy of care/attention. In reference to an experience at the ED after fainting, June (37, woman) stated that “basically it was no big deal and they said I didn’t need to be there…a bit embarrassing to be there for no reason”. Reflecting on their fainting experiences, many participants dismissed their symptoms and suggested that calling EMS would have been (or was) “too much of a fuss” or “excessive”. Curtis (28, man) indicated that he did not seek emergency medical assistance after fainting because “it was just a normal boring everyday faint thing that would be a waste of time to pursue”.
Gender-specific beliefs. Several women in the sample used gendered language to describe syncope and fainting symptoms. Feminine (e.g., “girly”, “damsel in distress”, “swooning”, and “dramatic”) and infantilising (e.g., “whiny baby”, and “silly”), terms emerged throughout the interviews in reference to fainting, often in reference to why patients felt (or would have felt) embarrassed for contacting EMS after fainting.
Oh, it just seemed like such a, I don’t know, girly thing to do. (Paula, 38, woman)
Theme 4: Contextual Factors
Participants incorporated unique characteristics of the fainting event into their decision-making about calling EMS.
Influential Others
Influential others, including friends and family members and third-party bystanders, impacted decision-making in various ways. Participants often described events where one of these people called an ambulance while they were unconscious, or against their wishes/instruction.
When I fainted at the office, they lost their minds. They called [EMS]. I had to go to the hospital, and …you know that you're going to be fine. (Megan, 30, woman)
Other participants indicated they sought care in order to mitigate concerns and fears expressed by their loved ones. Some participants reported seeking advice regarding how to respond to the faint and were advised by loved ones to call an ambulance.
I remember one of my girlfriends was an RN. I called her, and I was like, "What…is going on? Why am I feeling like this?" She's like, "You need to call the ambulance…You need to call 911." (Megan, 30, woman)
Symptoms
Symptoms, including injuries sustained from falling, were extremely influential in the decision to seek EMS care.
Symptom severity. Nearly every participant indicated symptoms that were “serious” and/or “abnormal” given their syncope history would prompt them to seek EMS care after fainting. These included: extended period of unconsciousness (perceived timeframes warranting medical attention ranged from > 2 seconds to > 15 minutes of unconsciousness); vomiting; shortness of breath; heart palpitations; pain; convulsions; and blurred vision. Participants who fainted frequently and were familiar with their own typical symptoms indicated that symptoms would need to be “out of the ordinary” to justify a call to EMS. Megan, a 30-year-old woman who faints frequently, described an occasion when abnormal symptoms made her decide to call an ambulance:
Not only did I feel super lightheaded, but there was a pain in my chest, and it felt different than all the other times. When I'd fainted [previously], it was usually pretty quick, and I'd wake up, and I'd feel fine… That's what made me call is that it was different.
Fall-related injuries. Several participants indicated that, in general, they only contact EMS if physically hurt from a faint. One participant described lying about the cause of an injury sustained during a faint, to avoid “admitting” to EMS that she had fainted:
I wanted to lie to the paramedics and the hospital staff and say that I just fell, when it was
actually that I fainted and fell. So I left out that information completely because I know
how they react when you tell them I fainted. (Jane, 35, woman)
Some participants described injury as a desirable justification for the use of EMS.
I know that this is going to sound weird, but I was happy that I had hurt my knee. Just getting all this attention for something normal like a faint would have been embarrassing. (Holly, 19, woman).
Core Category: Judgement
The core category underpinning participants’ experiences of deciding to access EMS was the perception of judgement. There was a salient belief that EMS typically judge syncope as trivial, and negatively evaluate patients for utilizing healthcare resources unnecessarily. Past experiences of feeling ‘dismissed’ by ‘the system’ contributed to apprehension about being judged. The prospect of being judged unfavorably for calling EMS was a powerful deterrent from seeking care. For example, Amy (19, woman) described feeling “worried” about calling EMS out of concern that “I’d call, and (the symptoms) would stop, and (EMS) would get there, and…I’d be 100% fine. And they’d be like, ‘why are you wasting our time?’”.