This month, we speak to acclaimed emergency physician Paul Pepe, MD, MPH, MACP, FACEP, FCCM, chair of emergency medicine at the University of Texas Southwestern Medical Center and the Parkland Health and Hospital System, and medical director for Dallas EMS and the Dallas metro-area BioTel EMS system. Dr. Pepe delivered three presentations at the 2010 EMS World EXPO, including, with colleague Jane Wigginton, the keynote address. Here we discuss some of the specifics of his presentations. 

   Your keynote, "Sex, Drugs and R&R (Reanimation & Resuscitation)," concerns the role of sex hormones in cardiac arrest outcomes. What is that role?

   With cardiac arrest, it can appear on the surface that men do better, because they present more often with ventricular fibrillation. But when you break it down by presenting ECG, women actually have better outcomes. Initially we didn't think hormones were the reason, because the average age of women who have cardiac arrest is around 68.

   So we conducted a prospective study in Dallas over 10 years to try to see if there were any differences between men and women, and particularly look at those under age 50 vs. older than 50. We found that the women had much better outcomes, especially in cases where they had more ischemic insult--particularly in cases of asystole and pulseless electrical activity, the women had much better outcomes relative to the men. And the cohort of women under 50 was actually accountable for most of the differences.

   So there's this observation that women of child-bearing age do better, and we started thinking that indeed it is hormones. However, this conclusion was inferential--we didn't actually measure the hormone levels, but it sure sounded compelling. It turns out, in fact, that in the experimental literature, there are literally dozens and dozens of studies in which estrogen--also progesterone, but particularly estrogen--has been shown to be an extremely protective substance. In various animal experiments, it's not only protective, but it's actually therapeutic as well, meaning you could give a dose of it to a male or a female after an injury, and they would have better outcomes. It doesn't matter if it was a stroke or a head injury or cardiac arrest or something else; it turns out estrogen provides a substantive advantage in outcomes.