Overcoming the 911 Fear Factor Hector Caraballo, MD; Robert A. De Lorenzo, MD, MSM* *Corresponding Author. E-mail: robert.a.delorenzo.mil@mail.mil. 0196-0644/$-see front matter Copyright © 2014 by the American College of Emergency Physicians. http://dx.doi.org/10.1016/j.annemergmed.2014.12.006 A podcast for this article is available at www.annemergmed.com. SEE RELATED ARTICLE, P. 545. [Ann Emerg Med. 2015;65:553-555.] Where to elect there is but one, / ’Tis Hobson’s choice—take that, or none.—Thomas Ward, 1853 1 Someone encounters a person in cardiac arrest; ideally, that observer calls 911 and initiates cardiopulmonary resuscitation (CPR). This commonsense approach of assisting an ill family member or fallen bystander seems to carry minimal risk and does not require much self- sacrifice. However, this ideal behavior may not occur in all communities. Many perceive a Hobson’s choice when faced with having to call the authorities to obtain aid, fearing personal harm, loss of freedom, or economic burden. Real or perceived, these fears threaten a key link in the chain of survival. Health disparities by race, income, and geography are pervasive and complex. 2 Among the wealthiest countries, the United States ranks last with regard to access to care for individuals with low income. 3 Latinos experience increased age-adjusted years of potential life lost for conditions such as stroke, chronic liver disease, diabetes, and HIV compared with non-Hispanic whites. 4 Residents of Latino, black, and low-income communities have a higher likelihood of experiencing an out-of-hospital cardiac arrest, are less likely to receive bystander CPR, and are less likely to survive. 5,6 The population of Latinos in the United States is projected to increase from 54 million to more than 128 million by 2060. 7 The rapid growth and heterogeneity of this population creates a challenge to clinicians, policymakers, and researchers in meeting the health care needs of this dynamic group. 8 Sasson et al 5 used qualitative analysis of focus groups to explore the barriers and facilitators to CPR and calling 911 in a mainly Latino community of Denver County, CO. The neighborhoods targeted for analysis had at least twice the incidence of out-of-hospital cardiac arrest and below-average rates of bystander CPR, according to data collected with the intent of developing interventions for specific high-risk neighborhoods identified in previous publications. The authors concluded that the barriers to calling 911 include (1) fear surrounding law enforcement agents’ response in either implicating the bystander in wrongdoing with regard to an out-of-hospital cardiac arrest victim or being detained because of legal issues surrounding immigration status; (2) personal financial costs, immediate or delayed, related to activating emergency medical services (EMS); (3) 911 limitations in communicating with persons possessing limited English proficiency; (4) worry over misidentifying a cardiac arrest event for a less lethal problem; and (5) fear of retaliation or isolation from friends, family, or neighbors for involving the authorities. Not surprisingly, the study suggested there was no distinction between law enforcement agents and EMS personnel by this targeted population. Additionally, the authors concluded there was a lack of monetary resources to pay for both direct and indirect costs related to CPR training, and also a lack of health literacy surrounding cardiac arrest and benefits of CPR, which the study suggests may be greater in recent immigrants and those with limited English proficiency. Sasson et al 5 used quantitative, data-driven, and geographically focused methods to identify a high-risk population for out-of-hospital cardiac arrest by zip code. The effectiveness of interventions based on these data is the next step in improving care in this targeted group. The results of the study may not apply to all ethnic subgroups, but the methodology is a model other communities can use to gain insight and to guide efforts. There are limitations in the study, including the cohort assembly, which was 75% women; this may underrepresent men and fail to identify barriers and facilitators in that part of the population. It is also unclear whether the demographic makeup of focus groups reflects the demographics of out- of-hospital cardiac arrest individuals in those high-risk neighborhoods. Factors such as country of ancestry or origin, English proficiency, and immigration status may influence barriers to calling 911 or initiating CPR in identified high-risk communities. Emerging evidence suggests that data collected broadly on Latino populations can overlook important nuances with regard to disease rates and intervention Volume 65, no. 5 : May 2015 Annals of Emergency Medicine 553 EMERGENCY MEDICAL SERVICES/EDITORIAL