During a heart attack, cardiac arrest event or stroke, the minutes that pass before medical care is administered can cost heart muscle and brain function, but emergency medicine physician Comilla Sasson, who works at the University of Colorado School of Medicine in Aurora, noticed time and again that Latino families weren’t calling for an ambulance during those events. Instead of calling for emergency medical assistance, which arrives, in Denver, on average in less than eight minutes, they wait, calling for a friend or family member to drive them to the hospital instead.
“It’s one of the most frustrating things, especially for cardiac arrest because that’s when your heart stops and if you don’t call 911 right away, you basically have 10 minutes to save a life and so those 10 minutes are absolutely crucial,” Sasson says. “That delay can literally mean the difference between life and death.”
During strokes, physicians have a three-hour window to administer a clot-busting drug, or for heart attacks, there’s an hour and a half to get to the catheter lab, where a surgeon can perform procedures to open a blocked artery.
“I’ve seen delays of up to six hours to 24 hours,” Sasson says. “In those instances, you don’t get that clot-busting drug in that first three-hour window, there’s really very little that we can do for you, and it’s the difference of seeing somebody walk out of the hospital or live in the sick home for the rest of their lives at the age of 40.”
Sasson, who also works with the American Heart Association, is lead study author of the recently published “Barriers to Calling 911 and Learning and Performing Cardiopulmonary Resuscitation for Residents of Primarily Latino, High-Risk Neighborhoods in Denver, Colorado,” which appeared in the Annals of Emergency Medicine. The study utilized focus groups and detailed interviews with community leaders in Denver neighborhoods identified as having a high incidence of out-of-hospital cardiac arrest events. Their research found that poor and minority neighborhoods see lower rates of bystander-provided cardiopulmonary resuscitation (CPR) and lower survival rates with cardiac arrest. They found a lack of familiarity with CPR in those communities, and a reluctance to call 911 fueled by a distrust of police, language barriers, failure to identify a cardiac arrest event and concerns over the expense.
“It was really interesting to me just to get a sense of how much distrust there is of the police,” Sasson says.
Many of those interviewed reported an expectation that the police would ask for identification when they arrived on scene, a concern for those who might be undocumented or have undocumented family members. Some even believed that if they could not show proof of immigration status at the hospital, they would be denied treatment.
“Especially in the emergency department, we take care of anyone and everyone, regardless of immigration status, race, ethnicity, what language you speak, if you can pay or not pay — it doesn’t matter,” Sasson says.
Combating that perception is a question of consistently putting out the opposite message in the community, she says, and Denver 911, Denver EMS and Denver police have been contacted to confirm that they will not ID those who call 911.
“We believe there’s definitely a reluctance to report,” says Felisa Marcia, deputy district attorney for the 20th Judicial District in Boulder County.
Roughly 40,000 Latinos live in Boulder County.
Though she couldn’t speak to the specific study, Marcia says the Boulder district attorney’s office has undertaken serious efforts to create an environment that welcomes Spanish-speakers and develop resources with a level of cultural competency to address the needs of immigrants and other minorities in the community.
What they’ve learned in their efforts — word of which has spread far enough that Marcia reports getting phone calls from well outside the district — is that a consistent response and community participation are key.
“You can’t four days of the week have someone at the front desk who speaks Spanish but the fifth day not, because that fifth day might be the day that person walks in [who only speaks Spanish],” she says. “On the other side, we need the community groups and the organizations to invite us out, because we don’t know all the places where people need help. So we rely a lot on community liaison groups, other nonprofits, even other members of our own Boulder County system to tell us where the need is and to help us identify where we should go.”
They’ve done outreach in schools — and for a long time, people thought they would get carded at the door to schools as well, she says.
As a mark of Boulder County’s success, and the work left to be done in other communities, she points to a recent experience with a young man who made a complaint to the police in Boulder County, then realized that because the complainant was outside the jurisdiction, he would have to take the complaint to a different police department.
“He decided he wasn’t going to pursue a complaint outside the jurisdiction because he wasn’t sure what the police would be like in that jurisdiction,” he says.
The study Sasson completed also identified the need for increased education and a shift in messaging about CPR in the Latino community. Participants, particularly male participants, voiced concerns about performing CPR on a woman or child — would taking a woman’s shirt off to perform CPR be seen the wrong way or doing mouth-to-mouth look like trying to kiss a child?
It’s important to note that since 2008, the Heart Association has been distributing guidelines for hands-only CPR.
“The data now shows, the most important thing is getting oxygen and blood to the brain, and so that’s where the compressions on the chest, that’s what that does,” Sasson says. Most cardiac arrest victims take a gasp of air before their hearts stop, and that can leave about 10 minutes of oxygen in their lungs — enough time, “That’s enough time if you’re calling 911,” Sasson says.
But there’s more work to be done on an administrative end as well to improve access for the Latino population. Among the causes for delay that can be encountered in contacting 911 is a language barrier. If a person calls 911 who doesn’t speak English, Sasson says, she’s seen it, in one study, take anywhere from a minute to five minutes to find someone who can translate.
“The problem is that that’s really the difference between life and death, especially if someone’s not doing CPR while they’re being transferred around,” Sasson says. The American Heart Association has started to incorporate into their community-based CPR training teaching the English phrases, “heart stopped” and “Spanish interpreter.”
“If you’ve ever listened to 911 tapes, which are really tough to listen to some times, there can be a lot of fumbling that goes around just trying to figure out, from an English-speaker to a Spanish-speaker, what the emergency is,” she says.
Denver has made having bilingual capabilities a priority, she says, “That’s not the case in every city, unfortunately.”
The Boulder Sheriff ’s Department, which dispatches for six different law enforcement agencies in the area, has two bilingual dispatchers of 18 on staff. When those two are not available, dispatchers conference call in a program called LanguageLine Solution to provide translation services. LanguageLine can identify the caller’s language and translate, according to Steven Silbermann with the department, and accessing those services takes only as long as providing the department’s identification information and password. It’s available for use for deputies in the field as well. Most often, it’s used for Spanish-speaking callers, but has also translated for callers speaking Mandarin and Russian.
The American Heart Association has videos available online to provide 60-second training on hands-only CPR at www.heart.org/handsonlycpr and for Spanish-speakers at www.heart.org/rcp.
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