Table 4:

Coding themes/barriers in suspected OA-OHCA patients with example quotes

Barrier	Example quote
Communication barriers
Caller frustration/impatience Definition: Situations in which the caller indicates or responds with frustration or anger towards questions asked by the telecommunicator.	Caller 1: “I need to go clear my gddn [inaudible] [00:01:28].” Dispatcher: “How old is the patient?” Caller 2: “I don’t know how old he is.” Caller 1: “Gddn, what you want to write a book?” Dispatcher: “I don’t. Can you step away from him?” Caller 1: “[Inaudible – crosstalk] I know why so many people die with them motherf**s, man. Why you talk to us for? Hang up on that m [inaudible – crosstalk] –” (County A - A156)* Dispatcher: “[Redacted], take a deep breath and talk to me. I’ve got to ask you some questions, okay?” Caller: “Just send the f***g paramedics over. Like, dn.” Dispatcher: “Ma’am, is he breathing?” Caller: “No, he’s not [inaudible] [00:01:11] send the paramedics over you f****g idiot.” (County B - 14174)*
Interference from bystanders Definition: Scenarios in which multiple bystanders or callers are contributing to the situation or interfering with effective communication with the telecommunicator.	Caller: “The lady on the phone is telling me to do that. What are you talking about?” Bystander: “Yeah, but I have the Narcan –” Caller: “Okay, well then, do it. Just do it.” Bystander 1: “[Inaudible] Please don’t make me.” Dispatcher: “If you’re giving him the Narcan we’re good.” Bystander: “[Inaudible] Just do it, fk him.” Caller: “It’s on him. [Inaudible] the matter, just focus on him. Focus on him, not me. Focus on him.” Bystander: “Everybody shut the fk up. Please.” Caller: “Focus on him.” Bystander: “Hold up. He ain’t breathing.” Dispatcher: “Ma’am, did he give him the Narcan?” Caller: “Did you give him the Narcan? She’s asking.” (County A - A243) Caller: “He’s dying. Help me. [Redacted]” Bystander: “[Redacted], you gotta keep it together. They’re coming.” Caller: “Come on. Come on, hurry up. Hurry up.” Bystander: “Get out of the way. Get out of the way.” Caller: “Let me get up. Help me. Help me. He did drugs. He took drugs.” Bystander: “They know that. They know that.” (County B - 28392)
Psychological barriers
Fear of drugs Definition: Caller demonstrates a fear of drug involvement in the situation, thus causing delayed or lack of evaluation/treatment	Caller: Okay, I’m sorry, but these people are getting freaking drugs in, and I’m scared that’s what it is. And I don’t want one getting, I don’t want that to happen. I don’t know sir, down. I can’t get him up. I’m sorry ma’am, this is just, this is the first time on my watch this has happened. Yeah. Are you still with me? (County A - A121)
Fear of patient Definition: Fear that the patient may cause the caller or bystander physical harm.	Caller: “And I don’t know if he’s alive. I’m really honestly afraid to touch his neck or whatever.” Dispatcher: “Okay. Yeah.” Caller: “‘Cause if he is alive, I don’t know how he’s gonna respond.” (County A - A176)
Societal barriers
Apathy to assistance Definition: Caller indicates a distinct aversion to, or disinterest in assisting patient.	Caller: “Ma’am. I’m not a doctor. I’m getting ready to go in and eat some Mexican food, and I saw this guy on the sidewalk.” Dispatcher: “Okay. Are you able to check on the person to see if he’s breathing or not?” Caller: “No, ma’am. No, ma’am. I’m not walking over there. I don’t know what the situation is. I’m just trying to call in. If he’s having a heart attack or if he’s dying, then y’all can send somebody.” (County A - A297a) Bystander: “Can I just move?” Caller: “No.” Bystander: “I’m going outside.” Caller: “Sit your a** down.” Bystander: “Ma’am, I’ll be right out here. I need a cigarette.” Dispatcher: “Is there anybody there –” Caller: “I can’t deal with this. It’s your fault.” Bystander: “It ain’t my fault. I didn’t get into Ice.” (County B - 23265)
Legal concerns Definition: Caller expresses concern over or questions the legal ramifications of assisting patient.	Caller: “You guys have the Good Samaritan law out here, right?” Dispatcher: “I’m not sure, why? Tell me what happened, sir?” Caller: “I just – I mean, she took a tiny bit of fentanyl and like she’s – just like her eyes are open, but she’s not there, and I’m just scared. I’m just scared.” (County A - A204) Caller: “No. And can you make sure no police arrival, please.” Dispatcher: “You what?” Caller: “No police arrival, please. Just EMS.” (County B - 06432)
Conflicting responsibilities Definition: 1) Caller states they cannot assist patient due to other needs (i.e. providing childcare, work responsibilities, etc.). 2) Caller is unable to assist without obtaining permission from someone else, such as a work supervisor.	Caller: “I’m sorry. My manager – we’ve had a lot of drug issues going on at the hotel and he doesn’t want me to go in alone.” (County A - A152)
Naloxone-specific barriers
Lack of availability Definition: Caller or bystander indicates either naloxone/Narcan is unavailable or any existing supply has already been administered.	Caller: “I gave him one Narcan, that’s all I had. We, we...” (County A - A116) Dispatcher: “Okay. So, he’s got a history of using heroin? Do you have any Narcan?” Caller: “No. I don’t. Somebody took it.” (County B - 25543) Caller: “I’ve had Narcan, but I don’t know where it’s at and the only one I have is the one for injection and I don’t have the needle for it. It’s the one already pre-mixed in the needle, but no needle in.” (County B - 43831)
Lack of knowledge on use Definition: Caller or bystander indicates or demonstrates a lack of knowledge on how to administer naloxone.	Dispatcher: “Okay. Give me one moment here. If there’s a defibrillator available send someone to get it now and tell me when you have it, okay?” Caller: “I don’t believe there’s one available. I do have someone available with Narcan, though. How do I administer that?” [Inaudible – crosstalk]. (County A - A144) Caller: “I’ve got Narcan but I don’t know how to use it, right there.” (County B - 57707)