Cardiac Arrest Call-In Form: MedCom
Please use this form to enter a cardiac arrest case treated in Kalamazoo County. You can use the 'tab' button (not the arrows or return key) on your keyboard to move to the next field you wish to complete.

This form should be completed for cases involving any cardiac arrest whether resuscitation was or was not implemented. Thank you.
Date of cardiac arrest *
MM
/
DD
/
YYYY
Person reporting the arrest *
Please enter the name of the individual calling in the information OR if entering directly from the MFR agency the individual entering this information, thank you.
Your answer
Medical first responder agency involved *
Primary Apparatus # for this case: *
The primary apparatus does not have to be the unit which deployed an AED (if applicable).
Your answer
Demographic & Initial Resuscitation Information
Incident address *
Please enter the actual address for the incident. This helps match AED use by MFR's/Police/PSO's with the ALS record, thank you
Your answer
Incident City or Township *
Please enter the city or twp that the incident occured in. For cities just include the name, for townships' please include the letters Twp to distinguish these, thank you
Your answer
Was this a witnessed or unwitnessed arrest? *
Witnessed arrest is any arrest where the person was either seen or heard collapsing and almost immediately found to be in cardiac arrest.
Who Initiated CPR? *
Please fill this out to the best or your knowledge. An "Unknown" should be very uncommon.
If bystander CPR was performed in this case, did the EMD dispatcher provide CPR instructions? *
Please enter this information whenever possible as we attempt to track how often dispatch assisted bystander CPR is performed within Kalamazoo County, thank you.
Did MFR's perform CPR and/or use an AED on this patient *
Was an AED used in this case and if so what type? *
Please fill this out to the best or your knowledge. An "Unknown" should be very uncommon.
Was the AED utilized from a police car *
We are evaluating also the use of AED's that are implemented by Police/PSO's from their patrol vehicle. AED's that are implemented by Police/PSO's from a Fire or Rescue apparatus would be a "No" response, thank you
Initial AED rhythm analysis *
This is the first analyze the AED performs when implemented
Did the AED "shock" at any time prior to ALS arrival at the patients side? *
This is any shock whether the initial or subsequent evaluations prior to ALS arrival, thank you
Age of patient *
If unknown please enter "Unknown" thank you
Your answer
Sex of patient *
Was the patient transported to a hospital? *
This includes all transports for cardiac arrest as defined below
Which ALS ambulance agency transported the patient to the hospital
If transported, which hospital did the patient get transported to?
MFR Time Log & Data Submission
(USE MILITARY TIME-- 00:00)
Initial MFR time of dispatch
Your answer
Initial MFR time en route
Your answer
Initial MFR time on scene
Your answer
Initial MFR time at patient
Your answer
Initial ALS time at patient (if recorded)
Your answer
What will be done with the data card? *
Any additional notes on CPR or AED use
Please write in any additional comments you have related to this particular cardiac arrest case, thank you
Your answer
Was Narcan administered by MFR's for this case *
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