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uare received at MIEMSS:

Rev. 24 Jur200i **-__%


Fer a!ficiar use onr,
IT.{RYLAND EIIIS CARDIAC M{APD #._-
ARRESTFORI{
*ro n'd
be out bv*:he Hishest Lerer
r'"1;5:i'ff:fl::ffi",i:,rffiTm::a;, carr (whether ranspoaed or nor)
l' il{AlS}'iurnbertd?' o 312- bG Jurisdicrionorcsrnn*rciallncidenr
*:?J o1 aD
2'DateofCardi1c.4.rrest:+l-o,g3.Q.93.PatientName(Fir:tMiddleLut|
4. ptease.lt*pr..u
scene Location :
ofli uc-til
""0
li:il#,?lT.,iTLlllffii!'j;f :tr,llrNetSudium)@
ac. aiiressofs".n.Location
t ," hl'i,:P1":4,:Je L
Shect
City
5. *.' zip

;::_ -*t4-
5a. lf yes, tilHT*nfl.T"l';ffi:Hlri.**;Tjtr_1*r
by whom? t,afperson B)rstrtrder
i:":fifi,
Fcd*-+^,r .j_-
5h Esrimared ,. [ ] T.13q see the eveur ."ke prace?)
)- Yes I J No
5b. tirne of cardi;",*.r;T;, er"rs n spona.'i
:Af#rI$Xfi ?ffiTf.lttandbv i*',i*.Jr
6. Did the padentreceive
!ln.l
If CpR sa*e4
Ves t I No{f
6a.
i*r Cinran tir*,
Estimated
6b.Firstpen":-,lTi"g.cpniziiiii'.'*f; ,
6c. was cpR sarted pri* to
i*ru"ii;iy; 171- No [ ] ;;;.i
7. Did Dispatch provide Crn
*;i j-";o*;fmlff
errlsi*-1q lilffi ff
s wasi::i#::jfff,*j:::::"*#'fi*?,ffi,[J5r#;ft3;1;::TJilf,i.K,"1.1o"**,yesf
r Noff
ii1ffi#ffi::#'Xf';g;";, ml***"t "*"" ora
;:. lrus n.,pooa"r?yesr l Dispatchcd

9' Suspected cause of Arrcst (chcck all


[ r,. No

tpp]yl Medicar cardiac[-1f{esgi3lory


that
Dmgsffoison[ ] Drowningr
1Ab;;ii'i;;iiil;;i'i?r.ii t ] Traumat I Elecrical shock[ ] suicide[ ]
r-i.,riol,_I_---- unknown [-f
l0' was initial Ditp"':lg-s9$bv EMS
the
*r::::*r.3ined & equipped wio an AED or manuar
defibri[ator? ycsri ., No
i8l ?,'Xff Tffj,'*:*i;;*"f*;ifrn:;#".k.#x[dtrffl,manu*a.nbri,,ator? *..s t]
1xr i r
I l ' was the patient defibllratSd (i'e" shockedl
ii HllliHiIl'li liillio."?fi*
ur*
il;
riyay$.arca{lr rys Rlngderr
b;;,.,tr;tlfder?
yes
[] go to I ra
time)
Nof_''n r,, r:
--, -
i :
.-" , -io r**itary
tVas pediatric
a
Bywhom?
AEDiadapto, *# -
,.,
_- t I '.
,t*rrr*_rg
tI
-^r"ni=p.ra.4,:
Toal nurnber of EMS-AED.sI*L !r"rr_eg I I
voourio.iir;rr"i;i-i;;i-i _
I rc. Did the patient receive Eo.o ro pati€nt #
Total nurnber of EMS ."**i,[*t .*o[ ]
grven ro the padent: #
12. Upon ud3lar hospirat. indicate parienr.s
condidon:
a. puJse resrored: V.,1 .llilitutt'Tine
b. Breathing restor€d: 1 -\o*f If Yes- Time pulse Restored:

!; i:ffi:,T:ff:::::51;.-- v.!ii
V., f f )foj,f If Yes. Time Breathing Restored:
:

i:;ij-
*'as Erminared in field by prorocol
If Yes- Time padent Conscious:

Report Complaed by:


fr{Ls
Titte c.nin"utloiGt---TrnG
Station ooor.ri,ffi-
Jurisdiction#
or email
"*
:t Ln;il
was a n1;1lir,1'lrt#i'lilgTiF,",""if
rI
\'R-AED sricker on the AED?) yes
tr1'es. b;- whorn? E:frs
r t rir"il-p"ri". ;;,:::;.igJi;ll'"::ji:::a
il;#;:*::Jlill,i;:ii r*o r r
Please Far to
'utEllss Toll Free 877'787a089aloag uitb I copy of the
pho trArs Fornr & Addifionar l{arrative
Questio ns? n e .! t I E.r tss ca loiac r rr* H-"rii"" | _87 7 -g37-7 721