Example 1: Bystander CPR Pre-Arrival Instructions Call Review Sheet

(ALL TIMES IN MILITARY FORMAT using hh:mm:ss) Run number: Date of call: / /

Time of E911: : :

Time call received: : :

Time first responders dispatched: : :

Initial call type: Did the call type change during the incident?  Yes  No

If yes, what was the final call type: Patient’s age: Years

Patient’s gender:  Male  Female

Patient location:   Home/Residence  Public Building  Street/Hwy   Nursing Home  Residence/Institution  Physician Office/Clinic   Educational Institution  Unknown  Hospital   Recreation/Sport  Industrial Place  Jail   Airport  Other

Caller’s gender:  Male  Female

Caller’s relationship to patient:   spouse/companion  sibling  son/daughter   parent  friend/acquaintance  other family   medical provider  other non-family  unknown

Did the caller state victim appeared dead?  Yes  No

Did the caller state victim appeared blue?  Yes  No

Did the caller state victim felt cold?  Yes  No Did the caller state CPR was already initiated?  Yes  No

Did the dispatcher ask if the victim was responsive?  Yes  No  N/A (already stated by caller)

Did the dispatcher ask if the victim was breathing?  Yes  No  N/A (already stated by caller)

If the victim was breathing, did the dispatcher ask if the victim’s breathing was normal?  Yes  No  N/A (victim not breathing)

How did the caller describe the victim’s breathing? Did caller describe snoring (agonal) breathing?  Yes  No

Was the caller alone with the patient?  Yes  No  N/A (unknown)

Caller states bystander has training in CPR (e.g. medical professional, EMT):  Yes  No

Was the patient determined to have obvious death?  Yes 

If the patient was determined to be dead, did the dispatcher instruct the caller to stop all resuscitation procedures?  Yes  No  N/A

Did the dispatcher state “I am going to help you do CPR until help arrives. Listen carefully. I’ll tell you exactly what to do.”?

 Yes  No If no, what did dispatcher say:

Did the dispatcher ask if there was an AED at the location?  Yes  No If yes, did the dispatcher instruct the caller to apply the AED?  Yes  No  N/A

Did the caller state that an AED was already in use?  Yes  No

Assign emotional content of caller: Beginning of call End of call Uncontrollable, hysterical Yelling, not listening, uncooperative Moderately upset, but cooperative Anxious, but cooperative Normal conversational speech What was the presumed cause of the cardiac arrest? (pick one)  Cardiac  Trauma  Respiratory  Drowning  Electrocution  Other Record the time for each task, as directed by the dispatcher

Task Time (minutes into the call) : 1 Check for breathing : 2 Move patient to hard surface : 3 CPR landmarks : 4 Perform compressions : 5 Arrival of first responder

Were there any delays in following the pre-arrival instructions?  Yes  No If yes, describe: Caller refused to perform actions Chronic physical limitations of caller (e.g., cannot walk) Acute physical limitation of the caller (e.g., vomiting) Emotional state of caller Disagreeable patient characteristics (e.g., vomit or odor) Presence of agonal breathing Medical legal concern Other:

Did the rescuer perform chest compressions (complete direction 10)?  Yes  No

If yes, time chest compressions began : Did rescuer continue to follow the instructions until EMS arrived in the house (e.g., did they continue compressions even when they heard the siren)?  Yes  No  N/A  Unknown

: Time call ended

Survival Data can be abstracted from EMS records, if available