EMS 20/20 Call Submission

1

Please provide your full name* This field is required.

First Name

Last Name

2

Please provide an email where we can contact you.* This field is required.We will reach out to you via this email if your call is selected.

example@example.com

Confirm Email

3

Which category(s) would the call you're submitting likely qualify as for Continuing Education.* This field is required.Example: If the underlying condition was an MI, then "cardiac" would be the best call.

Behavioral

Cardiac

Medical

OBGYN

Respiratory

Stroke

Trauma

Eh, lets just say... "It's complicated"

4

What was your provider level at the time of this call?* This field is required.

EMR

EMT (or equivalent)

EMT - Intermediate (We still exist dammit!)

Paramedic (or equivalent)

RN

Student Intern

Other

5

How long had you worked at your provider level at the time of the call?* This field is required.

Student/Intern

0-3 years

*cough cough* 4 years

5-10 years

11+ years

6

What type of service provider did you work for at the time of the call?* This field is required.

Fire Department

Non-profit ambulance service

Private ambulance service

Hospital based ambulance service

Government owned ambulance service (if you work for the city or state)

HEMS

Other

7

What is the approximate size of the service provider you worked for?If you were non-transporting select “other”

1-10 ambulances

11-20 ambulances

21-30 ambulances

more than 30 ambulances

Other

8

What were the provider levels of the other crew members?Choose the option that best describes their provider level - we can get specific details later.

Student/Intern

EMT

EMT Intermediate

EMT advanced

Paramedic

RN

I worked alone

Other

9

Please briefly describe your EMS system to us.Average call volume per shift at the time of the call and any other crew/service/system details that are relevant to the call.

10

Tell us the story of what happened on your call (dispatch to the transfer of care). * This field is required.While we love detailed submissions, please DO NOT include HIPAA sensitive information (no names, addresses, date of birth) or include other provider's full names.

11

Do you have any images associated with this call? * This field is required.Images include 12 lead EKGs, cardiac rhythm strips, protocol pages, equipment, etc

YESNO

12

Briefly tell us what images would accompany your call?If your call is selected we will contact you by email to schedule an interview and request those images at that time.

13

Final question: were you able to obtain any follow-up information on your patient?* This field is required.Diagnoses, labs, hospital treatments, medical director input, etc.

YESNO

14

What follow-up information were you able to obtain?