The 2007 Susquehanna Regional EMS ALS Protocols require providers to notify the Regional Program Agency (SREMS) of any time a patient is transported with an ST Elevation Myocardial Infarction (STEMI). Please use this form to submit information about your call. Any questions should be directed to the SREMS Office at 607-778-1280 or your agency's ALS Supervisor.
In charge Provider Name:
EMT#
Agency:
Agency Code#
Date of Call: //
Full PCR Number: (Include beginning "4-" or "5-")
Did the patient initially wish to go to a hospital capable of Cardiac Catherization?
Yes
No
If No, did you contact Medical Command at their choice facility and ask for a referral to a "STEMI Center"?
Yes
No
N/A
Did the Medical Command Physician refer you to the nearest "STEMI Center?"
Yes
No
N/A
Medical Command Physician:
Comments/Concerns:
Your Signature: __________________________________________ Date:_____________
