PreCare: Redefining What Prehospital Care Can Be

When someone collapses in cardiac arrest, the standard response is fast, skilled, and follows a well-rehearsed protocol: call 911, begin CPR, use a defibrillator, transport to hospital. That system saves lives, but only a minority, and the ability to improve patient outcomes has changed very little for many years. For a specific and significant group of patients — those whose cardiac arrest has a reversible cause that the standard system has not been able to address — it is not enough. For these patients, survival depends not just on speed but also on diagnosis and advanced critical care monitoring to individualize treatment. Diagnosis and advanced monitoring, in many prehospital environments, like BC, are beyond reach.

A programme operating out of Sydney, Australia is changing that. NSW Ambulance's (Greater Sydney Area HEMS) PreCare initiative — developed in collaboration with Royal Prince Alfred, St Vincent's, and Westmead hospitals — deploys a Medical Cardiac Arrest Team (MCAT) to out-of-hospital cardiac arrests alongside the standard paramedic response. The MCAT brings two physicians and specialist paramedics with advanced training directly to the patient. What they bring with them changes the entire clinical picture.

The team arrives equipped with the tools to investigate — not just to resuscitate. Point-of-care ultrasound allows the physician to visualise the heart in real time, guiding CPR quality and identifying the cause of arrest. Transoesophageal echocardiography (TEE), arterial line placement, and blood gas analysis give the team a dynamic, high-resolution picture of what is happening inside the patient's body while resuscitation continues. Advanced pharmacology targets specific physiological derangements. And where the cause of cardiac arrest is identified as one that can be treated — a massive blood clot, for example — the team can deploy a portable extracorporeal membrane oxygenation (ECMO or e-CPR) circuit that bypasses the heart and lungs entirely, maintaining blood flow while definitive treatment is organized.

This approach is built on a simple but profound shift in philosophy: the goal of prehospital cardiac arrest care is not just to perform standard ‘one-size fits all’ resuscitation. It is to deliver optimized resuscitation targeted to the individual patient, identify why the heart stopped, and to treat that cause, rather than its consequences.

What the Evidence Shows

Published data from the Sydney MCAT programme are compelling. A 2026 retrospective cohort study examined 129 consecutive patients attended by the team between January 2024 and September 2025. The rate of return of spontaneous circulation (ROSC) — the key intermediate outcome measure in cardiac arrest — was 49 per cent. For context, population-level ROSC rates for out-of-hospital cardiac arrest across high-income countries typically range from 20 to 35 percent. Earlier MCAT arrival was independently associated with improved ROSC, reinforcing that the team's value lies in early, integrated intervention rather than rescue at the end of a failed resuscitation.

The programme has also been studied for its impact on the paramedics who work within it — with striking results. A 2026 qualitative study by Critical Care Paramedics Jacob Tant, Jackie Buckthought, and colleagues, drawing on interviews with NSW paramedics who participated in MCAT responses, identified five transformative themes: mentorship and learning, a deeper understanding of cardiac arrest physiology, clinical empowerment, genuine collaborative care between professional disciplines, and what the authors termed 'cause-directed care.' That last concept is significant: the shift from following a resuscitation protocol to actively trying to identify and reverse the underlying cause of arrest. Paramedics described working alongside the physician-led team as professionally transformative — not a threat to their role, but a profound enhancement of it.

The International Liaison Committee on Resuscitation (ILCOR) has recognized that prehospital critical care — specifically, physician-led resuscitation teams — represents an important and evidence-supported frontier in cardiac arrest outcomes. The Sydney PreCare model is one of the most developed current demonstrations of what that looks like in practice.

Why This Matters in British Columbia: The Story of Rowan Hamilton

In November 2024, Rowan Hamilton — a 20-year-old from Surrey — died following a cardiac arrest. He had been assessed and discharged from Surrey Memorial Hospital. The next day at work, he deteriorated further and suffered a cardiac arrested. Paramedics responded, resuscitated, and transported him. He died.

What emerged afterward is important to understand clearly and compassionately. Rowan had a massive pulmonary embolism — a catastrophic clot blocking blood flow through his lungs. The only treatment with a realistic chance of saving his life at that point was ECMO: bypassing his heart and lungs while the clot was treated. That capability existed in hospitals in Metro Vancouver, but not pre-hospital. However, it was not available at the hospital where he was taken.

The paramedics who cared for Rowan did their best in the system they work in. Diagnosing a pulmonary embolism during an active cardiac arrest requires point-of-care ultrasound, ideally TEE, real-time physiological interpretation, and the kind of integrated clinical reasoning that a physician with prehospital training can perform in the field. Without that diagnosis, the nearest appropriate hospital is the right destination. The system gave them no other option. The system failed Rowan — not the people within it.

The PreCare question is this: what would have been different?

With a physician-led team like Sydney's MCAT alongside those paramedics, TEE or point-of-care ultrasound could have identified the massive PE in the prehospital environment. A physician with the diagnostic authority and clinical context to interpret that finding could have made a different transport decision in real time and initiated ECMO (e-CPR). Even without the pre-hospital ECMO capability with the diagnosis made, the team could have delivered clot-busting drugs, optimized his resuscitation and directed Rowan to the hospital with ECMO capability, rather than the nearest emergency department.

We cannot say with certainty that Rowan would have survived. Massive PE with cardiac arrest carries a severe prognosis even in the best circumstances. But the Sydney programme exists precisely because some patients in exactly these circumstances — reversible cause, identified in time, treated with ECMO — do survive. And in BC today, those patients have no pathway to that outcome, because the team that could identify the cause and change the response does not exist.

MRBC's model of care is built directly on this logic. An interprofessional prehospital team, including a physician, changes what is possible at the scene of a cardiac arrest. It does not replace paramedics — it transforms what paramedics and their patients have access to. The question for British Columbia is not whether this model works. The evidence says it does. The question is when we will build it.

Rowan Hamilton's family has spoken publicly and with grace about what happened to him. We hold them in our thoughts and hope that his story contributes to a conversation that prevents others from being lost in the same way.