Ch05 EMS Emergency Medical Services Communications.docx

Chapter 5 EMS Communications Unit Summary Upon completion of this chapter and related course assignments, students will be able to identify the role and significance of effective communication by the paramedic. Students should be able to describe the phases of communication during an EMS event, including those performed by the emergency communications dispatcher. They should be familiar with the integral role of the emergency dispatcher as part of the EMS team. Students should be familiar with standard interview techniques, common errors to avoid, as well as nonverbal skills that may be employed during a patient interview. They will understand methods and strategies employed to assess a patient’s mental status, develop patient rapport, and interview patients of various age, cultural, disability, mental status, and levels of cooperation. Students should be able to identify patient and assessment information that is essential for verbal reporting to medical direction and receiving facilities. They should be able to identify electronic technology that may be used to collect and exchange both patient and/or scene information. National EMS Education Standard Competencies Preparatory Integrates comprehensive knowledge of the EMS system, safety/well-being of the paramedic, and medical/legal and ethical issues, which is intended to improve the health of EMS personnel, patients, and the community. EMS System Communication Communication needed to • Call for resources (p 129) • Transfer care of the patient (p 130) • Interact within the team structure (p 130) • EMS communication system (p 121) • Communication with other health care professionals (p 130) • Team communication and dynamics (pp 130, 131) Therapeutic Communication Principles of communicating with patients in a manner that achieves a positive relationship • Interviewing techniques (pp 134-135) • Adjusting communication strategies for age, stage of development, patients with special needs, and differing cultures (pp 137-141) • Verbal defusing strategies (p 138) • Family presence issues (pp 133, 134, 139, 140) • Dealing with difficult patients (pp 137-138) • Factors that affect communication (p 126) Medical Terminology Integrates comprehensive anatomic and medical terminology and abbreviations into written and oral communication with colleagues and other health care professionals. Knowledge Objectives Identify the importance of communications when providing EMS. (p 121) Identify the role of verbal and electronic communications in the provision of EMS. (p 121) Describe the phases of communications necessary to complete a typical EMS event. (p 130) Identify the importance of proper terminology when communicating during an EMS event. (p 130) List factors that impede effective verbal communications. (p 126) List factors that enhance verbal communications. (pp 132-134) Identify technology used to collect and exchange patient and/or scene information electronically. (pp 122-126) Recognize the legal status of patient medical information exchanged electronically. (p 127) Identify the components of the local EMS communications system, and describe their function and use. (pp 121-122) Identify and differentiate among the following communications systems a. Simplex (p 123) b. Multiplex (p 123) c. Duplex (p 123) d. Trunked (p 123) e. Digital communications (p 123) f. Cellular telephone (p 124) g. Computer (pp 123, 124) Identify components of the local dispatch communications system, and describe their function and use. (pp 121-122) Describe the functions and responsibilities of the Federal Communications Commission. (pp 123, 126) Describe how an EMS dispatcher functions as an integral part of the EMS team. (pp 131-132) Identify the role of the emergency medical dispatcher in a typical EMS event. (pp 131-132) Identify the importance of prearrival instructions in a typical EMS event. (p 132) Describe the purpose of verbal communication of patient information to the hospital. (p 129) List information that should be included in patient assessment information verbally reported to medical direction. (pp 129-130) Identify internal and external factors that affect a patient/bystander interview conducted by a paramedic. (pp 132-133) Discuss the strategies for developing patient rapport. (pp 133-134) Provide examples of open-ended and closed-ended questions. (p 134) Discuss common errors made by paramedics when interviewing patients. (p 137) Identify the nonverbal skills that are used in patient interviewing. (p 137) Discuss strategies to obtain information from a patient. (pp 136-137) Summarize the methods to assess mental status based on interview techniques. (p 135) Differentiate the strategies a paramedic uses when interviewing a patient who is hostile compared with one who is cooperative. (p 138) Summarize developmental considerations of various age groups that influence patient interviewing. (pp 138-139) Discuss unique interviewing techniques necessary to employ with patients who have special needs. (p 139) Discuss interviewing considerations used by paramedics in cross-cultural communications. (pp 139-141) Skills Objectives There are no skills objectives for this chapter. Readings and Preparation Review all instructional materials including Chapter 5 of Nancy Caroline’s Emergency Care in the Streets, Seventh Edition, and all related presentation support materials. • Review local radio protocols and procedures for conducting both dispatch and medical communications, including special devices or applications for communicating with patients with special needs or language barriers. • Review local protocols and procedures for operating radio/telephonic communication equipment, including procedures for equipment failure. • Review local protocols and procedures for operating radio/telephonic communication equipment during mass casualty or disaster events • Obtain local receiving facility protocols or numbers for submitting radio/telephonic communications regarding patient care reports (Note: Some facilities are moving toward recorded phone lines with specific numbers to call in patient reports that vary based on condition) • Review current status of communications in the public safety and health care industry. The most current report, Joint Advisory Committee on Communications Capabilities of Emergency Medical and Public Health Care Facilities, February 4, 2008, is available free online at http://www.ems.gov/pdf/FCC-JAC-Report.pdf. • Remind students that in some special circumstances, especially ones in which the incident command system (ICS for mass-casualty incidents [MCIs], etc.) is in place, common terminology must be used. For a brief reading on common terminology in the ICS, visit the FEMA website at http://www.fema.gov/emergency/nims/ICSpopup.htm#item1. Support Materials • Lecture PowerPoint presentation • Case Study PowerPoint presentation • Obtain a copy of your state’s communications plan for EMS responses. • Create your own scenario cards with pertinent information necessary for students to construct a verbal interview with a patient, online patient care report, and bedside patient care report. Be certain you have incorporated patients with a variety of disabilities, special needs, of different age groups, those with cultural considerations, and levels of mental status. This will facilitate a comprehensive patient selection for role play in later exercises. • If possible, obtain shortwave radios sold at major retail outlets for practice using microphones and communication of information. This allows students to get a realistic feel for distance from the microphone and distortion that may occur when receiving transmitted information. They can be utilized during role play activities. • Incorporate devices that will allow students to “feel” what it is like to be hearing or visually impaired, such as earplugs to simulate hearing loss, reading glasses covered with plastic wrap to simulate visual problems, and so forth. Have students practice conducting patient interviews during role-play exercises to understand challenges posed with these patient groups. Enhancements • Direct students to visit the companion website to Nancy Caroline’s Emergency Care in the Streets, Seventh Edition, at http://www.paramedic.emszone.com for online activities. • This link provides access to an established site that collects, evaluates, and disseminates public safety communications information: http://publicsafety.fcc.gov/pshs/clearinghouse/index.htm. • Some students may not have visited or accessed the local emergency communications center. If possible, consider arranging a field trip for students to see emergency dispatch in progress. • Students may not be familiar with modern telemetry devices and Bluetooth-capable monitors that allow for transmission of patient data. If the program does not have access to these devices, ask a local EMS service to bring in the devices to demonstrate how this technology works. • Meet with the local emergency communications center manager, and arrange to have an experienced dispatcher familiar with all phases of the call taking, pre-arrival instructions, and dispatching of emergency calls come to speak with the class about common concerns identified by communications center personnel when dealing with public safety or emergency medical services providers. • If available, consider using the supplemental text, Patient Assessment Practice Scenarios, as material for generating calls for documentation. This will allow students to practice patient assessment in conjunction with communication. Available from http://www.jblearning.com, the ISBN for this product is 978-0-7637-7820-0. • If available, consider using the supplemental text, Patient Assessment Practice Scenarios, as material for generating calls for communication. This will allow students to practice patient assessment in conjunction with documentation. Available from http://www.jblearning.com, the ISBN for this product is 978-0-7637-7820-0. • Content connections: Remind students that all patient care interactions and EMS responses require communication. Students should be able to relate the information found in this chapter with every chapter in the text. Each chapter in the text will have communication essentials that should be incorporated into their interview techniques, online patient reports, and bedside patient care report. Students should also be reminded that proper medical terminology is necessary to reflect compentency of the paramedic. For communication of verbal reports, pronunciation is also a skill that should be practiced to ensure the listener is able to adequately interpret information. Remind students that later chapters on geriatrics, pediatrics, and violence may have additional requirements that require more specific communication strategies. These should be noted as encountered throughout this chapter. • Cultural considerations: Discuss various language and inflection barriers that may be present in the local population. Consider how this may impact students during clinicals. Encourage students to obtain additional resources such as phrasebooks or digital applications that will enable them to effectively communicate with these patient groups. Various cultural and religious beliefs also may be reflected with issues related to cross-gender communications or granting of consent for treatment. Identify any local populations that may result in the need for additional considerations. People communicate in a variety of ways, such as through eye contact, body position, and facial expressions. Many factors need to be taken into consideration during communication. Patients with special needs may require you to consider alternative forms of communication. For example, if your patient is deaf and you cannot communicate using sign language, you may need to communicate by having the patient write down his or her feelings. Culture can affect the way the patient, family, and/or caregiver interprets cues. Remind students that guessing a patient’s cultural preferences may result in misinterpretation or feelings of bias. Ask the patient or family member direct questions regarding cultural practices to demonstrate caring and consideration for their particular needs. Teaching Tips Emphasize that verbal communications to receiving facilities and communications centers are most likely recorded. Students must understand the importance of audible, clear, professional, thorough, and accurate reporting. This can be illustrated through use of locally approved communication guidelines during simulations conducted throughout the remainder of the course. Remind students that all radio communications are governed by the Federal Communications Commission, appropriate radio etiquette must be utilized at all times under FCC Rules and Regulations, and fines may be imposed for infractions. Local medical guidelines and protocols should be reviewed with the students to include procedures for reporting equipment failure, communications during disasters and mass casualty events, and methods for communication when traditional modalities are unavailable. Unit Activities Writing activities: Assign each student a state to research the emergency communications plan. Have them prepare a short report highlighting the key concepts of the plan during routine communications, interoperability, and guidelines specific to emergency situations for comparison with their own state’s plan. Ask that they identify which is most comprehensive and describe the rationale for their selection. Student presentations: Assign students a variety of languages, including sign-language, that may be encountered during patient care. Ask them to prepare a presentation of essential terminology translated for communication with patients speaking those languages. Group activities: Have students use scenarios prepared by you to practice skills and strategies to effectively interview and communicate with patients of various ages, disabilities, cultures, mental status, and cooperation. After completing the role-play scenarios, groups should discuss those strategies that appeared most effective. Alternative: Have students use scenario cards to practice delivery of patient care reports using shortwave hand-held radios from different locations to simulate how information is relayed and received. Visual thinking: Identify video clips (sound muted) that display a variety of nonverbal cues or body language during a communication. Have students describe what they “see” being communicated and discuss the various findings. Play the clip with the sound on to allow students to compare their findings with the actual conversation occurring. Try to identify clips that are not obvious or well known to students. Pre-Lecture You are the Provider “You are the Provider” is a progressive case study that encourages critical-thinking skills. Instructor Directions Direct students to read the “You are the Provider” scenario found throughout Chapter 5. • You may wish to assign students to a partner or a group. Direct them to review the discussion questions at the end of the scenario and prepare a response to each question. Facilitate a class dialogue centered on the discussion questions and the Patient Care Report. • You may also use this as an individual activity and ask students to turn in their comments on a separate piece of paper. Lecture I. Introduction A. In EMS communication, information must move rapidly, efficiently, and effectively. 1. To convey emergency information, you need to know: a. What constitutes an EMS communications system b. Who needs to talk with whom c. What technical resources are available d. How to make communication as efficient as possible 2. The emergency medical dispatcher (EMD) plays a crucial role in EMS communication. a. The EMD facilitates all phases of EMS communications. b. To communicate with the EMD, you must learn how to: i. Organize information into a brief orderly verbal report. ii. Transmit information by radio or telephone. 3. Communicating with the patient is called therapeutic communication. a. Involves the skill of communicating with people during extremely difficult times 4. A good paramedic should: a. Put forth his or her best efforts. b. Maintain a professional demeanor. c. Possess skilled communication techniques. II. EMS Communications Systems A. EMS communication requires the use of specialized equipment. 1. Communication systems are based on using radio signals. a. You must learn about radio signals and the equipment needed to send and receive them. 2. You must have a reliable method to communicate with medical direction. a. Cellular devices and mobile data terminals can help. b. The system must provide 24-hour contact with local and regional medical facilities. 3. Backup communication systems are needed. a. Example: Even if you primarily use a digital radio, you should also have a cellular phone. b. Backup communication systems are especially critical during disasters and multiple casualty incidents. i. Towers may be damaged. ii. Cell sites may be disabled. iii. Computer data servers may be crippled. iv. Amateur radio groups often establish communication during disasters. v. Communication equipment is available after a major incident through local emergency offices. B. Communication system components 1. EMS communication systems vary considerably. a. They serve moderate to large populations. 2. Base stations a. Should have radio equipment consisting of, at least, a transmitter, receiver, and antenna b. Serve as dispatch and coordination areas c. Should be in contact with all other system elements d. Use high-power output (45 to 275 W). i. Maximum allowable power is set by Federal Communications Commission (FCC) and printed on a license. e. Must be equipped with an antenna i. Preferably situated on a hill or high building close to the base f. Antenna system is a vital part in transmission and reception efficiency. 3. Mobile transmitters/receivers (transceivers) a. Two-way radios mounted on vehicles b. Varied power ranges determine the distance of effective transmission: i. Example: A 7.5 W transmitter will transmit 10 to 12 miles. ii. Transmission distances are greater over water or flat areas, reduced in mountainous areas or around tall buildings. iii. Typical mobile transmitter is 20 to 50 W. 4. Portable transmitter/receivers a. Hand-held radios b. Used by: i. Paramedics working at a distance from their vehicle ii. Physician consultants when not at the hospital c. Power up to 5 W i. Gives limited range ii. Can be boosted by retransmission through vehicle 5. Repeaters a. Miniature base stations used to extend range of a telemetry or voice communication system b. May be: i. Stationary (fixed repeaters) ii. Carried in emergency vehicles (mobile repeaters) c. Pick up weak signals and retransmit them at higher power on another frequency i. Extends the range of low-power portable radios ii. Allows more members of the system to hear one another 6. Remote consoles a. Usually located in a hospital emergency department b. Terminals that receive transmissions from the field and transmit messages back i. Usually through base stations c. Connected to the base station by dedicated telephone lines, microwave, or radio d. Consist of: i. An amplifier and speaker for incoming voice reception ii. A decoder for translating the telemetry signal into an oscilloscope tracing or printout iii. A microphone for voice transmission C. Radio communications 1. A radio transmits signals by electromagnetic waves. a. When transmitted by waves, energy can be characterized by the length of wave it produces. i. Examples: Relatively long wavelengths produce audible sound, while shorter wavelengths are in the infrared light spectrum. b. Radio wavelengths allow tuning when you adjust your radio to the proper frequency. i. Frequency is how frequently the wave recurs in a given time (usually 1 second). ii. Short wavelengths are repeated with higher frequency than longer wavelengths. c. Radio wavelengths are designated in cycles per second or hertz, named after the man who first described electromagnetic waves. d. Common abbreviations are: i. Hertz (Hz)—cycles per second ii. Kilohertz (kHz)—1,000 cycles per second iii. Megahertz (MHz)—1 million cycles per second iv. Gigahertz (GHz)—1 billion cycles per second 2. Radio waves occur in the electronic frequency spectrum 3 kHz to 3,000 GHz. a. Normal voice requires 3 kHz at minimum. b. Frequency bands are portions of the radio frequency spectrum assigned to specific uses. c. Two most commonly used bands for medical communication are the very high frequency (VHF) band and the ultrahigh frequency (UHF) band: i. The VHF band extends from 30 to 175 MHz; 30 to 50 MHz low band and 150 to 175 MHz high band. ii. Low-band frequencies have high ranges (up to 2,000 miles) but are sensitive to changes in the ionosphere. (a) Can cause “skip interference” iii. High-band frequencies have shorter ranges but transmit without interference. iv. The most commonly used VHF high-band frequency is the 150 to 160 MHz range. (a) Historically, main band assigned by FCC v. In the 1970s, the UHF was assigned to EMS as MED channels. vi. The UHF band extends from 300 to 3,000 MHz. (a) Most medical communications occur around 450 to 470 MHz. (b) At these frequencies, communications have no skip interference and minimal noise (signal distortion) vii. The UHF band penetrates better in dense populations and works inside buildings. (a) Despite its shorter range (b) Is also easily absorbed by rain and environmental objects d. 800 MHZ is commonly used in EMS systems because of its penetration, minimal interference, and reduced channel noise. i. It works well in metropolitan areas. ii. It allows trunking, in which multiple agencies or systems can share frequencies. iii. 800-MHz radio can also be linked to a computer system to transmit voiceless communications. iv. A dispatcher can reprogram radios in a trunked system so that agencies that don’t routinely communicate can do so during an emergency incident. e. The Federal Communications Commission (FCC) controls US frequency allocation. i. VHF bands assigned for general emergency radio transmissions ii. UHF bands assigned for ambulance-to-hospital telemetry systems iii. Band assignments will be given by your EMS system. 3. EMS systems must perform a communications check (COMM CHEK) routinely. a. At least monthly b. COMM CHEK should confirm ability to send and receive voice and ECG. c. Log the success or failure. d. Most effective when part of standard operating policy 4. Modes of radio operation a. Simplex system: Portable units can transmit (by voice or telemetry) and receive (by voice) only in one mode at any given time. i. Requires only a single radio frequency b. Duplex: Network that uses two frequencies to permit simultaneous transmission and reception (like a telephone) c. Multiplex: Combines two or more signals for simultaneous transmission on one frequency d. An ambulance service can design a communications system to provide voice communications and continuous telemetry in one of four ways: i. Transmit on two frequencies of a channel allocated for telemetry (duplex) (a) One for the voice signal and one for the telemetry signal (b) Ambulances must have two UHF transmitters (one voice, one telemetry) and once receiver (voice). ii. Multiplex telemetry and voice on one frequency of the UHF pair and receive voice communications on the other (a) Requires one UHF transmitter on the vehicle and demultiplexing equipment on the base station iii. Ambulance can transmit telemetry data on UHF frequency and voice data on VHF frequency. (a) Requires a UHF and a VHF transmitter on the vehicle (two simplex systems). iv. Increasing trend to transmit ECG telemetry by cellular phones (a) Full duplex capacity (b) Many available channels (c) High-quality signal that can be maintained over distance (d) Lower capital and maintenance cost 5. Digital radio and trunked systems a. Digital radio helps clear up distorted or lost transmissions. b. Conventional radios have fixed radio frequency (RF) channels, so the user can only select one channel at a time. c. Digital trunked radios have channels related by groups. i. Allow simultaneous conversations on one physical channel. d. Digital systems communicate data from computer-aided dispatch (CAD). i. A computer collects call information and recommends sending to closest unit. ii. Dispatches data directly by data transfer iii. EMS unit will see what is seen on CAD terminal. (a) Example: Provides a textual location and mapping information iv. Allows ambulance driver to flag the call as received v. Recommends emergency actions, known as pre-arrival instructions (PAI), to the dispatcher to begin care vi. Allows access to physician-reviewed data related to most EMS-related emergencies D. Cellular telephones 1. Use 3 W or less 2. Mobile antennas a. Typically limited to 10 to 15 miles range over average terrain b. Base station antennae are located higher, increasing range. 3. Cell phones are commonly used in EMS communications systems. a. Low-power portable radios b. Communicate through interconnected repeater stations called “cells” c. Linked by computer systems d. Connected to the telephone network 4. Paramedics need to know: a. Commonly used phone numbers i. Examples: Medical control, local hospital EDs, dispatch centers b. Locations of cellular dead spots 5. Many cellular systems make equipment and air time available at little or no cost. a. Public can often call 9-1-1 at no charge. b. Easy access may result in overloading and jamming. i. Examples: Multiple-casualty incidents (MCIs) or disasters c. Have a backup communications plan to circumvent overloads. 6. Most newer cell phones have built in global positioning system (GPS) specifically for emergencies. a. Helps CAD know where the call is originating b. Many vehicles also have vehicle locator and navigation systems based on GPS technology that notify emergency services when a crash occurs. 7. Typically, cell phone calls for emergency services go through a routing center, rather than directly to local dispatch. a. 9-1-1 cell calls usually go through a regional or statewide agency such as the state police. 8. National Emergency Number Association estimates that more than 75% of US population live in areas where wireless 9-1-1 services deliver caller’s call-back and location to the appropriate public safety answering point (PSAP). E. Backup communications systems 1. Most systems include landline (backup) in addition to radio communication. a. Link fixed components of the system (hospitals, public safety services, poison control, etc.). 2. Telephones may be patched into radio transmission through the base station. 3. Cellular phones are becoming increasingly popular in EMS communications. a. Overcome problems of overcrowded frequencies b. Less expensive than radios c. Generally give clearer signals d. Enable paramedics to communicate with anyone with a telephone 4. Disasters are the main limitation of using cell phones as a backup. a. Cell towers may be affected. b. Cell sites overloaded with civilian traffic c. In disasters, older low-band and high-band simplex systems remain operable. i. Can still transmit and receive because most base stations have generators F. Biotelemetry 1. Capability of measuring vital life signs and transmitting them to a distant terminal 2. Started with transmission of ECGs a. Often used for other measurements 3. Space program uses telemetry for vital signs of astronauts 4. Term often shortened to telemetry 5. Usually, telemetry is a quick way to say you are transmitting an ECG signal from a patient to a receiving station. a. Standard ECG is composed of low-frequency signals (100 Hz or less). b. To ensure that ECG is not filtered out, signal must be encoded if being transmitted over a channel also used to transmit voice. i. Over UHF frequencies, it is confined to 1 lead of a 12-lead ECG so it can be used to interpret cardiac rhythms. ii. For more complete diagnoses, uses all 12 leads. iii. Most newer systems use facsimile technology to allow transmission of ECGs to the receiving hospital before the ambulance arrives. 6. ECG signal can be distorted by extraneous spikes and waves (known as noise), which may arise from: a. Muscle tremor b. Loose ECG electrodes c. Sources of 60-cycle alternating current (AC), such as transformers and power lines d. Attenuation (reduction) of transmitter power, caused by weak batteries or transmission beyond transmitter’s range 7. Eugene Nagel started ECG telemetry in Miami, Florida, in the early 1970s. a. Important role in establishing paramedic profession i. Allowed doctors to supervise paramedics caring for patients in the field ii. Led to public acceptance of paramedics carrying out procedures such as defibrillation and cardiac drug administration b. Many states made it mandatory for all ALS units to have telemetry capabilities. 8. ECG telemetry has been used less frequently over the past decade because paramedics are more skilled in dysrhythmia recognition. a. Rely solely on paramedic’s assessment b. Rarely require confirmation by a physician 9. Two developments occurred to bring a reassessment of prehospital ECG telemetry. a. Conclusive research on the use of fibrinolytic agents indicated that the earlier the agents were given during an acute myocardial infarction, the better the chances of myocardial reperfusion. b. Cell phone and facsimile technology made it possible to transmit a 12-lead ECG from a moving ambulance to a hospital. i. Can diagnose myocardial infarction before the patient reaches the hospital 10. Early diagnoses a. Enables the hospital to prepare for the administration of fibrinolytic therapy or coronary cauterization immediately as the patient arrives b. In some EMS systems, the fibrinolytics are administered in the prehospital setting. 11. Some form of telemetry will be a part of emergency care for the foreseeable future because technology can facilitate assessment and treatment in the prehospital setting. 12. Information other than ECGs may also be transmitted to the receiving hospital before the patient arrives. a. Advancements in technology are occurring rapidly. b. Keep up with the technology that will improve communication of patient information. 13. Old telemetry system can be used. a. Requires a functional biotelemetry system b. In cases where older radio biotelemetry systems were replaced by newer technology (fax or digital), the ECG is: i. Captured on the heart monitor ii. Stored in the machine as a data file (a) Can be transmitted to hospital via a cell phone link (b) In other services, transmitted by e-mail (c) Some systems “dump” patient data directly into patient charts. (d) Enables immediate transmission G. Factors may affect communications. 1. Equipment failures 2. System problems may include: a. Radio tower issues b. Computer crashes c. Telemetry failure d. Audio problems 3. Paramedics must be able to: a. Troubleshoot quickly. b. Use planned redundancy if you cannot fix it. 4. Follow local protocols regarding radio failure. III. Communicating by Radio A. The effectiveness of the EMS communication network depends on: 1. Technical hardware 2. People who use it B. Effective communication by radio in emergencies requires skill and experience. 1. “Freezing” at the microphone or talking excessively is neither appropriate or useful. 2. Effective communication requires: a. Knowledge of rules governing communication b. Understanding of conventions for transmitting information by radio 3. Remember: The purpose of talking on the radio is to transit pertinent information. a. Keep communication simple, brief, and direct. 4. Practice effective communication. 5. Be familiar with the various methods of communication that will be required through your radio. 6. As part of your job, you will need to: a. Demonstrate effective communication with the dispatcher from the beginning to the end of the call. b. Communicate effectively with the receiving medical facility. c. Deliver a precise and direct radio report in an organized, systematic manner. C. FCC regulations 1. The FCC is the agency that regulates US radio and television communication. 2. For radio, the FCC: a. Issues licenses b. Allocates frequencies c. Establishes technical standards d. Establishes and reinforces regulations for operating radio equipment 3. The FCC monitors transmissions on various frequencies and conducts spot checks of base stations to ensure they are licensed. 4. Fines can be imposed for failing to follow FCC rules and regulations. 5. The FCC requires that communications over frequencies allocated for emergency medical use are confined to that use. a. Use of obscenities and transmissions unrelated to medical services are forbidden. 6. To communicate a personal message, notify recipient by radio to contact the base by phone. a. To communicate a personal request to the dispatcher, use a telephone. 7. EMS communications are regulated by the Special Emergency Radio Service provisions of the FCC Rules and Regulations, Part 90. a. A copy of Part 90 should be available for reference at your base station. D. Clarity of transmission 1. Regardless of the type of communication, the basic model of communication involves a: a. Sender b. Clear message c. Receiver d. Feedback loop (repeating the information for confirmation) i. Ensures the exact message that was sent is received and interpreted properly by the receiver (a) Example: If an emergency department orders 100 mg of lidocaine by IV push, paramedic should repeat the order, “Give the patient 100 mg of lidocaine, IV push, correct?” 2. For communication to occur someone at the other end of the radio has to be able to hear and understand what you say. 3. The first principle of communicating by radio is clarity. 4. The following guidelines can improve the clarity of your transmissions: a. Before you begin to transmit, check the volume, and then listen to make sure the channel is clear. i. If another radio transmission is in progress, wait until the parties have finished transmitting before you try to get on the air. b. Once the channel is quiet, press the transmit key for at least 1 second before you start speaking. i. Ensures that the beginning of your message is not lost c. Start your transmission with the identifying information: i. Give the number or the name of the unit being called first. ii. Then your own identification (a) For example, “Williamsburg Hospital, this is Medic 3.” d. Keep your mouth close to the microphone, but not too close. i. About 2" to 3" is usually ideal e. Speak clearly and distinctly, pronouncing each word carefully. f. Do not shout! i. Shouting distorts the signal. ii. Speak in a normal pitch. g. Do not talk with your mouth full. i. It muffles transmission. h. Keep calm, and keep your voice free from emotion. i. Use a normal conversational tone. i. Keep your transmissions brief. j. Try having your radio reports taped at some point to critique your own transmissions and perfect your style. k. If you have a long message to transmit, break the message into 30-second segments, checking at the end of each segment to determine whether it was received and understood. l. Do not waste air time with unnecessary phrases, such as “be advised.” i. Courtesy is taken for granted. ii. There is no need to use air time for social graces such as “please” and “thank you.” m. When speaking a word or name that might be misunderstood, spell it out, using the international radiotelephony spelling alphabet (or NATO phonetic alphabet) or a similar system. i. Refer to Table 1. n. When presenting numbers that might be misunderstood, transmit the number as a whole, then digit by digit. i. For example, if the respirations are 16, you would say, “The respirations are sixteen, that is, one-six.” E. Content of transmissions 1. Radio transmissions should be brief, to the point, and professional in tone. 2. Guidelines for what you should and should not include in EMS radio communications: a. Remember, anyone may be listening. i. Protect the privacy of the patient at all times. ii. Do not use patient’s name on the air. iii. Do not transmit personal information about the patient. iv. Follow HIPAA guidelines and local laws. v. Certain types of confidential cases, such as rape or psychiatric problems, should be identified by established codes or given in face-to-face communications at the ED. vi. Do not assume your cell phone offers protected conversations. vii. Do not say anything on the radio or phone you would not want others to hear. b. The agency being called must signal that it is ready to receive the information. c. Be impersonal. i. Use “we,” not “I,” to refer to yourself. ii. Use proper names and titles to refer to others when necessary. d. Always use clear text. i. Do not use codes or signals. e. Reduce background noise. i. Roll up windows to limit interference. f. Do not try to be a comedian or a critic. i. There is no place for unprofessional behavior, sarcasm, or other poor conduct on emergency medical radio frequencies. g. Do not use profane language on the air. i. The FCC might issue civil monetary penalties, revoke a license, or deny a renewal application. ii. If convicted in a federal district court, you can face criminal fines and/or imprisonment for not more than 2 years. h. Use professional language. i. Do not show off. ii. Communication is the goal. iii. Use proper medical terminology, but use it correctly. i. Avoid using words that are difficult to hear. i. Examples: “Affirmative” instead of “yes,” “negative” instead of “no” j. Use standard formats agreed on by your EMS service for transmission of information. i. For example: The patient’s history should always be presented in the same order. ii. Helps prevent listeners from missing part of the transmission k. When you finish transmitting, notify the receiver that the transmission is finished. i. This can be a simple “Over,” or “End of transmission.” l. Obtain confirmation that the transmission was received. i. When you receive instructions by radio from the dispatcher or from medical control, echo the order back to make certain you have understood it correctly. m. Question any orders you did not hear clearly or did not understand. n. Use EMS frequencies only for emergency medical communications. F. Codes 1. Some ambulance services use radio codes; most do not. 2. Codes were used to: a. Maintain security. b. Keep air time as brief as possible. c. Decrease likelihood of misunderstanding or noise. d. Prevent the patient, family, and bystanders from understanding what is being said. i. Avoid alarming patient with information that might increase anxiety or worsen condition. ii. Avoid sitting right next to the patient while transmitting your report to the ED. 3. For codes to be effective: a. Everyone must learn the code meanings. b. They should be simple and standardized within a given region. c. A copy of the code should be posted at every radio terminal. 4. The 10-code system a. Once commonly used b. Has been phased out in many EMS systems c. No longer recommended by the National Incident Management System (NIMS) d. If codes are still used in your agency, learn the code system used. 5. One of the main purposes of codes is to keep airtime brief. a. They should be: i. Kept simple ii. Used only when really needed 6. During MCIs, abandon codes and use words all personnel can understand. 7. Most EMS systems use standard terms rather than codes for day-to-day operations as well. G. Response to the scene 1. When a call is received, you should follow a standard method of communications. a. Methodology is usually standardized for the individual agency. b. Different agencies may have differing methods. i. Most are similar in content c. When you are alerted by dispatch, record the location and call information as it is given. i. Ensures you fully understand the transmission d. After call is dispatched and details are recorded, respond to the dispatcher that you have received the information. 2. A standard sequence: a. Tell dispatch you received the message and are responding to the alert. i. Confirm the location and call reference. (a) Ensures there has been an effective and accurate transfer of information (b) Establishes your dispatch time b. EMS unit leaves its location and begins its trip to the scene. i. Document by contacting dispatch and announcing your action. (a) Established your en route time c. Next transmission should be your arrival on scene. i. Notify dispatch. (a) Allows a time stamp to document unit arrival (b) Can be used to record your observations and findings regarding the scene ii. Opportunity to: (a) Give prearrival instructions to other responding agencies, if applicable. (b) Call for additional resources. d. After you have treated your patient(s) and are ready to provide transport, contact dispatch again to confirm your actions. i. Establishes a time stamp for departing the scene ii. Documents that you completed operations at the scene and are en route to the hospital (a) Again, a time stamp is generated for the record. iii. If you are not able to communicate with dispatch while on scene, you must maintain a list of procedure times and event times while on scene. (a) These can be logged by responders or jotted down on a notepad for later communication to dispatch. (b) When given to dispatch after the call, tell them to note your times in the record for documentation purposes. e. The next radio transmission to dispatch is to notify them of your arrival at the medical facility. i. Confirms arrival at the hospital ii. Establishes status of your unit iii. Important because it documents the unit’s unavailability for further service at this time f. The last transmission confirms call completion and establishes status. i. If the unit is available, it means that they can respond to another call. ii. If not, it establishes their status and intent. (a) As soon as the unit is resupplied and available, the unit should notify dispatch. 3. Radio transmissions should be brief, to the point, and professional in tone. a. Never assume dispatch knows your status. i. Always notify them of your status. ii. Always confirm their receipt of transmission. H. Relaying information to medical control 1. Radio communications between paramedics and physician should be concise and accurate. 2. Using a standard format for communicating with medical control ensures information is relayed consistently and completely. 3. In larger EMS systems, paramedics may need to take patient(s) to a different facility than medical control: a. Follow local protocols. b. Notify both facilities of your destination. c. Medical control orders coming from another facility will usually be accepted by receiving facility. I. Format for reporting medical information 1. The following medical information should be included in a report: a. Patient’s age and sex b. Patient’s chief complaint c. Brief, pertinent history of present illness or injury d. Anything else from patient’s medical history relative to current situation, including: i. Underlying medical conditions ii. Medications iii. Allergies e. Patient’s level of consciousness and degree of distress f. Patient’s mental status g. Patient’s vital signs h. Pertinent physical findings in head-to-toe order i. ECG findings j. Treatment given so far and response to treatment k. Estimated time of arrival at receiving facility 2. Transmit information quickly, completely, and in a well-organized fashion. a. Example: Initially relay: “We have a 53-year-old man reporting severe shortness of breath, which wakened him from sleep and is worse when he is lying down. He has a history of hypertension and takes Diuril. He is alert but in significant respiratory distress, with a pulse of 130 and regular, respirations 36 and labored, and a BP of 190/120. Physical exam reveals no JVD but crackles and wheezes in both lung fields. He has 2+ pitting ankle edema. We are sending you an ECG”; rather than simply, “We have a patient with a pulse of 130, a blood pressure of 190/120, and respirations of 30. We’re sending you a strip.” i. Reduce physician’s need to ask questions to get essential information. b. Gather information thoroughly at the scene, and organize it clearly before reporting. c. Tip: Write your reporting format on a card that you can refer to. 3. Continue to monitor and assess patient; report any changes. IV. Communication With Health Care Professionals A. Phases of communication 1. Communication has several essential phases. a. You will exchange information with many people: i. Patient ii. Bystanders iii. Patient’s family iv. Medical control v. Receiving medical facility vi. Dispatch center vii. Law enforcement viii. Members of the EMS team b. You should stay in constant communication with your partner. 2. Each communication phase has specific terminology. a. Communicate with patients in terms they understand. b. Relay information to medical facility using medical terminology. c. Avoid slang terms. B. Medical terminology 1. Learn established medical terms and abbreviations. a. Your EMS system may have approved lists of terms. b. Most terminology comes from Latin. 2. Learn common expressions, eg, packaging a patient for transport. 3. Review anatomy, physiology, and documentation chapters to familiarize yourself with medical terminology. C. In-person report 1. Be sensitive with in-person reporting to a physician. a. Step outside patient care room or speak softly when transferring information to medical practitioner. 2. Be brief. 3. Share information that may not have been provided in a radio report. a. Provide this information to a medical practitioner of equal or higher level so as to: i. Keep confidentiality. ii. Ensure care continuity. V. Dispatching A. “To dispatch” means “to send out on a mission,” but EMD does more. B. As a member of the paramedic team, the EMD: 1. Obtains as much information as possible about the emergency 2. Directs the appropriate team to the scene 3. Provides the caller with advice to manage the situation until help arrives 4. Monitors and coordinates communication with the field 5. Maintains written records of the response C. Receipt of the call for help 1. EMD assumes caller needs help. a. Caller may be too upset to be clear. b. EMD must be able to understand caller’s distress. 2. EMD must do the following: a. Answer the telephone promptly. b. Identify himself or herself and the agency. c. Speak directly into the mouthpiece. d. Observe telephone courtesy: i. Be calm and professional. ii. Inform caller what is being done and how soon to expect help. (a) May provide emergency medical dispatch—vital first aid information that can be administered while awaiting ambulance. e. Take charge of conversation. i. Ask questions pertaining to safety. ii. Ask for useful information regarding specific situations: (a) Is residence door locked? (b) What pets does the patient have? D. Information gathering 1. Ask questions to gather the following information: a. Patient’s exact location i. Street name and number, name of community ii. If rural area, landmarks (eg, water tower) b. Call-back number i. In case call is disconnected or more information is needed ii. Discourages pranks iii. With enhanced 9-1-1 system, EMD may only need to confirm this information on screen. c. Patient’s problem d. Specific information on the patient’s condition: i. Is patient conscious? ii. Is patient breathing? iii. Is patient bleeding badly? e. For motor vehicle crash: i. Kinds of vehicles and cargo involved ii. Number of persons injured and extent of injuries iii. Apparent hazards at the scene (eg, fire, power lines) (a) EMD can contact other relevant agencies to control hazards. E. Dispatch 1. After being told location, call back number, and apparent problem, dispatcher asks the caller to wait on the line. 2. EMD decides which crews and vehicles to dispatch depending on: a. Nature and location of call b. Units available 3. EMD contacts appropriate crew and describes nature of call and location. 4. EMD may return to caller to gather rest of the information. 5. If EMD learns of conditions that affect travel to or actions at the scene, EMD contacts you en route so you can: a. Decide whether to use emergency warning devices. b. Anticipate equipment needed or tasks to be performed. 6. EMD may remind you to fasten seat belts en route. F. Advice to the caller 1. After directing rescue crews, EMD maintains contact with caller. a. Tells caller what is being done (eg, an ambulance will arrive in 5 min.) b. If EMD suspects patient has life-threatening emergency, provides caller with simple emergency care instructions (eg, airway maintenance) 2. EMDs should receive training in giving instructions by telephone. a. Most of this training is based on original dispatch system designed by Jeff Clawson, MD, in Salt Lake City, Utah, in early 1980s. i. This system is used throughout the world. G. Ongoing communications with the field 1. EMD coordinates communications between ambulance and medical control. 2. EMD contacts any other agencies (eg, fire, police) who may be required at scene. 3. Refer to Table 2 for phases of dispatch. 4. General practice to use standard military time for documentation (see Chapter 6, Documentation) VI. Therapeutic Communication A. Paramedics often see people at their worst and most vulnerable. B. At least half of calls involve entering people’s homes at very private moments. 1. Treat each invitation into a home as an honor to be welcomed at a time and place where others would not be. 2. Convince people you want to hear what they have to say. 3. Give them your undivided attention. 4. Do not talk about patients in their presence as if they are inanimate or not there. 5. Pay attention to patient answers the first time. 6. Jot down patient’s responses. 7. Listening transmit information, as well as talking. 8. Employ “active listening”: a. Repeat the key parts of a patient’s response to questions. b. Use expressions that assure patients you want to hear what they say, such as: c. When patient thanks you, say “You’re welcome,” not “No problem.” d. If patients say, “I’m sorry,” tell them they don’t need to be sorry, because you are here to help them because you want to be. 9. Reduce noise, and promote a quiet, calm atmosphere: a. Try not to shout. b. In noisy situations, like a bar, ask bartender to turn off music, turn up lights, etc. c. Remove patients as quickly as possible from chaotic situations to the back of the ambulance. d. If you need to run a compressor or engine, shut it off as soon as you can. e. Talk close to your patient’s ears in a calm voice. 10. Take patient’s medical and health history all at one time, if possible. 11. Manage the scene so you can ask personal questions quietly and privately. a. Some private questions may not fall under routine medical history but are important to diagnosing a patient. i. (These are called payoff questions and are explained in more detail later.) 12. Communicating with patients in chaotic sometimes dangerous environments is critical to skills of assessment and healing. C. Developing rapport 1. Good rapport with your patient is essential for obtaining good medical information. 2. Start by establishing an atmosphere of trust and comfort: a. Put the patient at ease. b. Reassure the patient with remarks like, “We are here to take care of you, but we need some information to do that.” c. People in crisis are highly perceptive; your challenge is to convey calm and genuine concern for someone you have never met. d. People do better if you can relieve their fear. 3. Obtaining information is a learned skill, which can be difficult: a. Some patients are resistant to giving personal details. b. Some patients have trouble focusing because of chaos. c. Some patients may be numbed by their own physical condition. d. Some patients may feel threatened by you or others at the scene. 4. If patients are reluctant to share personal information: a. Explain why you need their name and date of birth. b. Reassure them that all information is confidential and protected by law. 5. If patients have trouble focusing, move them safely to the ambulance: a. Creates a calmer atmosphere. b. Makes talking and listening easier. 6. If patients feel threatened: a. Cautiously approach using open postures. b. Smile and be calm. c. Reassure the patient. d. Take things slower if possible. 7. Tips for positive communication: a. Introduce yourself and obtain patient’s first name, then use it. b. Make and keep eye contact. c. Position yourself at patient’s level or slightly lower. d. Be honest. e. Use language patient can understand. f. Be aware of body language. g. Speak calmly and clearly. h. If patient has hearing deficits, make sure your lips and face are visible. i. Allow patient time to answer. j. Always act confident and professional. k. Treat others, including EMS officials, at the scene with respect. Patient will pick up on how you and others are treated. 8. Introductions a. Interpersonal communications is the exchange of information between two or more persons. b. Principles to bridge communication i. Introduce yourself. ii. Make and maintain eye contact. (a) Reinforces trust and honesty (b) Allows evaluation of patient’s neurologic status (c) Eyes may signal behavioral unrest, as in certain psychiatric conditions iii. Get on the same level as the patient. iv. Promotes trust and alleviates anxiety, particularly with children v. Position yourself so patient can easily see you. vi. Be aware of body language. (a) Use open-handed gestures. (b) Do not cross arms. (c) Do not react with skepticism. vii. Use the patient’s name in all interactions. viii. Speak slowly and calmly. ix. Always be honest. x. If patient is from another country or culture, find a family member to interpret. (a) If you do not speak the language fluently, it is usually not effective to try to speak the language. c. Two basic factors are necessary to improve communication. i. First, external factors, such as noise and language barriers, can make communication difficult. ii. Second, internal factors, such as lack of acceptance or empathy, and poor listening skills, can affect communication. d. Take good notes. 9. Respect and protect patient’s modesty. a. Especially important for elderly, adolescents, and sometimes very young. b. Even if patient is not personally sensitive to modesty, family members are. D. Conducting the interview 1. Interviewing is an important skill to develop and maintain. 2. There are two types of interview questions: a. Open-ended questions i. Allows patients to give you feedback and information ii. Allows you to judge patient’s mentation iii. Example open-ended question: “How are you feeling at this moment?” b. Closed-ended question i. Also known as direct questions ii. Used to elicit a specific answer iii. Example closed-ended question: “What year were you born?” 3. Develop a standard set of questions for collecting medical history. 4. Avoid talking down to patients, but use terms people without medical training will understand. 5. Standard questions could include: a. Have you ever had heart problems? b. Any lung problems? c. Any high or low blood pressure? d. Diabetes? e. Seizures? f. Fainting spells? g. Any prior head injury? h. Do you have both lungs and both kidneys? i. If patient is female and of childbearing age, ask: i. For history of pregnancies, deliveries, and abortions ii. When was last menstrual period, and was it normal? iii. Any gynecologic surgeries? 6. Seasoned paramedics often develop additional questions for specific circumstances, called “payoff questions.” a. Payoff questions can reveal huge subsurface issues. b. They can reveal a hidden reason paramedic was called. c. Example payoff questions: i. Have you ever felt like this before? ii. Have you been upset about anything lately? iii. Are you afraid of someone? (Ask only in private.) iv. Have you been thinking about hurting yourself? v. What happened the last time you felt this way? 7. Ask questions so as to produce most useful answers: a. Don’t ask leading questions. b. Pose questions clearly and in an even tone. c. Ask questions one at a time, and do not rush the patient. E. Assessing mental status 1. Mental status is often a prime indicator of the extent of illness or injury. a. Changes in mental status can be an early warning signal of a patient’s deterioration. 2. The AVPU method is a quick way to establish mental status: a. The first step is A: Alert to person, place, and day. i. Can the patient answer questions everyone should be able to answer, eg, “What is your name?” ii. If patient can’t answer these questions, move on to second step, verbal response. b. The second step is V: Verbal response. i. Have patient respond to simple verbal commands, eg, “Raise your left arm.” ii. Appropriate response to V shows a degree of acuity, but lesser than A. iii. If patient cannot follow verbal instructions, try step 3, response to pain. c. The third step is R: Response to pain stimulus. i. Pinch finger web or squeeze finger. ii. Movement to withdraw, shows “responsive to pain stimulus.” iii. If unresponsive to pain, move on to step 4, unresponsive. d. The fourth step is U: Unresponsive. i. Patient who does not respond to any questions, voice commands, or pain stimulus is termed “unresponsive.” 3. Continually check mental status during the interview. a. Patient should be able to quickly answer questions regarding who and where they are, and why you were called. b. Is speech impaired in any way? Patient should: i. Speak clearly. ii. Use logical sentences. iii. Understand questions. iv. Give appropriate responses. F. Strategies to elicit useful responses to questions 1. Reflection a. Repeating a word or phrase a patient has used to encourage more detail. i. Example: Patient says, “I can’t catch my breath.” You say, “You said you can’t catch your breath.” Patient may then respond more fully, explaining the condition and circumstances in more detail. b. This technique can produce more information than patient originally gave. 2. Empathy a. Feeling what the patient is feeling. i. Example: If patient expresses sadness or despondency about a situation, such as a recent death, you may say something like, “I am terribly sorry. I don’t know how I would feel in that situation, but I am sure I would feel similarly.” b. Showing concern and caring and suggesting a visit to the hospital might help patient stay alive and well. 3. Confrontation a. Making your patients aware that you understand something is inconsistent about their story b. Remain professional and nonjudgmental. i. Example: You say, “You sound so negative; are you considering suicide?” If patient’s response is noncommittal, keep asking questions about his or her intentions. c. This technique helps you assess patient’s level of distress and/or aggressiveness. 4. Interpretation a. Vocalize what you think the patient is saying and invite patient to correct you. b. Can be used when: i. You are not sure what a patient is telling you. ii. A patient refuses to give needed information c. Example: If a teenager acts distressed and says she is afraid she might hurt her parents if she tells them what is wrong, and says her parents don’t like her boyfriend, you might ask a question like, “This may be totally wrong, but I must ask the question so I can inform the doctor for your well-being. Do you think you are pregnant?” d .Interpretation requires your best intuition and diplomatic skills. i. Possible phrase to begin with is, “So if I understand what you are saying correctly . . .” 5. Facilitation a. Use phrases to encourage patients to provide more information. i. Examples: “Please say more,” or “Please feel welcome to tell me about it.” 6. Being quiet a. If patients seem to be trying to put something into words, be patient and do not say anything for a few seconds. 7. Clarification a. Ask patients to explain what they mean if you do not understand. 8. Redirection a. If patients mention something in passing or avoid a certain question, politely redirect their attention to it until you get an answer. 9. Simplification and summarization a. If patient’s response is confusing or disorganized, try summarizing their comments in simpler terms and see if they agree. G. Common interviewing errors 1. Never provide false assurance; be neutral and objective. 2. Do not give advice. a. You are not a physician or counselor. Expressing your opinions could lead patients not to seek medical help or to reject transport. 3. Do not consider yourself an authority. 4. Do not use avoidance language. a. Be direct and honest. b. Stay away from professional jargon. c. Use clear, concise terms. d. Do not interrupt or talk too much; you need to hear from the patient. H. Nonverbal skills 1. First impressions are important. a. Look and act professional at all times to instill confidence. 2. Project an air of patience and calm. a. An impatient paramedic will stress the patient. 3. Avoid gestures, facial expressions, and “closed postures” that send negative signals. a. Don’t frown or smirk at answers. b. Maintain constant, nonjudgmental eye contact. c. Keep your voice calm and neutral. d. Encourage answers; don’t demand them. 4. Some people do not like to be touched, while it is reassuring to others. a. Start by touching a shoulder or arm to reassure or mitigate fear. b. If they react positively, use touch to help reassure. If not, use other strategies. I. Special interview situations 1. Special communication techniques may be required with patients who are uncommunicative, hostile, very young or very old, or have special needs. a. Avoid stereotyping any patient group. b. Do not be judgmental. 2. Patients who are difficult or potentially violent present challenges. a. Patients may be: i. Scared or panicked ii. Under the influence of drugs or alcohol iii. Having behavioral or mental issues iv. Having a bad day b. Use patience, persistence, and persuasion when caring for difficult patients. i. Approach patient cautiously, maintaining eye contact. ii. Introduce yourself and ask for patient’s name. iii. Use open-ended questions. iv. Provide positive feedback. v. Make sure patient understands you. vi. Continue to ask questions, rephrasing as necessary. 3. People who are hostile a. The heightened emotion of emergency situations can cause patients to become hostile. b. Acknowledge hostile person’s concerns: i. Remain calm, and try to understand his or her arguments. ii. Use questioning, clarification, and summary. c. You may need to get help from law enforcement to defuse a hostile person. d. Expect to receive insults from people in crisis, possibly almost daily. i. Never respond in kind. ii. Trading insults can escalate a situation. iii. It is senseless, unprofessional, and can be dangerous. e. Hostile patients may present a threat to you or others. i. Always approach with caution, maintaining eye contact. ii. Try not to interview an angry patient by yourself. iii. Identify escape routes from the scene. iv. Approach the patient from the front, with hands visible and open. v. If safe, get on the patient’s level. vi. Ask permission to ask questions and touch the patient. vii. Be honest. viii. Watch for signs of possible attack such as violent language, or body language such as clenched fists, intense staring, breathing heavily through clenched teeth, and other threatening gestures. ix. Always be prepared to escape. 4. Sexually aggressive patients a. If you encounter sexually aggressive patients, follow your agency’s policies. b. Make sure a second person is always present when you are with patient. c. Communicate professionally and politely. d. Make sure your words are not sexually ambiguous. e. Document your encounter and get witness names and signatures. 5. Special considerations of age a. Older people i. Don’t assume older people are harder to communicate with than others. ii. Older people tend to have more complex illnesses because they may have multiple diseases or conditions. iii. Older people may be taking more medications. iv. Geriatric patients have individual differences related to hearing, eyesight, mentation, and mobility, which you may need to adapt to. b. Children i. Children tend to protest pain vigorously. ii. They may be afraid of strangers. iii. Can panic when separated from parents iv. Their bodies may be unfamiliar; practice may be needed for you to become comfortable with simple procedures. v. Tips for communicating with small children: (a) Use friendly eye contact, smiles, and calm explanations. (b) Minimize movements, lower your voice, and touch gently. (c) Keep eye level at or below child’s level. (d) Involve parent in hands-on care, especially with infants and toddlers. (e) In absence of parents, toys such as teddy bears may be helpful. (f) Improvise toys such as inflating an exam glove and marking it to look like a chicken. c. Adolescents i. Children age 12 and above may not want parents present during exams. ii. Do not refuse parent’s prerogative to be present with adolescent, but communicate to physician if parent insists over adolescent’s wishes. iii. Generally, deal with adolescents as adults, offering realistic options and choices. iv. Protect modesty of any children over age 2, particularly adolescents. v. Avoid disrobing patients unless necessary. 6. People who live with special challenges a. Caregivers may take classes in sign language or lip reading to aid communication. b. Use family members or primary caretakers to facilitate communication. c. Help patient access their glasses, hearing aids, or other devices that might help communication or reduce fears. d. Touch and eye contact may help convey kindness or reassurance. i. Example: A light touch on a shoulder or a brief one-armed hug e. Pervasive developmental disorders (PDDS), such as autism, cause delays in childhood development and may have lifelong effects. i. Children with autism may have difficulty with language skills. ii. They may also have difficulty communicating nonverbally. iii. People with PDDs range widely in skill development, from being unable to speak to having problems with meaning and rhythm of words and sentences. iv. Communicate with people with PDDs through a caregiver if possible. 7. Cross-cultural communication a. Be considerate and professional with people of different races, religions, genders, classes, and lifestyles. b. Learning the language or culture of the population in your service area shows respect and facilitates communication. i. Example: Eye contact usually demonstrates active listening, but some cultures consider it disrespectful. ii. Classes on cultural sensitivity teach how to show respect, interest, and concern for other cultures. iii. Be open to educating yourself about the groups in your community and how to communicate effectively. c. Be aware that cultures and religions may have certain beliefs that conflict with standard medical procedures, such as giving a blood transfusion. i. Keep in mind that a patient may not share the beliefs of his or her family or culture. ii. Remember also that even if you and the patient disagree about the source of illness, he or she may still be willing to accept treatment. d. Manners i. Manners are not uniform across cultures. (a) Example: In some cultures it is permissible to wear a cap indoors; in others, it is considered rude; in still others, wearing a head covering has religious connotations. (b) Address patients respectfully with terms like, “yes, sir” or “yes, ma’am,” and “please” and “thank you.” (c) Ask permission to touch or treat by using phrases like “may I?” e. Hand gestures i. The perception of hand gestures varies in different cultures. (a) For example, the “thumbs up” sign that Americans use for “okay” is the equivalent of the middle finger in some Arab and Latin countries. f. Body language i. Body language may also be interpreted differently by different cultures. ii. The smile is used almost universally as a sign of goodwill; use it often. iii. Bowing: Bowing shows respect in Japan. iv. Touching the head: Many Asians do not touch the head as it is considered the most sacred part of the body. v. Touching with the left hand: Islamic and Hindu cultures avoid touching with the left hand; it is rude and offensive to use the left hand in greeting. vi. Feet: Showing the bottom of the feet is offensive in Muslim nations and much of Thailand. vii. Slouching: Slouching is considered rude in Japan and Northern Europe. viii. Hands in pockets. This is considered disrespectful in Turkey. ix. Sitting with legs crossed: This position is disrespectful in Turkey and Ghana. x. Hands on hips: This can convey hostility in Mexico and Argentina. xi. Eye contact: Avoiding direct eye contact shows respect in some Asian, African, Latin American, and Caribbean countries. Eye contact shows interest and honesty in Arab, Somali, and Brazilian cultures. xii. Nodding: Indian and Arab cultures may signal agreement by moving head side to side; they may indicate “No” by tipping the head back and clicking the tongue. VII. Summary A. You must be able to communicate rapidly, efficiently, and effectively when responding to a call to fulfill your role as a paramedic. B. The phases of communication include notification, potential pre-arrival instructions for the caller, dispatch, communication during on-scene care, and communication with the receiving facility while en route. C. The dispatcher communicates with people who call in an emergency, and with the EMS unit in sending it to the scene. Most of his or her telecommunication is done through digital technology. D. The dispatcher identifies the exact location of the patient, the telephone number, the nature of the problem, and specific information about the patient’s condition and emergency, such as the types of vehicles involved in a motor vehicle crash or hazards at the scene. E. The dispatcher is also responsible for monitoring communications with the ambulance, coordinating communication with medical control and other agencies, and recording the times when the various phases of the call occurred. F. Emergency medical dispatch requires special training that teaches dispatchers to provide basic medical instructions to emergency callers over the phone. Updates resulting from this pre-arrival care can be communicated to the EMS crew as they are en route. G. Radio is one of the main methods of communication in EMS. The most commonly used bands for medical communications are the very high frequency (VHF) and ultrahigh frequency (UHF) band. The higher the band, the less interference there is, but the shorter the transmission range. H. Trunking is the ability for multiple agencies or systems to share frequencies. This allows the dispatcher to reprogram radios so agencies that do not normally talk to each other are able to, if necessary, such as in a multiple-casualty incident. I. The Federal Communications Commission controls frequency allocation and licensing in the United States. It also establishes technical standards for radio equipment, establishes and enforces rules and regulations for the operation of radio equipment, and monitors transmissions. Communications over frequencies allotted for medical purposes are supposed to be used strictly for that purpose. J. Telemetry is used to transmit vital life signs to a distant terminal. In EMS, it is usually used for transmitting an ECG. This can be useful in diagnosing myocardial infarction and can allow the hospital to prepare to administer fibrinolytic therapy. K. Cellular telephones are becoming more common in EMS communications systems. Many newer cell phones have global positioning systems built in that aid the enhanced 9-1-1 operator to determine exactly where the call is being made. L. Systems used for radio transmission include simplex, duplex, and multiplex. Simplex operates on one frequency and allows the transmission to go one way. Duplex operates on two frequencies and allows simultaneous transmission and reception. Multiplex operates on two or more frequencies and allows for more than one transmission simultaneously. M. An EMS communications system consists of a base station, mobile and portable transmitters or receivers, a repeater, a remote console, and a landline or backup communications system. N. Keep radio communication simple, brief, and direct. One of the main goals is clarity. Use the international radiotelephony spelling alphabet to aid transmission of spellings. O. Remember that your words can be heard by anyone who is listening. Keep your communications professional at all times. Do not transmit a patient’s name or personal information over the radio; this would be in violation of HIPAA. P. Most ambulance systems use plain English in radio communications, but some use radio codes. If your agency uses codes, be sure to learn them. Q. When reporting medical information, include the patient’s age and sex, chief complaint, brief history, level of consciousness, degree of distress, vital signs, mental status, physical findings, ECG findings, treatment, and response to treatment. R. Most of the people you will meet during responses will be in crisis and having the worst day of their lives. S. At least half of the calls you will run as a paramedic will take you into people’s homes, day and night, and in the most private moments of their lives. Try to see every invitation into the home of someone else as a personal honor in a time and place where no one else would be welcome. T. If you want people to tell you about their problems, convince them you want to hear what they have to say. Give them your undivided attention. U. Active listening is repeating the key parts of a patient’s responses to questions. It helps confirm the information the patient is providing and ensures there is no misunderstanding. V. A therapeutic communicator’s most essential challenge is to convey calm, unmistakable, genuine concern for someone he or she has never met. W. When you first meet your patients, introduce yourself and ask them for their name. This communicates your respect for them. X. Even if you are not convinced that patients are in real trouble, consider the possibility that they are terribly frightened. Y. External factors, such as noise, lighting, distracting equipment, and interruptions, can make communication with a patient difficult. Z. Patient modesty matters, no matter how acute the medical condition. If the patient is not personally sensitive to it, family members most certainly are. AA. When you need to know how patients feel, try asking open-ended questions—questions that do not have a yes or no answer, and which do not give them specific options from which to choose. BB. When you are trying to find facts (for example, a medical history), use closed-ended or direct questions. CC. If you sense that patients are trying to put something into words, but are having trouble, be patient. Do not say anything at all for a few seconds. Let them talk. DD. If you have tried clarification and you are still not sure what patients are trying to tell you, sometimes it helps to vocalize what you think they have said and invite them to correct you. EE. Nonverbal communication can be as powerful as words. FF. Direct eye contact generally communicates honesty and concern. GG. Posture is important. Try to position your eyes at the same level or below the level of the patient’s eyes. HH. Some people do not like to be touched at all; to others, it is a valuable assurance that someone cares about them. You should try gently touching patients on a neutral part of the body, such as a shoulder or arm, especially when you are trying to reassure them or to mitigate their fear. II. Hostile or angry patients may present a threat to you and others. Always approach with caution and maintain eye contact. Try not to interview them by yourself. JJ. Try not to presume that older people are any harder to communicate with than anyone else, just because they are older. KK. Children can pose treatment and communication challenges even to the best EMS personnel. Minimize your movements, lower your voice, and touch them as gently as you can. Try keeping your eye level at or below the child’s by sitting on the floor and placing the child on the cot or on a parent’s lap. LL. When you encounter a patient who has trouble communicating, remember that family members or primary caregivers who know these patients well can facilitate your efforts. Just as importantly, they can also help you alleviate fear. MM. Dealing with people of cultures different from your own can be challenging. It is always considered a mark of your respect if you make an effort to learn about their language and culture. NN. Manners, hand gestures, and body language may differ among cultures. Remember that another person’s culture may have different rules for polite behavior than your own. Post-Lecture This section contains various student-centered end-of-chapter activities designed as enhancements to the instructor’s presentation. As time permits, these activities may be presented in class. They are also designed to be used as homework activities. Assessment in Action This activity is designed to assist the student in gaining a further understanding of issues surrounding the provision of prehospital care. The activity incorporates both critical thinking and application of paramedic knowledge. Instructor Directions 1. Direct students to read the “Assessment in Action” scenario located in the Prep Kit at the end of Chapter 5. 2. Direct students to read and individually answer the quiz questions at the end of the scenario. Allow approximately 10 minutes for this part of the activity. Facilitate a class review and dialogue of the answers, allowing students to correct responses as may be needed. Use the quiz question answers noted below to assist in building this review. Allow approximately 10 minutes for this part of the activity. 3. You may wish to ask students to complete the activity on their own and turn in their answers on a separate piece of paper. Answers to Assessment in Action Questions 1. Answer: B. When someone calls and reports an emergency to EMS Rationale: The first stage of the EMS response is notification; that is, someone has to tell EMS that an emergency exists. Usually notification is carried out by telephone or cellular phone, and the person requesting help communicates with the emergency medical dispatcher (EMD). A universal emergency telephone number—9-1-1 in the United States—and the availability of telephones and cellular phones in most places has greatly helped speed up the process of notification. Notification may, less frequently, come by radio, when the emergency is detected by law enforcement personnel or other public vehicle. 2. Answer: B. After the location of the patient, telephone number, and chief complaint are obtained Rationale: At the point when your EMD has obtained the address of the emergency, the telephone number of the caller, and the apparent problem, the EMD should ask the caller to wait on the line. The EMD must then decide, assuming the call is a medical emergency within the service’s jurisdiction, which crew(s) and vehicle(s) will be dispatched. That decision will be governed by the nature and location of the call. The appropriate crew is contacted and informed of the nature of the call and its exact location. 3. Answer: A. Exact location from which the call is made, the telephone number, and the chief complaint Rationale: The method used to gather information from a caller is most often a series of short questions asked by the EMD. When a call for EMS comes in, the EMD should elicit the following minimum information: 1. The exact location of the patient(s), including the street name and number; the proper geographic designation (such as whether the street is East Maple or West Maple) and the name of the community (adjacent towns may have streets by the same name). If the call comes from a rural area, the dispatcher should try to establish landmarks (such as the nearest cross-street or business establishment, water tower, or antenna). 2. The telephone number (call-back number) of the caller, in case the call is disconnected or there is a need to phone the caller for more information. It is not uncommon for paramedics not to be able to find the address and to ask for help from the original caller. Asking for the caller’s telephone number also helps discourage nuisance calls to EMS because prank callers are reluctant to supply their phone numbers. 3. The dispatcher also needs the caller’s perception of the nature of his or her or the patient’s problem. 4. Answer: C. Caller address and phone number Rationale: In services equipped with an enhanced 9-1-1 system, much of the information mentioned—such as the phone number and location of the caller—is recorded automatically through sophisticated telephone technology, and the EMD need only confirm the information that appears on their computer screen. This information must be verified by the dispatcher to make sure the patient is located at the same location shown on the enhanced 9-1-1 screen. 5. Answer: D. Level of responsiveness, breathing, and bleeding Rationale: Rationale: Specific information concerning the patient’s condition will help evaluate the urgency of the situation and the EMD’s need to provide the caller with prearrival instructions by phone. The EMD should ask specifically the following questions: • Is the patient responsive? • If not, is the patient breathing? • Is the patient bleeding badly? This is not unlike what EMS providers do on each and every call for medical assistance. Additional Questions 6. Rationale: Yes. You may offend someone without even realizing it. Cultural sensitivity and cultural diversity have become important words. There are many classes and seminars designed to teach how to deal with cultural differences between employees and contacts. The overarching principles that all such classes teach is respect. In other cultures, appearance and manner can mean everything and a lack of respect is unforgivable. The social purposes, mannerisms, etiquette, and idiosyncrasies of all cultures are too numerous to list; it is your responsibility to research various groups in your community and to learn how to interact effectively with each of them. 7. Rationale: Acknowledge the hostile person’s concerns and empathize with him or her. Remain calm and try to understand the person’s arguments. Use questioning, clarification, and summary to help the person feel heard and understood. Never respond to hostility with hostility. Nothing escalates a situation faster than trading insults with people, and very often when it involves a patient there are plenty of witnesses. It makes no sense, and it can be dangerous. Always approach the patient with caution and maintain eye contact. Try not to interview an angry patient by yourself. It is a good idea for your partner to be present, but have him or her stay a little farther back to prevent the patient from feeling crowded. Here are some additional tips for dealing with potentially violent patients: 1. As you enter the scene, identify escape routes. 2. Approach the patient from the front, with your hands visible and open. 3. If safe to do so, assume the patient’s level. 4. Ask permission to ask questions and to touch him her her. 5. Always be honest. 6. Be wary for signs of impending attack such as clenched fists, violent language, tensed neck and face muscles, and threatening gestures. 7. Consider the possibility that you may not be able to defuse an angry person, in which case you may have to defer to law enforcement personnel. 8. Always be prepared to escape if necessary. Assignments A. Review all materials from this lesson and be prepared for a lesson quiz to be administered (date to be determined by instructor). B. Read Chapter 6, Documentation, for the next class session. Unit Assessment Keyed for Instructors 1. Define and discuss what is meant by therapeutic communication. Answer: Therapeutic communication is communicating with the patient. It involves the art and skill of communicating with patients who may not be functioning in their normal state of mind or at their best. Patients should be given your undivided attention and not treated as though they were a nuisance. When the patient is communicating, you should be listening to them and hearing what they have to say. (p 121, 132) 2. Identify and describe three common components of an EMS communication system. Answer: a) The base station serves as a dispatch and coordination area and should ideally be in contact with all other elements of the system. It generally uses relatively high power output as determined by the FCC and should be eqiupped with a minimum of transmitter, receiver, and antenna. b) Mobile transmitters/receivers (mobile transceivers) are two-way radios mounted in a vehicle, and power ranges may vary depending on power output. c) Portable transmitter/receivers are usually hand-held radios carried by paramedics when away from the vehicle but need to communicate with the base station or others. Power output is low, and ranges may be limited unless boosted by retransmission through the vehicle. d) Repeaters are miniature base stations used to extend transmitting and receiving range. They may be fixed or mobile. e) Remote consoles are usually located in hospital emergency departments. They are connected to the base station and may be used for voice or telemetry transmission. (p 121-122) 3. Differentiate between very high frequency (VHF) and ultrahigh frequency (UHF) bands used for medical communications. Answer: VHF bands extend from approximately 30-175 MHz and have been divided into a low and high band. Low bands (30-50 MHz) are unpredictable due to atmospheric changes that can cause patchy loss of communications. High bands (150-175 MHz) are more reliable but have shorter transmission ranges and are the most commonly used VHF frequencies. The UHF band with frequencies of 450-470 MHz are most commonly used for medical transmissions. They have better penetration in dense metropolitan areas but a shorter range and can be absorbed by rain and environmental objects. This band includes the 800 MHz frequencies that can be linked to a computer system to transmit voiceless communications. (p 122-123) 4. Describe the significance of digital radio and trunked systems in EMS. Answer: Digital trunked systems are capable of carrying simultaneous conversations on one physical channel. They also allow communication of text from a computer-aided dispatch (CAD) with EMS mobile units by data transfer. The drivers may receive call information and communicate information on a mobile display by pressing a button. p 123 5. Define and discuss the significance of biotelemetry in modern prehospital care. Answer: Biotelemetry is the capability of measuring and transmitting a patient’s vital signs to a distant terminal. It began historically as a means of transmitting ECGs and has improved the ability of the paramedic to facilitate assessment and treatment of acute myocardial infarctions in the prehospital setting. By allowing physicians to review transmitted ECGs the patient may be moved directly to the cardiac catheterization lab for emergent treatment of coronary events. Other vital signs captured by these telemetry devices may also be transmitted to receiving facilities and uploaded into electronic patient care reports. (p 124-126) 6. Differentiate between an open-ended and closed-ended question, and identify circumstances when each would be appropriate. Answer: Open-ended questions should be used during the patient interview to allow for feedback and gauging of mentation. Closed-ended questions are direct questions used when trying to elicit a specific answer. These are best incorporated as standard questions concerning medical history that may be asked of almost all patients. Open-ended questions can be employed to obtain more specific details when warranted. All questions should be clearly asked one at a time and patients allowed to answer at their own pace and without leading them. (p 134-135) 7. Explain when and how use of interpretation may be an appropriate method during a patient interview. Answer: If the patient is refusing to give needed information or there is uncertainty about what they are trying to relate, interpretation may be an appropriate strategy to obtain what is being asked. In this method, you are able to diplomatically express what the interpreted meaning is then ask the patient to clarify if you are misunderstanding what is being said. Intuition is important if you are attempting to elicit information the patient is not providing when constructing your interpretation. (p 136) 8. Describe three common interviewing errors. Answer: a) Providing false assurances or making unlikely claims should be avoided and instead maintain neutrality and objectivity. b) Avoid giving advice to prevent potential refusals of the patient to seek medical help. c) Do not consider yourself to be an authority or to act as one but instead recognize this should be limited to the physician. d) Be direct and honest, and do not use avoidance language when speaking with the patient. e) Use clear, concise terms that are not complicated and the average person can understand. f) Do not interrupt the patient or talk excessively to ensure you are hearing the patient. (p 137) 9. Discuss the importance of nonverbal skills in communication. Answer: Opinions are often formed at the first impression or observation of a person. The paramedic should have a professional appearance and demeanor to project competence and caring. Displaying an air of patience and calm is important to keep the patient less stressed and comfortable. Avoid sending negative signals with gestures, facial expressions, or a “closed” posture and maintain constant nonjudgmental eye contact with the patient. This will encourage the patient to answer questions and communicate with you. Watch for patient reaction to gentle or reassuring touches. Not all patients like to be touched and may pull away. (p 137) 10. Identify challenges and considerations when dealing with the hostile person. Answer: Emergency situations can be emotionally charged and may cause some people to become hostile or angry, even toward the paramedic. It is important to acknowledge their concerns and attempt to understand the arguments presented while remaining calm. Interview methods such as questioning, clarification, and summary may help them feel as though they are being heard and understood. Not all situations can be defused by the paramedic and may require law enforcement assistance. Hostile patients may pose a threat to the paramedic and others. Interview with caution, maintain eye contact, and try to ensure your partner is present without making the patient feel crowded. Be wary for signs of potential violence and prepared to escape if necessary. (p 138) Unit Assessment 1. Define and discuss what is meant by therapeutic communication. 2. Identify and describe three common components of an EMS communication system. 3. Differentiate between very high frequency (VHF) and ultrahigh frequency (UHF) bands used for medical communications. 4. Describe the significance of digital radio and trunked systems in EMS. 5. Define and discuss the significance of biotelemetry in modern prehospital care. 6. Differentiate between an open-ended and closed-ended question, and identify circumstances when each would be appropriate. 7. Explain when and how use of interpretation may be an appropriate method during a patient interview. 8. Describe three common interviewing errors. 9. Discuss the importance of nonverbal skills in communication. 10. Identify challenges and considerations when dealing with the hostile person.