Pre-Hospital Communication

Context

In the emergency department, communication is essential. It ensures that all members of the team are aware of what is going on within the department and allows those in charge to identify issues early and implement plans to overcome them. Whilst not always performed perfectly, communication in the ED is relatively easy we are all generally in the same building and so can discuss things face-to-face. We can use non-verbal forms of communication and are often able to grab a colleague to come and look at something rather than trying to describe it over the telephone.

Pre-hospitally, communication is more difficult, and so getting it right is even more crucial. With paramedics, technicians, officers, emergency call operators and dispatchers, and other staff all spread out over a vast area often covering several counties, communication is often only possible over radio. This makes clear, concise two-way messages important, as information can often be lost or interrupted. Passing information verbally is no substitute for seeing what is going on, and that can lead to difficulties too. In a major incident, multiple agencies are involved, and so co-ordination of inter-agency communication is a key step in the response.

Reports such as that into the London Bombings¹, and Grenfell Tower fire², have consistently highlighted a need to improve how we communicate in the pre-hospital environment.

Learning Bite

Coordination and communication underpins the success of any situation.

A basic model for communication consists of:

• • The sender and receiver
  • The message itself
  • The medium of the message
  • Contextual factors such as timing and environmental factors
  • Feedback³

The pre-hospital environment could negatively impact on all these components. The sender could be miles away from the receiver, passing an important message via radio that may get cut off or interrupted by background noise or signal issues, unclear whether the receiver has heard (or indeed understood) what they want to say.

Good pre-hospital communication technique aims to reduce these risks and optimise each element. We will explore this further in this module.

Definitions

Emergency Operations Centre

Each regional ambulance service in the UK has an Emergency Operations Centre (EOC). It is here where 999 or 112 calls requesting the ambulance service get taken, passed to an emergency medical dispatcher, prioritised, and resources allocated. Whilst crews are en route, the call handler may continue to provide clinical advice and talk those who are with the patient through any life-saving efforts, such as CPR. In most ambulance trusts the call handler and dispatcher are separate roles, but some trusts combine them.⁴

There are currently two approved triage systems in use to prioritise calls.⁵

Advanced Medical Priority Dispatch System (AMPDS), which is an international system used in many ambulance services in the UK. It assigns a code (such as 06E01 Breathing Problems, Ineffective Breathing) which may be familiar to those of you who already work pre-hospitally. This code then has a priority allocated with an associated recommended response timeframe.
NHS Pathways, a UK system which is used in NHS 111 and a few 999 services. It is hierarchical and so questions asked early on are designed to pick out life-threatening problems and trigger ambulance response if needed, progressing through to less urgent conditions requiring a less urgent response.
Call handlers are usually not clinicians, and so clinical advice they give over the phone is usually generated by the triage systems above in response to questions answered by the caller. Sending an ambulance is not the only option available and calls may rather be routed to other teams such as mental health nurses, the patients general practitioner, or a clinical desk where a senior paramedic or other clinician talks to the caller and asks further questions to decide on the most appropriate response.

Each centre also has a trauma desk, where senior paramedics review calls remotely to expedite the sending of critical resources, such as HEMS, advanced paramedics, BASICS clinicians or MERIT teams to the scene. As well as co-ordinating the ambulance service response to these patients, they also advise crews attending trauma patients on decisions such as whether to convey the patient to a major trauma centre or a trauma unit, based on decision tools and the clinical picture.

Airwave

All emergency services in the UK use a version of radio communications based on the terrestrial trunked radio (TETRA) specification. In England, Wales, and Scotland, this is the Airwave system. In Northern Ireland it is called Barracuda.

Advantages of TETRA over previously used VHF or UHF radio include being much lower frequency which therefore gives longer range, and the ability to easily communicate not only across the whole network, but individually with either the control centre or other users. The network is a hybrid of VHF radio and mobile phone technology and can withstand high numbers of concurrent users, such as during a major incident. Encryption is used to prevent eavesdropping; it is highly secure and provides reliable and high-quality transmissions. Emergency buttons on the units allow the user to transmit emergency signals to the dispatcher, overriding any other activity taking place at the same time.

As well as the Airwave system already mentioned, there are many different types of communication that can be used in the pre-hospital environment.

Radio

Generally used as the primary method of communication, a wide variety of frequencies allow users to talk to each other or in different groups without interference. Radio allows rapid communication with portable units, though depend on the ability to transmit signal between the units, which may be difficult indoors, underground, or due to other geographical features.

The Radio Amateurs Emergency Network (RAYNET) is a British national voluntary communications service provided by amateur radio operators. On police request, they will attend incidents to establish a local radio network to supplement emergency communication channels.⁶

Mobiles

Preferred over radio for direct communication such passing a pre-alert to the hospital red phone, or when a lengthier conversation is required (in order not to tie up the radio channel). Mobile phone conversations bypass the central control however, and therefore the activity might not be logged or recorded in a standard format.

During major incidents, conventional phone networks may be overloaded and ineffective. At the request of the Police Gold Commander (in charge of the major incident response), the Mobile Telecommunication Privileged Access Scheme (MTPAS) may be activated, giving designated emergency responders a higher likelihood of being able to make a call than other customers.⁷

Direct signals

Hand signals can be used to pass information over short distances in line of sight. The Fire and Rescue Service uses repeated short whistle blasts as a standard evacuation signal, and many search and rescue teams will also have agreed whistle signals. These require familiarity with use, and for individuals to be able to interpret signals in what may be a chaotic environment.

Runners

Over short distances, runners are a fast and reliable option at the scene of a major incident and can be take photographs or be given handwritten notes and diagrams so that the message is not inadvertently altered en route. Difficult terrain can make using runners more difficult, and it is vital that it is clear who they are to report to.

Radio Net

A radio net is three or more radio users communicating with each other on a common channel or frequency. Each user has a call sign to identify themselves. In small nets, users may talk directly to each other, though generally there will be a co-ordinating control call sign in a fixed location, through which all radio traffic and information must go and be logged.

Voluntary services will often utilise multiple radio nets at public events, with different teams or resources using different channels. This requires control to monitor and respond to teams on several frequencies.

Most radios utilise a half-duplex system (think walkie-talkies), where all units can send and receive messages, but not at the same time. This requires the use of a push-to-talk button, and good radio etiquette to keep messages brief and to complete messages with the word over indicating the end of transmission and ensuring that only one party transmits at a time. A disadvantage of this system is that if multiple parties try to talk at the same time, interference occurs, and messages get lost.

The TETRA system uses half-duplex but has the functionality to also be used as a duplex system like mobile phones with both parties able to speak simultaneously.

Frequencies

Each of the emergency services uses different frequencies.

General tips and etiquette

• Listen before transmitting to ensure you do not cut across another user
• Pause for one second after pressing the push-to-talk button there is often a delay in the system and the first part of your message could be cut off otherwise
• Speak across the microphone rather than into it as this will help to reduce additional vocal sounds
• Speak at a normal volume, shouting into the radio can lead to distortion
• Be natural, maintain a normal speaking rhythm, speaking clearly and distinctly, sending the message phrase by phrase rather than word by word
• Use a slightly higher pitch as this transmits best through interference, but try to avoid extremes of pitch or varying this through your message

Learning bite

Accuracy, brevity and clarity are the ABCs of radio communication. Think about what you are going to say before you say it to ensure it is brief and to the point. There should be no unnecessary talk on the radio.

Phonetic Alphabet

Table 1: Phonetic alphabet

Letter	Description	Letter	Description
A	Alpha	N	November
B	Bravo	O	Oscar
C	Charlie	P	Papa
D	Delta	Q	Quebec
E	Echo	R	Romeo
F	Foxtrot	S	Sierra
G	Golf	T	Tango
H	Hotel	U	Uniform
I	India	V	Victor
J	Juliet	W	Whiskey
K	Kilo	X	X-ray
L	Lima	Y	Yankee
M	Mike	Z	Zulu

The International Radiotelephony Spelling Alphabet, commonly known as the NATO or ICAO phonetic alphabet, was initially developed to improve communication, particularly on low-quality or long-distance communication systems. It has been in its current form since 1956 having been revised several times since spelling alphabets first came into use before World War One. Early versions contained words such as Delta and eXtra, and Nectar and Victor, and therefore could easily be misheard over the radio.⁸

Apparent spelling mistakes such as the f in Alfa and tt in Juliett are intentional and designed to ensure correct pronunciation. There is also international convention for pronunciation of numerals across radio communications, as follows:⁹

0	Zero	5	Fife
1	Wun	6	Six
2	Too	7	Seven
3	Tree	8	Ait
4	Fower	9	Niner

Common Words/Phrases

Each radio user is allocated a call sign, which often corresponds to their role. This enables directed communication between users and means control can keep track of resources and their locations. It is important to use your call sign when passing information or answering your radio. Convention dictates using the call sign of the person you are contacting first, followed by your own call sign.

Common procedure words are used to facilitate communication by conveying information in a condensed format.

Radio check used to ask the other party about the signal strength and readability of your transmission, the response could be loud and clear, weak but readable, weak and distorted, or strong but distorted. Some services use the term ‘5 by 5’ for loud and clear on a scale of 1 (bad) to 5 (excellent) signal and readability.

Yes and no self-explanatory, generally used instead of affirmative and negative as these can be mistaken for one another particularly if the first part of the message is cut off. Doubling is sometimes used for clarity, e.g. ‘yes yes’ or ‘no no’.

Over used to end your transmission in an ongoing conversation
Out used to end a conversation (over and out are never used together), only one person needs to say out and this should be control in most cases to ensure all other channel users hear that the conversation has finished in case they are waiting to send a message
Roger I received your last transmission satisfactorily
Say again I did not receive or understand your last message, please say again
Figures I am about to read a series of numbers
I spell I am about to spell a word
Read back Please read back to me what I just told you
Wait I have received your message, give me a second to reply usually used in the middle of a conversation
Standby I am too busy to take your call right now but will call you back later
Priority I have a priority message and need to interrupt someone else to send it in order to transmit this you would wait for a gap, then transmit priority, priority and your call sign, e.g. priority. priority, Mike 1, over then wait for control to reply before passing any further message

Learning bite

Knowledge of common procedure words helps to keep radio conversations brief and clear.

Example Radio Conversation

Example radio conversation between control and M1 (medic on scene) to illustrate some of the common procedure words in context:

M1: Control, this is Mike 1, radio check, over
Control: Mike 1, this is control, loud and clear, over
M1: Control, Mike 1, major incident declared, I have a METHANE report when you are ready, over
Control: Mike 1 wait, over

(few seconds pass)
Control: Mike 1 from control, ready for your METHANE report, over
M1: Control, Mike 1, major incident declared at sixty-seven figures six seven Rafferty Street, I spell Romeo Alfa Foxtrot Foxtrot Echo Romeo Tango Yankee Rafferty Street. This is an apartment complex fire with hazards of falling debris, fire and potential building collapse. All received so far? Over
Control: Mike 1, control, roger, over
M1: Control, Mike 1, access via Old Road, I spell Oscar Lima Delta Old Road. Estimated thirty-two figures three two casualties. Request fire, ambulance including HEMS if available, police and local council, read back, over
Control: Mike 1, control, received, I read back (and would be repeated back to confirm), all correct? Over
M1: Control, Mike 1, all correct, over
Control: Mike 1, control, further resources en route, continue as per major incident protocols, we will contact you again in five minutes, out.

Standby Calls

All UK emergency departments have a red phone, used by the ambulance service to pre-alert the ED of the arrival of patients with serious injury or illness. These are sometimes referred to as blue calls or red calls. Usually pre-alerts are passed indirectly, first from the ambulance to the EOC and then on to the receiving hospital. This ensures the transfer of information is concise as there is not the facility for a conversation between treating and receiving teams. It also leaves the crew free to continue managing the patient en route. However, there is a risk of incorrect information being transmitted due to the intermediary.

If there is a senior paramedic or other clinician accompanying the patient, they may opt to pass the pre-alert directly through to the ED red phone, particularly if there are any special requirements that they feel should be in place on arrival.

If you are in hospital and taking the pre-alert call, you should:

• Inform the duty consultant
• Inform the nurse-in-charge and the senior nurse in the resuscitation area
• Assemble any equipment or resources required prior to patient arrival
• Alert any other clinical teams, such as anaesthetics, blood bank, or surgical teams, or activate your local trauma team or major haemorrhage protocol if required

ATMIST(ER)

Messages must be accurate, brief, and concise. Use of acronyms to standardise this is useful and allows both pre- and in-hospital teams to transfer information in a structured way. If you are the person sending the message, it is useful to have all the information written down before making the call to ensure the correct information is transmitted efficiently.

For trauma pre-alerts, NICE guidelines recommend following the ATMISTER format¹⁰:

A Age and sex of the injured person

T Time of incident

M Mechanism of injury

I Injuries suspected

S Signs, including vital signs and GCS

T Treatment so far

E Estimated time of arrival (ETA) at the emergency department

R Requirements on arrival

The ambulance call sign and time of call should also be transmitted.

The ATMIST portion of the pre-alert then largely forms the handover once the pre-hospital team arrive at the ED.

For medical patients, the same format can be used, replacing mechanism and injuries with the medical issue.

M/ETHANE

A major incident is defined as

An event or situation with a range of serious consequences which requires special arrangements to be implemented by one or more emergency responder agency.¹¹

M/ETHANE is the recognised common model for passing major incident information between services and their control rooms. For incidents falling below the major incident threshold ETHANE can be used, however there should be joint decision making with intermittent consideration of whether a developing incident surpasses that threshold.¹²

The first resources from each responder agency should send a M/ETHANE report as soon as possible to establish situational awareness. Information gathered from multiple messages will build to support shared awareness across all agencies.

We have already seen an example M/ETHANE message shared in the radio communication example earlier on in the module. The format for this message is:

Poor communication can lead to failures in the management of major incidents. It can also compromise individual patient care if incorrect information is transmitted.

Common pitfalls include

• Talking too quickly or quietly know what you are going to say, and say it slowly and clearly enough to be understood
• Long, complicated messages brevity is key, keep it simple
• Interrupting other users listen before you speak
• Poor quality radio signals radio checks are vital to ensure the signal is good

All methods of communication have weaknesses, and it is important to remember this and take steps to minimise errors and issues in information transmission.

Dont forget, you arent communicating something so that you understand, youre communicating something so that the other person understands.

1. Barnes R et al., Report of the 7 July Review Committee. Greater London Authority. 2006.
2. Update on the implementation of the Grenfell Tower Inquiry Phase 1 recommendations. Greater London Authority. 2020.
3. Corey AM. Introducing Communication. In: Pierce T, The Evolution of Human Communication: from Theory to Practice (2^nd ed.) Ontario, Canada: EtrePress; 2019.
4. NHS Health Careers. Call handler/emergency medical dispatcher. Available from https://www.healthcareers.nhs.uk/explore-roles/ambulance-service-team/roles-ambulance-service/emergency-medical-dispatchercall-handler [accessed 25th January 2021].
5. Turner J and Jacques R. Ambulance Response Programme Review, report of ARP phase 2.3 implementation. NHS England. Gateway publication reference 08296, 2018.
6. RAYNET-UK website. [accessed 25th January 2021].
7. Cabinet Office. Resilient communications. [accessed 25th January 2021].
8. North Atlantic Treaty Organisation. NATO phonetic alphabet, codes and signals. [accessed 25th January 2021].
9. International Civil Aviation Organization. Annex 10: Aeronautical Telecommunications Volume II: Communication Procedures including those with PANS status (7^th ed.) 2016.
10. National Institute for Health and Care Excellence (NICE), Major Trauma service delivery: NICE Guideline [NG40]. [Accessed 25th January 2021].
11. Cabinet Office. Emergency responder interoperability: lexicon. [Accessed 25th January 2021].
12. Joint Emergency Services Interoperability Principles. Early stages of an incident & M/ETHANE. [accessed 25th January 2021].
13. Reid C, Brindley P et al., Zero point survey: a multidisciplinary idea to STEP UP resuscitation effectiveness. Clin Exp Emerg Med 2018;5(3):139-143.
14. Reid C. The Zero Point Survey. (YouTube video) [Accessed 25th January 2021].
15. Joint Royal Colleges Ambulance Liaison Committee. JRCALC Clinical Guidelines. 2019.