This part of your course is going to deal with all the aspects of communication.  The 'immediate' interpretation of the title would lead the student to believe that it is a chapter concerned with "radios."  The 'immediate' conclusion as a result of the interpretation would be; "I don't need that right now, I can learn it later."  Nothing could be further from the TRUTH.

As an effective COMMUNICATOR you will need certain skills.  Those skills will be developed later from a knowledge base that MUST be established now.  As an effective COMMUNICATOR you will need to be comfortable with not only the radio, but also comfortable with giving  'report' to other medical providers (both 'in person' and via the radio,) comfortable with interviewing patients (adults, children, and patients whose communications abilities and/or skills might be hampered,) and communicating with the superiors and administrators of your 'system' via written reports.

We will do our best to help establish that knowledge base.  Stick with us, this stuff can get pretty 'dry,' but should be considered important.

Radio Communications

A well-founded basis in radio communications, needs to start with an understanding of the equipment.

Radios come is several sizes and 'flavors.'  There are giant sized base-station radios, medium sized mobile radios, and small sized hand-held radios.  And each is available in an AM or FM 'flavor.'  A recent addition to the communication equipment arsenal is the cellular telephone, which in most areas has become a very effective form of mobile communication.  Whether large- medium- or small-sized, the radios (including the cell phone) all work in the same basic fashion.  A radio (or wireless phone) begins the 'communication' process by sending out a carrier signal.  This signal is used to 'link' the two communications devices (the 'transmitter' and the 'receiver.')  Once the link is established, the carrier frequency is "changed" (modulated) in some small way (by the 'transmitter,') and the 'receiver' interprets and translates those changes into understandable sound.  In an AM transmitter, the carrier signal's "amplitude" is modulated, meaning that the size of the sine wave (carrier frequency) is made either taller or shorter as a result of the input from the microphone, and those 'changes' are interpreted by the receiver as sounds.  In an FM transmitter, the "frequency" of the sine wave is modulated, meaning the the number of waves in the sine wave is increased or decreased (by the transmitter,) as a result of input from the microphone, and those 'changes' are interpreted by the receiver as sound.  Most two-way communication radios are "Simplex" communications, meaning that 'communication' can occur in only one direction at a time.  In the case of the cellular telephone, however, the communicating ability is "Duplex," meaning that two users can talk at the same time and both can hear the other.

The Federal Communications Commission (FCC) is responsible for coordinating all radio communications throughout the United States.  A formidable responsibility when one considers the number of  frequencies and the number of transmitters (AM, FM, Simplex, and Duplex) that are available.  But a responsibility well managed when one considers the reliability of the system to provide a clear communicating 'environment' for the hundreds of thousands of 'operators' using the system at any given moment.  In an effort to maintain that reliability, the FCC on an un-announced ongoing basis, monitors certain frequencies in certain areas of the country to be certain that all FCC regulations are being followed.

Also available, to the everyday consumer, in today's market is an array of different monitoring devices.  From "scanners" to small hand-held "receive-only portables."

We offer this information to assure you that the possibility that 'someone else' is listening to your radio communications (including cellular telephone communications) is very great.

When using a radio with simplex capability, several considerations must be observed:

1. Before transmitting, 'monitor' the frequency to be certain that others are not already conducting a 'conversation.'  Due this for several seconds.  It is not uncommon, during any 'conversation,' for there to be pauses in communication.  Because this is a simplex system, if you "key" the microphone while others are talking, or if you "key" the microphone at the same time as another user, the resulting 'noise' at the receiver will be unintelligible.

2. When you depress the "Push-to-Talk" (PTT) button on the microphone, wait about 2 seconds (or about the amount of time it takes to inhale) before talking.  This gives the carrier frequency enough time to 'establish' the transmitter/receiver connection.

3. When speaking hold the microphone about 2 inches from your mouth, located directly in front of your mouth, and speak at normal volume levels.  Shouting into a microphone will lead to unintelligible communication at the receiver end.  In an AM radio the 'sounds' will be distorted because the amount of 'amplitude modulation' will be greater than the receiver's ability to 'interpret' those changes.  In an FM radio, the excessive amount of 'frequency modulation' will cause the sound to "clip" (brief periods of no sound at all) at the receiver end, because the frequency has been 'modulated' beyond the limits of the carrier frequency.  Some systems are equipped with "noise-canceling" microphones, especially in areas where there is excessive ambient noise (like an airport field, or the field in a crowded football stadium.)  A "noise-canceling" microphone can be identified by a small arch-shaped piece of flexible rubber attached to the superior aspect of the 'face' of the microphone.  The purpose of this piece of rubber is to act as a gauge to help properly position the microphone.  Properly positioned, the small piece of rubber will rest on the user's upper lip (significantly closer to the user's mouth than 'normal,') and when properly positioned will intelligibly convey the user's words, while blocking the ambient noise.

4. According to local protocol, use ONLY acceptable language while talking on the radio.  Some areas insist on 'coded language' (such as "10" codes or "Q" codes) while other areas use 'understandable' English.  Whichever the case, understand that 'others' are listening, and the professionalism and/or future of YOUR ENTIRE SYSTEM are at jeopardy if you decide to "clown around" on the radio.  Unless specifically requested by medical control, it is not considered common practice to transmit demographic information (name, address, etc.) about the patient.

"Repeater" systems are usually simplex radio systems that utilize a low wattage transmitter, to transmit to a nearby high wattage transmitter which 'relays' your message to the final receiver.  This enables the 'sender' of the message to rid himself of some of the bulky equipment necessary to 'create' a "high wattage message" (all of the "heavy metal" is 'up on the hill' in the "repeater,)  in order to 'reach' a difficult location (due to either the terrain or the distance between the sender and 'ultimate' receiver.)  Keep in mind that the amount of time necessary to 'establish' the 'carrier link' is twice what it would normally be (there are actually two transmitters involved, as well as two frequencies [one for you, and one for the "big guy" on the hill].)  With that in mind, you would have to 'pause' for an additional 'heart beat' after pushing the PTT button, before talking.  If you are using a "repeater" system, it is likely that when you push the PTT button, you will hear a "confirmation" chirp that indicates the the repeater has "opened" and the the carrier is established.

Duplex radio systems, and cellular telephones also utilize two different frequencies to accomplish the duplex capability.  One frequency in one direction, the other for simultaneous 'return' communication.

Although systems using two different frequencies are more difficult to 'monitor,' they are still "unprotected" "non-secure" communications, and, as such, are susceptible to being intercepted.  Trust us, the minute YOU decide to "stray" from the accepted 'language' of your radio system, someone will hear it and it will get "back to you."  DO NOT JEOPARDIZE the professional public image that your predecessors have established in the community, by deviating from acceptable practice.

The final subject of concern regarding radios would be communicating with "Dispatch."  Specifically, when.  There should be a minimum of six communications between the responding squad and the dispatcher.  They are:

1. When the responding squad went into service.

2. When the squad arrived at the scene.

3. When the squad was enroute to the receiving hospital.

4. When the squad completed the 'transfer,' or 'cleared' the hospital.

5. When the squad was enroute back to the squad building.

6. When the squad arrived at the squad building and went out of service.

As you will see later, these "times" are part of something called a "minimum data set."  (More on that later.)

Verbal Communications

Whether 'in-person' or over the radio, you will have to develop your ability to "paint a picture" of the condition of your patient or the severity of the problem, in the mind of your listener in a relatively short period of time. 

"Medical Situation" television shows would lead the viewer to believe that it is appropriate to 'burst' through the doors into the Emergency Department rattling (usually shouting) off a bunch of vital signs, chief complaints, findings, interventions and results.  "Reality TV Medical Shows" however present quite a different environment.  On such "reality" shows, beepers alert specialized teams to the impending arrival of acute patients, preparation at the 'in-house' level is accomplished because the 'street providers' were also well prepared and provided the appropriate information to that 'in-house' team in a timely manner, BEFORE arriving at the Emergency Department.

Back out in the street, different levels of 'support' (First Aide, Basic Life Support, and Advance Life Support) are going to exchange information about the present "Chief Complaint," "Vital Signs," "Assessment Results" (findings,) "Interventions," and "Outcomes" (results of Intervention,) with each other.  A properly completed "Patient Assessment" will prepare the EMT-B to communicate the information in a clear, concise, accurate manner to the Advanced Life Support provider (Paramedic.)  That "information" will be incorporated into the paramedic's report along with the 'advanced' findings, interventions, and results.  The paramedic will then establish 'medical control,' by reporting to the "medical control doctor" using their 'completed' report as a guideline.  The 'advanced' team will then implement any additional orders given by 'medical control,' reassess for results from that additional 'advanced' intervention, follow-up with 'medical control' (if necessary) while enroute to the receiving facility.  The 'advanced' team will then notify the receiving facility of their impending arrival, including all of the information incorporated from the 'basic' team, interventions and results (from the 'advanced' team,) and an estimated time of arrival at the receiving facility.  Upon arrival at the receiving facility, the 'advanced' team will repeat the last report to the receiving team of in-house medical providers.

All of the foregoing assumes the involvement of a ALS team.  If no ALS support is deemed necessary for this patient, then the responsibility for notifying the receiving the facility (of the patient's impending arrival) is assumed by the BLS squad.

Whether an ALS team is 'on board' or not, the BLS squad still has a responsibility to complete a written report as suggested later on this page.

How 'bout a "short" war story.  This kind of explains what happens when the initial 'preparation' is not done adequately.

As a relatively new medic, I was dispatched to the scene of a motor vehicle accident with injuries.  A motorcyclist had hit the passenger's side of a motor vehicle and had been "launched" over the car, coming to rest approximately 35-40 feet from the 'scene.'  The driver of the motor vehicle was uninjured, but the passenger (an elderly lady) had sustained significant head and facial trauma from the flying glass.  The cyclist (a 20-25 year old male) had sustained injuries consistent with a motorcycle helmet that had been split into two halves as a result of the force of the impact.  He was responding (at times, inappropriately) to verbal stimuli.    My partner accepted responsibility for the more serious patient (cyclist) that would require transport to the nearest Trauma Center via helicopter.  My patient apparently less severe would require a Trauma Center but would tolerate a land-based ambulance transfer.  From that point on, I was unaware of the cyclist's condition, interventions or outcome.  My attention was concentrated on my patient.  BLS had dressed the facial wounds of the elderly patient and had provided an accurate set of vital signs.  While the patient was being 'packaged' by BLS for removal from the vehicle, I took another set of vital signs, in order to trend them against what the BLS team reported.  There had been no significant changes.  But space restrictions within the vehicle prevented me from listening to the patient's lungs.  That turned out to be VERY significant.  While waiting for the BLS team to complete the extrication, I contacted medical control and reported the information that I had, noting the absence of "breath sounds," and highlighting that BLS was having some difficulty completing the extrication because, at the same time, they were trying to control the bleeding from one of the 'dressed' wounds on the side of the patient's head. (A wound that I had not yet evaluated, because it was "dressed.")  Under better circumstances the orders would have included "Two large bore IV's with Ringers Lactate, Wide opened" for this patient of significant trauma.  The medical control doctor advised me that without knowing the condition of the patients lungs, that he would order the two IV's but they would have to be kept at KVO (a slow rate, sufficient to Keep the Vein Open)  until the lungs had been "cleared," at which time the order would be upgraded to "Wide opened."  Medical control also advised us to "keep an eye on that 'problem' wound, and evaluate the "color" of the blood.  I understood the orders and the reasons for them.  Within the next couple of minutes, the extrication was complete, and my patient was loaded into the back of the ambulance, where the two IV's were started (running at KVO.)  I "cleared" the lungs and my attention to the order 'update' was immediately distracted by the BLS provider who stated that he was still having a problem controlling the flow of blood from one of several facial wounds.  Several layers of 4X4 gauze had been soaked and it just didn't seem to be slowing.  At that point, it would have been appropriate to expose the 'problem' wound and reassess it.  I didn't.  If I had I probably would have 'found' the spurting temporal artery and employed the proper method of 'clamping' the arterial bleed.  Instead I tried to 'save this sinking ship' by directing the EMT-B to add more gauze.  Within minutes of the 'effort,' the patient became unresponsive, went into respiratory insufficiency, and just generally scared the hell out me.  What I did next came not from a "greater knowledge" of emergency 'street' medicine, but more from a "knee-jerk" reaction as a result of my recent training.  I immediately grabbed both IV restricting clamps and opened both "Wide opened," (something I should have done immediately after "clearing" the lungs.) Within 10 seconds, the patient's breathing normalized and her level of consciousness returned to Alert & Oriented.  We arrived at the hospital, without further incident, to find a trauma team waiting on the dock for a "Trauma Code" (a trauma patient in cardiac arrest.) I informed them that, "It wasn't us."  But they had only two patient's 'incoming,' one via helicopter (arrived several minutes ago in "serious but stable" condition,) and one via ambulance, (a "trauma code.")  It seems that the driver of the ambulance had heard the confusion in the back of the ambulance as I directed the BLS attendant to "grab a bag-valve-mask" (preparing for the worst,) and had radioed ahead to the Trauma Center that the patient was "coding."   As embarrassed as the driver was, and as "unnecessary" as the alert turned out to be, I felt (in retrospect) very secure, knowing that this kind of 'back-up' was available to me.  I actually lost count of the number of times that I thanked the driver.  The outcome was good, but think of how much 'better' it would have been if 'proper' assessment and communication protocols had been followed.

Sorry, that was a 'little bit longer' than I thought it would be, but it makes a good point.  That the scene of any emergency is more likely to be confusing, than it is likely to be "the sterile environment" that is suggested by the 'perfect world' as explained in the "Back out on the street..." paragraph that preceded the 'war story.'  If the BLS team had properly assessed the 'arterial' bleed (employing a more appropriate method of control,) and if the paramedic had properly assessed the lungs (prior to "report,") and if the paramedic had followed up (as suggested by medical control) and reassessed the 'problem' wound, then NONE of the "emotionally upsetting" and "near life-threatening" events would have occurred while enroute to the Trauma Center.  But then again, we wouldn't have had such a great war story.

Patient Communications

After 'talking' to literally thousands of patients, it's become apparent that these PEOPLE just want to 'feel better,' and need to know that if there's a 'problem' that they can count on someone else to 'help'  them "fix it."

Nevertheless, every patient needs to be approached with a guarded, friendly approach.  As much as that might sound like an oxymoron, it is a skill that can be developed.  Approach every patient with an open mind, no preconceived notions, no 'baggage' from the disagreement that you just had with your partner, no 'attitudes' because this call got you out of bed in the middle of the night, no expectations because this is the third time this week you've been called out to the same house.  Just an "open" mind, a "clean slate."  This 'uncluttered' mental status will better prepare you to 'accept' anything that the patient may 'throw' your way, including anything that might jeopardize your safety.  Add to that clean slate a sense of sympathy for the discomfort that the patient is experiencing (whether real or imagined,) no matter what time of day or night, and you will be well on your way to developing a "guarded, friendly approach."

Once comfortable, and able to 'drop your guard,' a little, try to turn the somewhat impersonal 'information collection interview' into a 'little chat' that you are going to have with this person.  To do this convincingly you must first be very comfortable with those "medical-problem sub-categories" discussed in the previous chapter, and the associated questions for each medical emergency.  Comfortable enough with the 'questions' to be able to 'change gears' in the middle of the interview when it suddenly becomes apparent from the patient's answers to the first few questions, that you've been "barking up the wrong tree," and must now start over with another 'set' of questions.  So if it wasn't stated convincingly enough in the previous chapter, let us restate that committing those 'problems' and associated questions to memory is a MUST.

During your 'little chat,' assume a position that puts the patient at ease and let some of your personality show (heck, you wouldn't be involved in this "business" if you didn't care about other people.)  Listen, with obvious enthusiasm, as if everything the patient is telling you is important.  Realistically, some, if not most, of the information WILL be important.  One way to convey that 'enthusiasm' is to maintain eye contact, and a good position from which to maintain eye contact is from the same level as the patient.  Use the patient's name as much as is appropriate (a very subjective 'interpretation' depending on the circumstances and your 'level of comfort.') 

Answer questions truthfully and never answer a question that is beyond your expertise by 'attempting to make stuff up.'  When speaking with the patient use words that are certain to be understood by the patient.  Avoid medical terminology, local jargon, and socially unacceptable language.  If you limit your responses to areas of knowledge with which you are comfortable, your demeanor will remain comfortable, you will be able to speak authoritatively and will convey an attitude of confidence to the patient. 

Understand that this patient was uncomfortable enough to 'ask' a group of strangers for help, and sometimes at VERY unreasonable hours.  There is obviously 'a lot on their mind.'  Give them some extra time to answer questions, don't rush them. 

If the patient has a hearing impairment, speak distinctly but don't 'over do it.'  Never shout.  If necessary position your mouth closer to the patient's ear, in order to maintain "communication," while using a "normal conversational level."  They may be profoundly 'deaf' and completely incapable of hearing.  It is not uncommon that such an individual would, however, be capable of reading lips.  Unless you have been formally trained to do so, don't "try" sign language, it will only confuse the issue.  And this is also not the time for charades.  If all other forms of acceptable communication have failed, try a pad of paper and a pencil.

If the patient is visually  challenged, add a sense of compassion and tactual communication to the interview by placing a 'caring hand' on their shoulder (if you don't have a "caring hand"...use someone else's...just kidding.)  Not all "blind people" are profoundly blind, some have varying degrees of light perception.  Nevertheless, their visual challenge (to whatever degree) has hampered their ability to visually 'evaluate' what is happening around them.  Take a little time to explain what is happening, both TO them and AROUND them, before it happens. 

The apparent concern that you display for these patients being adequately 'informed' (whether the impairment is auditorial or visual) will ultimately create a bond between you and the patient, which will add to the patient's sense of comfort, and YOUR appearance as a 'qualified' provider.

If the patient is a child, remember that you represent an authority figure and how intimidating that must be for a youngster.  Add to that intimidation the fear that has been generated by whatever illness or injury necessitated this "call," and the fact that there are suddenly a bunch of "strangers" in this child 'world' who are showing a keen interest in the child.  If at all possible have Mom or Dad hold the infant or toddler while the assessment is conducted.  Respect the modesty of a child old enough to understand "modesty," and explain, in "understandable detail" (another oxymoron?) what is going to happen.  As with any patient, don't lie to them.  If something IS going to hurt, tell them (gently, and compassionately.)  Some may need to be assured that they have done nothing "wrong," and that they are not going to be "separated" from their family (to that 'end,' involve family members in the assessment and treatment process to the extent that it is possible.)  Most children understand 'authority,' and expect you to 'exercise' the authority that you represent.  Do so with compassion, and understand that a "compassionate, authoritative, helpful figure" will ultimately become a source of comfort for this frightened child.

We feel that it is a fair assumption that, because you have involved yourself in this training program and have set your goals to achieve this position of community service, that you are the kind of person that truly cares about other people.  We also feel that this aspect of patient care (called 'communication') is a logical extension of YOUR personality.  This is, very possibly, a part of the communications process that you WILL learn later.  For now, just allow your personality to develop the "style" that will become 'yours' when (as an EMT-B) you are charged with the responsibility of bringing some 'comfort' into the lives of those 'uncomfortable' people that we call "patients."

Written Communications

In order to discuss written communications, we need to "shift gears."  As a matter of fact, we need "to turn this boat around."  Unlike patient communications, the written report is one that should be more factual and less emotional, have more substance and less personality.  Heck it's 'cold, hard facts.'  A good written report leaves no questions in the mind of the reader about what happened, when it happened, where it happened, why it happened, or how it happened.  Evaluate every report that you write for "what, when, where, why and how," (before you submit it,) and if you've left no question unanswered, it will be accepted as a "good report."

The purpose of 'records keeping' is to add to the "knowledge base" of the "industry."  From that 'base,' administrators will be able to justify the allocation of funds for equipment, training, and personnel.  From that 'base' educators will be able to demonstrate the effectiveness of proper technique and compare provider performance to patient outcome (and modify training programs as indicated.)  From that 'base,' individual units will be able to compare 'runs,' 'reasons,' 'response times,' and 'results,' re-allocating resources, as required. (Sorry that just kinda' happened, almost like it had a life of it's own, Ed.)  And, from that 'base,' the public will be made aware of the usefulness of the service and thereby justify it's existence.  As an element of that knowledge base, the report that you write is going to become part of a "permanent record." (often referred to as the "patient's permanent medical record".)  Those charged with the responsibility for collecting 'permanent' information for the EMS community have identified a "minimum data set."  The following list represents the "minimum data" for a report from pre-hospital EMS.

1. Chief Complaint

2. Level of Consciousness/Mental Status

3. Systolic Blood Pressure (Pt > 3yoa)

4. Capillary Refill (Pt < 6yoa)

5. Skin color, temperature, and condition

6. Pulse

7. Respiratory rate and effort

8. Time the event was reported

9. Time the event was dispatched (unit notified)

10. Time the unit arrived on scene

11. Time the unit left scene (enroute to hospital)

12. Time the unit arrive at hospital

13. Time patient was transferred.

Understand that YOUR report is only a "part" of the ultimate permanent record and that your "minimum data set" is significantly smaller than the 'set' for the entire record.

Every EMS (pre-hospital) "run form," "trip sheet," or "report" must include the  "minimum data set," appropriate for the level of care that is being provided.  All 'reports' will probably include more than just the 'minimum.'

Included in that "more" will be a narrative section (the "what, where, when, why, and how" part of the report.)  As the name implies it's a 'story' of what happened.  In addition to the "what, where, when, why, and how" you should include "special" events or occurrences (abnormal traffic/weather conditions, unexpected events that significantly affected patient care, patient outcomes, if available, patient refusal of treatment, etc.,) and you should 'arrange' your narrative in chronological order.  Also included in that "more" will be a section for patient demographics containing, "name, address, age, date of birth, and other contact information.

If you make an error on the report, draw a single line through the error, initial the line, and make the correct entry next to the error.  Do not attempt to obliterate the error.  Errors are a fact of life, they exist.  Attempting to obliterate them places "questions" in the readers mind about the sincerity of the "author."  Minimize their occurrence as much as possible, but when they happen, accept responsibility for them.

If you stick to the simple guidelines suggested above, and keep in mind that the report you are writing will become part of a much larger "knowledge base," with all of the implications associated with that 'base,' this "part of your job," (usually considered a "pain in the neck,") will become a challenging and rewarding experience.

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