Chapter 3. Communications

Communication is the exchange of information. Successful communication reaches the correct recipient in a timely manner and is interpreted accurately. In resource-poor situations, especially following disasters, difficulty with communication is usually the major problem faced by health care and other service/rescue providers.

Multiple space-based satellite communication systems have been used internationally during disasters.1 Even in the best circumstances, this type of communication may not be available until several hours, or even days, after major disasters. However, good communication is needed immediately. Whichever makeshift methods are used depends upon what resources are still available.

Relying on a predisaster or "normal" telecommunication system—such as landline telephones, cellular telephones, or pager systems—to work in austere circumstances is foolish. Communication systems fail during disasters due to (a) network/signal problems, (b) electrical power loss, (c) damage to infrastructure, (d) surviving infrastructure (telephone, cellular phones, etc.) overload, or (e) system damage that overwhelms repair crews.

In disasters and other chaotic situations, successful control of the situation depends upon obtaining adequate information and distributing messages to those with "boots on the ground." This often takes ingenuity.

For example, rather than being used for rescue or extraction, the first helicopter on the scene of a widespread disaster, such as a commercial airliner crash, may best be used as a command and control center for subsequently arriving ground rescue units. The relative positions of the victims and rescue units can be better seen from an elevated vantage point than from the ground. Experience has shown that directing rescue units from the air in these circumstances may save the lives of victims who may otherwise not have been found in a timely manner. This approach also ensures more efficient use of rescue units.

Most ambulances now have large roof markings for identification from above. If ambulances do not have these, apply temporary markings using water-based paint or tape. Number and letter (alphanumeric) combinations should be used to minimize duplication. Symbols (star, box, tree) may also be used with or without an alphanumeric designation. Everything should be very large, so the controller can see it easily from the air.

In chaotic situations, it is often difficult to keep track of contact information for the multiple teams, agencies, and individuals. Keep and carry a personal log with this information, as well as a record of important events, directions, methods of making/procuring equipment or supplies, and so forth. During the response to Hurricane Katrina, such a log proved invaluable for tracking the constantly changing satellite and cell phone numbers for key contacts from multiple agencies. Use a small spiral notebook that can fit in your pocket, or a hardback, bound notebook, as some military personnel use.

During power outages and other crises, cell phones may often be used to bypass other failed systems. However, even with a functional system (i.e., the cell towers working), cell phones may not work inside all the areas of modern hospitals because of shielding and other dense barriers to the signals. More mundane, it may be difficult to locate cell phones or landlines designated for emergency use in the dark. Putting a piece of reflective tape on them can help, assuming that there is any light source.

One fix to the internal hospital communication problem is to use hard-wired, directly connected phones, similar to those used in caving. If possible, install direct lines in advance between key parts of the institution, such as between the emergency department, ICU, OR, command center, security, power station, laboratory, and medical records. In addition, use building wiring for a field phone conduit. The problem is getting surplus field phones. Wired intercoms may also be used if they can be configured to run on battery power. [Scott Clemans, Consulting Engineer, Tucson, Ariz., in a letter to the author, September 11, 2008.]

After an earthquake, be sure all phone handsets on the same line are in their cradles; if one is off the hook, no calls can be made or received. If you get a fast busy signal or an "all circuits are busy" recording, hang up and try again. You may have to wait several seconds for the dial tone as the circuits are rerouted. Have at least one phone that plugs directly into the phone jack in the wall. If a phone has an AC power adapter (cordless phone), it will not work if the power is out.

Even when the local circuits are overloaded, if telephone service remains uninterrupted, it may be possible to dial a long-distance number. Call a contact outside the local area (preferably in another state) who can call back into the affected area to relay messages.

Priority Status

Another solution (in the United States) is to arrange in advance for the organization or facility to obtain priority communication status. For landline communication, qualifying agencies may obtain this through the Government Emergency Telecommunications Service (GETS) program (http://gets.ncs.gov/; Tel: 866–627-2255). An equivalent service for wireless communication is the Wireless Priority Service (WPS) program (http://wps.ncs.gov/; Tel: 866–627-2255). These systems allow first responders, police and fire personnel, and federal, state, and local governments priority access to land and cell lines during a crisis. With GETS or WPS priority, the user dials a 710 phone number and then enters a code that grants priority to the call through the three major landline providers. If a call to the 710 number is made from a landline, the call is also granted priority on cellular providers' lines.2

Cellular Phones

Cellular phones are excellent communication tools when they function. However, there are three problems: (a) cell towers may be down (as after Hurricane Katrina); (b) power may not be available to recharge phones; or (c) buildings in which phones must be used have too much steel, concrete, and lead for cellular service to function effectively.

Interestingly, in some affected areas after Hurricane Katrina, text messaging seemed to work when voice messaging did not. Since Katrina, some hospitals are stocking cell phones with long-distance area codes, assuming that the phones will work even if the local cell towers are down. They won't.

Computer-Based Telephone

As with other computer applications, if the power is out and no batteries or generators are functioning, the computers (and thus Internet phones) will not work. If the power is on and the Internet provider is online, voice-over-Internet protocols (VoIP) are an excellent communication method. Some provide both audio and video connections.

Interpreters

In resource-poor circumstances, anyone who is willing and says that they are able to translate is often used as an interpreter. However, in such cases, there may be problems with a translation's accuracy and completeness. Additionally, the use of friends or family members as translators may interfere with patient confidentiality, cause patients to avoid sensitive issues, and disrupt established social roles.

Assessing translation skills can be difficult. Even when health care personnel are used as makeshift translators, accuracy may be an issue. About 20% of dual-role staff interpreters have insufficient bilingual skills to serve as interpreters in a medical encounter.3

Pictures

Without interpreters, pictorial representations may be effective for limited clinician–patient communication. It is best to prepare these pictorial representations in advance (Fig. 3-1). You can, of course, also draw simple figures and hope that the patient understands them.

When working with the deaf, use the pictures and supplement them with written messages back and forth—if the patient writes a language you understand.

Makeshift Signals

In a localized area, preset signals may be used for communication. Signal bells have been used for decades in mines and on ships to indicate specific needs or actions (e.g., send lift down, danger, help, time, etc.). Flags, whistles, lights and mirrors, or even hand signals can be used to transmit a message. It is important to predetermine the meaning of signals and to make certain that they can be heard or seen by the recipients.

Tracking Patients

Blackboards or white (erasable/grease marker) boards are used throughout the world to keep track of patients, personnel assignments, and patients' orders, tests, and bed assignments. These boards are used in all clinical areas, including emergency departments, operating rooms, and patient wards. It generally should have columns for the patient's room number, name, age, sex, problem/diagnostics (widest column), physician(s), nurse(s), admitting area, and consultations.

While this may seem to be the most obvious and easy solution to tracking and locating patients in the emergency, outpatient, and inpatient units, experience shows that many, if not most, providers around the world detest using it. If an unused white board has become a "white elephant," wasting space, remove the lines and turn it into a teaching board to illustrate procedures and with cases ("case-of-the-day") and questions. The staff often appreciates this approach to teaching.

In recent years, boards have been replaced in many institutions with computerized tracking systems. When computers go down or the electricity fails, track down an appropriate board to use (the best place to look is in the institution's administrative area). Remember to grab the writing instruments needed for that type of board.

Patient Records

Patient medical records are the most elegant method of transferring patient information to other clinicians and helping them pursue a relatively straightforward track toward diagnosis and therapy. Records communicate to others which treatments have been performed, results of tests, successes and failures with different therapies, and plans for future interventions.

Transferring Patient Records

When transferring a patient to the care of other clinicians, it is vital that the patient's records be transferred as well. This may mean the records are sent from battlefield to medical facility, from emergency department to ward, from clinic to hospital, or over hundreds or thousands of miles.

An old, workable method of transmitting the vital information that a tourniquet has been applied to a trauma patient is to write a large "T" on the patient's forehead using lipstick, grease pencil, heavy marking pen, or the patient's blood.

Clothespins, safety pins, a lanyard, string, or paperclips can be used to attach information about patients to their clothing during mass casualty situations or when they are being transferred to another facility. Make a hole through the papers (or their container/envelope) and reinforce it with tape to avoid ripping. Then use a paperclip or clothespin to attach the records to their clothing through a buttonhole or another part of the garment. A string or cloth tie may also be used to attach the records. Note that records may be lost if attached to medical equipment. Information can also be written directly on postoperative abdominal dressings (Fig. 3-2) or included on a USB (thumb) drive. Similarly, after initially providing fracture care, provide the patient with a "Fracture Passport," the name given to writing vital information on the patient's cast (Fig. 3-3).5

Transmitting Images

The wide availability of the Internet, digital photography, and camera phones makes transmitting images of patients and radiographs much simpler than in the past—and possible even in austere circumstances. Images can be transmitted (a) to get advice from distant consultants, (b) to avoid repeating costly and time-consuming radiography, and (c) to provide sufficient information so that receiving facilities can make appropriate preparations for patients before their arrival.

Useful Patient Information to Send

Useful patient images and information to send to other practitioners, government authorities (in the case of missing or dead patients), or to the patients include identifying and relatives' contact information, graphic patient charting (e.g., vital signs, anesthesia records, or medication lists), other vital written records (e.g., the history/physical exam, discharge summary, and list of medical/surgical interventions), test and monitoring results (including ECGs, rhythm strips, EEGs, lab tests), images of the patient's injuries or intraoperative photos, gross pathology specimens, radiographic and ultrasound images, and information or images of unidentified bodies or noncommunicative patients.

Pictures may be sent using e-mail or text messaging. On some models, the memory card can be removed and inserted into a computer or printer using an adapter. If the phone company has a way to transmit pictures (most do) and you subscribe, this should work smoothly. This photo may be sent to another cell phone or, for better resolution, to an e-mail address. To get the best photo, remain steady for at least a second after pushing the button, use the highest resolution, stand as close as possible to the subject, and do not use the digital zoom.

Transmitting Digital Camera Images

To transmit digital images via the Internet, download camera or digital x-ray images. Once downloaded to a computer, they can be sent via the Internet. In cases where bodies may need to be identified, images or information can be posted to a public Internet bulletin board.

For a digital radiograph, use a close-up setting and no flash; a standard radiograph, no flash; and for a patient/body photograph, no flash for close-ups. For studies with multiple images, such as CT scans, it is important to select and send the most clinically significant images, rather than the whole study.

Transmitting Images from a Phone's Camera

Images can be taken using the camera built into most cellular phones. They can then be downloaded to the Internet or sent through the same phone, depending upon the service provider and the services available on that phone. Both ends of these messages must be able to interpret the image format, or an "image protocol conversion" may be required. (This is not usually a problem while using standard photo formats.)

Images can be sent from most cellular phones to an e-mail address. The quality of the image, however, will be less than that is seen on an original photo or on the original document (e.g., ECG). However, it still should provide enough detail so clinical decisions can be made.

Images can also often be sent from one cell phone to another: This may not be available on all phones or with all cellular phone providers. When it works, it may take a while for the images to be transmitted. When transmitted, to best view the image, download it to a computer so the image can be manipulated.

Communicating Within Medical Facility

Paging Systems

Many modern hospitals rely heavily on their paging systems; these systems generally depend on the telephone system and on the normal power supply When backup generators kick in, these systems may fail. Prepare for this by keeping up-to-date contact lists, in paper and electronic forms. (Paper lists are important, since computers may not be operational.) Telephone numbers for vital sites within the facility (especially the radio or telephone hubs) as well as contact information for physicians and other hospital staff should be listed here.

Walkie-Talkies

Many hospitals plan to use walkie-talkies (low-wattage radios) for post-disaster internal communication. Except for line-of-sight (straight line without obstructions) communication, they are ineffective in modern buildings, such as hospitals.

Our tests have demonstrated that walkie-talkies and handheld radios (even up to 5 megawatts and with antenna repeaters placed) failed to transmit signals in any consistent manner in a modern hospital. The tests included checking transmission vertically and horizontally in the building. The only way these radios function in modern buildings is to use a "trunk" repeater (essentially, a giant antenna) running through the core of the building. Even then, experience shows that transmission is not consistent, and that there are numerous "dead" spots from which messages cannot be heard. These dead spots change daily, depending on atmospheric and other conditions.

Runners

When communication options are not available, it usually means there is (a) no electricity, (b) no Internet, and (c) no working land or cellular phones. To construct a runner system, remember that the goals of a runner system are to transmit messages between specific points ("nodes" or "hubs") within an institution or a local area in a manner that maximizes efficiency, that is, that uses the fewest runners (messengers) and has the fastest transmission times. Using set nodes or hubs is the efficient model that FedEx employs. [Alan Reeter, MSEE, Tucson, Ariz., in a conversation with the author, March 26, 2008.]

The types of messages transmitted between sites typically vary in volume and urgency. System efficiency can be increased if the senders designate each message as "1" urgent/stat, "2" important, or "3" routine or delay-tolerant. Category 1 messages are urgent requests for help, equipment, or supplies; critical lab reports; or urgent security warnings. Most clinical messages fall into category 2, while category 3 messages are administrative information, general announcements, and so forth. All level 3 messages can be routed to the central node, where they may be stored until several messages are collected to send to the same location. This "store-and-forward" technique conserves resources and decreases runners' frustrations from continually delivering status 3 messages.

Assuming that the message volume between different nodes (sites) varies and no mechanism exists to signal runners at different nodes that they are needed elsewhere to carry a message, the following method is a way to determine how many runners are needed.

The general scheme is to position the "command center" so that there is minimal distance between the command center and the nodes. With the normal scarcity of runners, base most runners at busiest nodes, with a minimum of one runner at every node. Have runners go in only one direction; let another runner return to the original node. (This system generally provides a rest period for the runners.)

The number of runners based at a node also depends upon the distance they need to travel (and the time it takes to do so) to reach the most distant or difficult-to-get-to site. In a hospital, this may mean running between a node in the basement and one in the 12th floor ICU. If the lab and pharmacy (two frequent-message sites) have satellite facilities near the busiest clinical nodes, this limits the number of messages (and runners) required.

The following formula helps to determine how many runners are needed. With a runner dedicated to each pair of nodes, the total number of runners will be N × (N − 1), where N = the number of message nodes. For example, 3 nodes require 6 runners, 4 nodes require 12 runners, and 6 nodes require 30 runners. Optimally, the number of runners at each node would be N minus 1, with each of 6 nodes having 5 runners (Fig. 3-4). Since this number is too large for most situations, either decrease the number of nodes or assign more runners to the high-priority nodes. (Be aware that doing so may decrease the system's efficiency.)

Runners need to work in shifts. Assuming that they work 12-hour shifts, the total number of runners required will be double the number for each shift (plus extras for illnesses and time off).

Typical hospital nodes may include the command center/central administration, emergency department, ICU 1, ICU 2, ward 1, ward 2, ward 3, OR, pharmacy, laboratory, personnel pool, security, food services, and ambulance bay/helipad. Adjacent areas (e.g., two wards next to each other) can share one communication node.

Regional Communication

Mobile Radios

The idea of using mobile radios is appealing. However, several problems exist. The first is that they can be very expensive, although the basic models cost only about $100 each. Next, there is the question of compatibility with other radios in use, concerns about message security, and the fact that the transmitting range diminishes depending on terrain, weather, buildings, body mass, and so forth. The range can be extended with one or more repeaters that rebroadcast the signals and thus increase their range.6

Despite these problems, consider using low-cost Family Radio Service radios to keep in touch with neighbors and family members. The range is 1 to 2 miles, and no license is required. Set up a network of these radios in your neighborhood to help each other in a disaster.7

Amateur Radio Operators (Hams)

Groups of amateur radio operators exist in many areas of the world to help with communications in disaster situations. In the United States, these groups are ARES and RACES. They generally have preset and tested equipment and can be activated in crises. This is an excellent method, even under austere circumstances, to communicate with others with similar amateur radio (not necessarily just ARES or RACES) capabilities.

Depending upon the extent of the disaster, telephones and radios can often be used for long-distance communication. Other options include the use of satellite phones and the Internet, assuming these are available. Any of these methods can be used in any resource-poor situation for telemedicine consultation with experts. Depending upon the system, satellite phones can be difficult to use, expensive, and subject to the vagaries of weather.

Internet

If the local computers (or handheld devices), servers, and Internet providers are operating, e-mail and VoIP (phone) are excellent communication tools. The Internet was designed to survive a nuclear holocaust, so the system will not go down; you just may not be able to access it when you need it.