Your Captain Speaking: Digital Communication in EMS
“Samantha, in aviation we learned a lot about digital communication, and in many regards, it was a stupendous leap forward. Pilots would now hate to go back to the old ways of strictly voice radio. There were slips and trips along the way but perhaps EMS could avoid some of these same foibles. Here are some things to think about beforehand.”
It would be great to incorporate lessons learned from aviation into EMS, but they won’t be easy. Let’s look at several of these from start to finish.
Controller-Pilot Data Link Communication in Aviation
The digital Controller-Pilot Data Link Communication (CPDLC) system for communication between pilot and air traffic control (ATC) first emerged in the late 1990s.
Atlas Air, which I once flew for, knew there were better comm systems than voice radio out there, but the new and expensive equipment needed was not a priority for the fleet of aircraft. It’s often the same for EMS.
“Just keep calling on the radio or a cellphone to medical control; it has always worked in the past.” Ambulance services are not awash in extra, so an upgraded comm system will be hard to justify. No different than an airline.
As one of the original proponents of CPDLC, I was then asked, “Show me the training program and how much it’s going to cost.” Are you going to purchase the entire suite of digital communication or just part of it? The months of delays dragged on.
The Rollout was Bumpy
At last, the equipment on the aircraft was installed, but the rank and file were not yet trained on CPDLC. Crews en route over the Atlantic Ocean would log in and think they were done making calls over the HF radio. They thought the reports were going out automatically. Nope. HF radio is extremely long range—thousands of miles, very scratchy, and usually not directed to a primary English language speaker.
Pilots would log in and not know that there was a confirmation process and reporting requirement. The flight plan didn’t include the codes saying they were CPDLC equipped, so ground stations were confused.
A message sent but not acknowledged—by a human—is no communication at all. This is a critical element for EMS in the future. A human must take notice of the information sent. Example: You send a text message to a friend, and it says “Delivered,” but that doesn’t mean they have read and understood the text.
Be Careful of Inflexibility—And Too Many Cooks
In some systems, there is only one way to fill out a form or make a request. Other systems have numerous ways to accomplish the same thing—that can cause confusion with new recruits. A single way of doing things can become inflexible to changes but the “many ways” approach is a training problem. That makes for a tough choice in selecting your system.
Telestroke for EMS
A recent National Institutes of Health study noted a few bright spots in EMS communication technology.
Alternatively, “telestroke” facilitates remote evaluation of acute stroke patients via an audiovisual link and transmission of computerized tomography images. Despite the physical separation, stroke specialists are able to examine patients, review brain imaging and make correct treatment decisions; transfer to a stroke center can then be performed as appropriate,” wrote the authors of Use of Telemedicine and Helicopter Transport to Improve Stroke Care in Remote Locations.1
The remote physician, nurse, or paramedic can establish a video link to the hospital and a stroke specialist can get a report from the paramedic, see the patient, and provide guidance to the crew and talk to the patient directly.
However, there are some broken threads here. The ED physician or stroke specialist is often a busy person and can’t drop everything to answer a video call. It may be several minutes of lost time in the ambulance or helicopter. I’m betting that the patient might want to say a few things or perhaps more than a few things on the video. Much of it may not be relevant to the chief complaint. The video needs to be high quality with pan and zoom. Audio quality needs to be equally good. Instead of a physician, perhaps more likely an ED nurse answers the call and are just a busy as the doctor. Not much is really accomplished. Nobody is happy, and your patient is perplexed that they didn’t get to talk to the physician very much.
Full Integration Needed
There’s no sense in getting a patchwork of digital communication tools when what EMS really needs is a fully integrated system that will communicate with other systems. The paramedic writes an EPR that’s transferred to the hospital patient record.
Software licenses often limit the range of the program’s reach. You get what you pay for and that’s not going to be changing. A big improvement for EMS would be an AI-assisted video/audio system (body camera) to capture the chief complaint, the signs and symptoms—the whole sample history including the vitals, blood sugar, and an EKG, as well as the the required signatures for HIPAA, billing, etc. This is possible in the near future with AI’s momentum.
But none of this is integrated with the next level of communications such as back to the ambulance service, medical control, and the receiving hospital. The receiving hospital will want the information forwarded to other levels in the hospital, such as triage and patient billing. Paramedics are best used when interacting with the patient and not doing “tablet time.”
Now time for a reality check. Doctors' offices and pharmacies today could not exist without a fax number to send and receive orders and prescriptions. This is really old school technology, but we haven’t progressed beyond sending things by fax—a clear indicator how slow some systems are to evolve.
Emergency Signal
A good aspect of the aviation CPDLC design was when the Declare an Emergency page was pulled up. It had all the information prefilled with where you were, destination, and altitude. I tested this page with my counterparts at Shanwick Oceanic and the instant I pressed the send button I could hear the alarm bell go off in the background on the other side of the Atlantic Ocean as we were also on a cellphone. This needs to be an option for EMS to instantly communicate the critical nature of a report. Only a few percentages of our calls are critical, but this is an important option to have. How about an MCI? Who else would need to be notified of an MCI? What about an officer down? You get my point.
Digital Signal Coverage
Some locations will have great signal coverage while others have “dead spots.” There are methods to improve coverage such as the SpaceX Starlink system but there is a cost, of course. The P25 Digital Radio is a land mobile radio (LMR) that is the current majority standard and widespread. Next up is the 5G/LTE broadband that creates Wi-Fi hotspots from ambulances to allow ECG transmissions, vitals and CAD navigation. Telecommunication platforms allow for video consults, remote diagnostics, and other data streams. Artificial intelligence-enhanced dispatch gives route prediction, evaluates low-acuity transports, reduces the number of lights and siren responses, and facilitates diversion to a more appropriate medical destination rather than always to the ED. Do you have a contingency plan if there is no signal? Computers always crash.
We are in an exciting age and emergency medicine will evolve but likely not as fast as we’d like. Individual improvements will be appreciated but quickly bump up against integration with other programs. Development of an agreed upon standard for the gathering of the data, evaluation of the data, and transmission of the information to all the needed stakeholders will take some time.
“Dick, we are close to a breakout of tremendous improvements but the mistakes of the past will have to be recognized and avoided. I can’t wait to see it!”
References
1. Use of Telemedicine and Helicopter Transport to Improve Stroke Care in Remote Locations. National Library of Medicine NIH, by Department of Neurology, Georgia Health Sciences University, 1122 15th St., Augusta, GA 30912, USA. https://pmc.ncbi.nlm.nih.gov/articles/PMC3752598/
About the Authors
Dick Blanchet, (Retired) BS, MBA, worked as a Paramedic for Abbott EMS in St. Louis, MO, and Illinois for more than 22 years. He was also a Captain with Atlas Air for 22 years on the Boeing 747 with more than 21,000 flight hours. As a USAF pilot for 22 years, he flew the C-9 Nightingale Aeromedical aircraft. A USAF Academy graduate with a Bachelor of Science degree, his Masters in Business Administration is from Golden Gate University.
Samantha Greene is a paramedic and field training officer for the Illinois Department of Public Health Region IV Southwestern Illinois EMS system, a paramedic and FTO for Columbia (Ill.) EMS, and works full time at the St. Louis South City Hospital Emergency Department as a paramedic. She was recently recognized as a GMR Star of Life.
