INTRODUCTION
Communication means successfully exchanging information so that the message reaches the correct recipient in a timely manner and is interpreted accurately. In resource-poor situations, especially following disasters, communication difficulties are usually the major problem health care and other service/rescue providers face.
POST-DISASTER COMMUNICATION NEEDS
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 network/signal problems, electrical power loss, damage to infrastructure, surviving infrastructure (telephone, cellular phones, etc.) overload, or system damage that overwhelms repair crews.
Multiple space-based satellite communication systems have been used internationally during disasters.1 Even in the best circumstances, however, this type of communication may not be available until several hours, or even days, after major disasters, while good communication is needed immediately. Whichever makeshift methods are used will depend on what resources are still available.
Experienced, prepared spokespeople are needed to communicate with the professional teams and the public before, during, and after disasters. They need specific skill sets that address “risk communication.” (See Table 3-1 and “Hardest Decisions: Who Allocates Scare Healthcare Resources” video at https://www.youtube.com/watch?v=w2qFjRNmtX4.) Building communication capacity prior to a disaster includes prewriting public service announcements in multiple languages that address questions that frequently arise during disasters (Table 3-2) and maintaining contact lists. These lists, to be updated on a scheduled basis, should include reliable information sources in frequently affected regions, media contacts that can rapidly disseminate information, and government agencies and nongovernmental organizations that can provide assistance.
|
|
ON-SCENE COMMAND AND CONTROL
In disasters and other chaotic situations, successful control of the situation depends on 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.
Many ambulances and rescue vehicles now have large roof markings for identification from above. If they 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.
TELEPHONES
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.
Cellular phones are an excellent communication tool 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.
A cell phone that has been dropped in fresh water may be salvageable, but it takes a while. Immediately remove the battery and memory chip and put them in a bowl, completely covering them with uncooked rice. After 2 to 3 days, use a toothbrush to gently brush away any remaining rice dust so that it doesn’t get trapped in the openings in the phone. Hopefully, the phone will work—if you recharge the battery.
New apps to assist with diagnosis and, indirectly, with therapy (see the “Distraction Analgesia” section in Chapter 14) appear constantly. The problem is that not all functions, especially videos and illustrations, are accessible without an Internet connection. Try them out while your phone is on “airplane mode” and with “WiFi” turned off and then on to see how well they will work in those situations.
While some remote areas of the world have cellular network signals, many do not. A cellular connection relies on line-of-sight radio frequency signals and may only be accessible from high points with a clear view of the surrounding area. If maps will be needed, download them prior to entering the remote or cell-service-poor area.3
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 (VoIPs) are an excellent communication method. If a strong signal is available, most provide both audio and video connections.
One solution 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, operating room, command center, security, power station, laboratory, and medical records. In addition, use building wiring for a field phone conduit. The problem is that surplus field phones are now scarce. Wired intercoms may also be used if they can be configured to run on battery power. (Scott Clemans, Consulting Engineer, Tucson, Ariz. Personal written communication, 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.
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://www.dhs.gov/government-emergency-telecommunications-service-gets; Tel: 866-627-2255). An equivalent service for wireless communication is the Wireless Priority Service (WPS) program (https://www.dhs.gov/wireless-priority-service-wps; 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.4
The Internet now forms society’s social, economic, management, and communication backbone. Any disruption causes havoc; widespread disruption may be a disaster. While the Internet was designed to survive a nuclear holocaust, components and institutional systems are vulnerable to power outages, programming errors, and intentional hacker attacks. So, while the Internet will not go down, it may not work as it should or you just may not be able to access it when you need it. However, if the local computers (or handheld devices), servers, and Internet providers are operating, messaging, e-mail, and VoIP (phone) are excellent communication tools.
More than 94% of health care institutions have been victims of cyberattacks, particularly data loss, monetary theft, medical device attacks, and infrastructure attacks.5 Planning to protect these systems includes taking a comprehensive inventory of all clinical, research, and business processes and systems that depend on Internet connectivity. Work-arounds then must be developed that include not only a total loss of Internet connectivity, but also the loss of specific components or functions. Connecting to the “cloud” is now vital for many institutions, because it often hosts electronic health records. Analyzing computer threats and devising processes should systems fail is complex, expensive, and not certain to work. Yet, it is worth the effort.6
PATIENT–CLINICIAN COMMUNICATION
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. In addition, 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 health care staff who also work as interpreters have insufficient bilingual skills to serve as interpreters in a medical encounter.7
