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“Cs of Communication;” two important characteristics are ketamine IV. The concentration of ketamine in the syringe is
clear and concise communication. 16,17 Furthermore, it is im- 10mg/mL.” An appropriate closed-loop response might be, “I
portant to recognize and avoid mitigating language (vague or understand the ketamine is mixed 10mg/mL. I am adminis-
noncommittal) ; be direct and to the point. These tenets of tering 20mg, 2mL, of ketamine IV.” Finally, “2mL with 20mg
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communication exist and are commonly applied in other areas of ketamine was administered.” The important aspect of this
of the military; for example, in the aviation community, the behavior is that information is provided to the message origi-
mantra for emergent communication is “Directive, descriptive, nator with positive confirmation that a task is complete. This
informative.” Language is structured such that the most im- communication strategy can be broadly applied and, in the
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portant information comes first, followed by information that context of Case 4, may have prevented one of the medical er-
augments the most critical content, and finally, any supple- rors reviewed here.
mental information.
These cases illustrate the negative impact that miscommunica-
Standardizing language is also key to optimizing safe and expe- tion can have on patient care, team effectiveness, and mission
ditious task completion. In general, team performance is more success. The need for growth in this arena is evident. While
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efficient when standardized terminology is used. When people improved communication strategies are often discussed con-
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hear expected or predictable words or phrases, they seem able cerning military operations at large, they are not stressed in
to coordinate activities and perform critical tasks more effec- the same way in the MPE. The techniques mentioned above
tively. This seems to hold when validated team performance could potentially be included in doctrinal guidelines and regu-
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tools compare the work of teams that use a standardized ver- lar medical training events.
nacular to teams that communicate in non-standardized ways.
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It is also important to realize that standardized communication Conclusion
is not inflexible or rigid. Novel circumstances necessitate free-
form communication to address dynamic, emergent situations. Miscommunication is a common cause of medical errors in
Standard phraseology is most important; however, more plastic civilian medicine. This case series demonstrates that miscom-
and adaptive communication is also effective when faced with munication impacts medical and technical rescue operations
an uncertain or time-sensitive situation. 22 in the MPE. Military medics would benefit from emphasizing
the importance of communication and its impact on medical
Communication failures at care transitions and handoffs are errors in a similar light as civilian medicine. Efforts should
a relatively common source of medical errors. 23–25 Developing be made to elevate awareness, education, and training. Imple-
common terminology and structure has been key to improv- menting a codified, standardized system for communication in
ing miscommunication at these important points in patient the MPE could mitigate this form of human error in combat
care. 26–28 Kunce et al. performed a recent review of verbal and medicine.
written handoff tools in the context of military operations.
The MIST tool used by Special Operations Forces (mechanism Based on research from within the civilian medical commu-
of injury, injuries, signs and symptoms, treatments) was fre- nity, the recommended focus for the MPE is pre-coordination
quently used and of significant utility. Moreover, the authors communication that continues through final patient move-
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commented that handoff communication was best when inter- ment; closed loop communication in all real-time treatment
ruptions were limited, the handoff was performed face-to-face, and handoffs; readbacks for high-consequence interventions
and there was an opportunity for the receiving party to review or drug administration; establishment of standardized brevity
information and ask questions. This approach, or a similar calls for well-rehearsed behaviors; and development of realis-
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structure adapted to arriving in the field at the scene of a mass tic methods for standard, thorough documentation on all pa-
casualty incident, may be useful. tients that considers the challenges associated with treatment
environments and patient movement. Widespread joint adop-
Understanding when to communicate is as important as content tion of such strategies could lead to fluency and proficiency
or structure. At times, team members are so focused on activi- for MPE providers and team members, ultimately mitigating
ties or busy completing other critical tasks that they may not be the contributing factors of miscommunication and reducing
prepared to receive a message. 30–32 They can also be distracted medical error.
by environmental factors, including noise. Furthermore,
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sometimes limiting information to what is most important Author Contributions
right at that moment is helpful; otherwise, the communication GE and SR conceived the study concept. All authors partici-
may simply be distracting. Surprisingly, decreased (or limited) pated in the literature review, collected the data, and partici-
team communication correlated with better team performance pated in its analysis. GE wrote the first draft. All authors read
under high-cognitive workload conditions. Anticipating that and approved the final manuscript.
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a team member may need a key piece of information is para-
mount. An important characteristic of a high-functioning team Disclosures
is that members anticipate the needs of others and communi- The authors declare that the research was conducted without
cate critical information before it is requested. 35 any commercial or financial relationships that could be con-
strued as a potential conflict of interest.
One communication challenge is ensuring that certain in-
formation is heard, acknowledged, and processed by those Disclaimer
carrying out the task or treatment. Therefore, closed-loop The requisite units have approved this publication for univer-
communication is necessary—meaning instructions between sal distribution. The information, content, and conclusions do
team members are reinforced by verbal feedback. 36,37 The loop not necessarily represent the official position or policy of US
can be closed immediately: “John, please administer 20mg of military or any other organization.

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