“A wise person once said that paramedicine is 90% communication, 10% everything else”
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Standardised Handover – IMISTAMBO
IMISTAMBO is the standardised handover mnemonic which should be used whenever a paramedic is handing over the care of a patient to another health care professional. Although it is usually used in hospitals, it can also be used when referring patients to GPs or others.
IDENTIFY –
Provide the patient’s name, date of birth and any other relevant identifiers (hospital number is a great one if you have it). Generally good form here to introduce yourself too.
Example: “This is Adam Smith, 1st Jan 1977. UR number 1012345.”
MECHANISM –
Describe the mechanism of any trauma which has occurred. Sometimes that will be as simple as a fall on outstretched hand (FOOSH) or as complicated as a plane crash. Note that mechanism is not required for medical patients. Commonly asked for details include;
- Height they fell from
- Speed the vehicle was going when it crashed
- Type of vehicle involved
- Was a seat belt worn? Did air bags deploy? Were they able to self-extricate?
- Any chemicals involved?
Example: “Patient was single occupant driver of a new model sedan. Traveling 80km/hr and struck tree, significant cabin intrusion and was mechanically trapped for 20 minutes. Seat belt worn, airbag fitted and deployed.”
INJURIES –
After describing the mechanism of injury, list the injuries sustained by the patient. Moving in a systematic manner from head to toe will ensure no injuries are missed during the handover.
Example: “Obvious head strike with loose teeth. Denies neck tenderness or decreased range of movement. Chest wall bruising consistent with seat-belt injury. Abdo soft, pelvis intact. Bilateral arms are not injured. Obviously deformed left femur which is neurovascularly intact. No back injuries.”
SIGNS AND SYMPTOMS –
One of the most important parts of handover, as it paints a picture of the patient’s condition and can help with diagnosis. A complete set of vital signs should be provided, as well as findings such as 12 lead ECG and chest auscultation. Symptoms such as pain (including description), nausea and lightheadedness should be included, as well as pertinent negatives.
Example: “Heart rate 110, sinus. BP 105/75. SpO2 97% RA. Resp rate 14, chest is clear. GCS 15, PEARL. Pain 7/10, described as aching located at the femur fracture. Nil nausea or seizure.”
TREATMENT –
An important part of handover is telling the receiving team what you have done – whether you are handing over to a full trauma team or referring a patient to their GP. Include all management, and mention anything you have withheld or the patient has refused. The time of interventions don’t tend to be given in verbal handover, as these are reflected in your patient care record.
Example: “Management has been application of collar, CT-6 applied to left leg. He has an 18G cannula in the right antecubital fossa and through that he has had 8mg IV Ondansetron and 150mcg IV Fentanyl. I’ve also given 125mg IN Ketamine and 1g oral Paracetamol. Pelvic binder has been applied prophylactically and warming initiated.”
At this stage, it is a good idea to pause for questions or clarifications before continuing
ALLERGIES –
Hand over any allergies or hypersensitivities.
Example: “Patient has no known allergies”
MEDICATIONS –
Include any medications the patient is currently taking, or is prescribed but not taking.
Example: “Patient is on Perindopril and Aspirin. He is also prescribed Atorvastatin but not currently adherent with that.”
BACKGROUND –
Here we include the patient’s relevant medical history. What defines relevance? Anything that is going to impact care today. Generally speaking any condition the patient is currently being treated for is relevant, as are any past surgeries which may affect the current presentation. Minor previous surgeries, such as childhood removal of tonsils or excision of small skin cancers are not generally relevant, but you can always include them in your patient care record. Vaccination status should also be mentioned in this section.
Example: “Patient has past history of hypertension, high cholesterol and appendectomy. Has had 3x COVID-19 vaccinations”
OTHER –
As the name implies, this section allows for anything else which you think is relevant but has not been covered. Remembering that this is a tool for handover/triage, only list the most important ‘other’ elements here – such as concerns about domestic violence or other social issues. I find this section becomes more important the less unwell the patient is.
Example: “Patient normally independent, we’ve called his partner and let them know he’s here”
Making a request – ISBAR
Although ISBAR can also be used as a handover mnemonic, I find it is more useful when making a request. This may include providing a brief handover to an intensive care crew or when making a field referral.
IDENTIFY –
Again starting with who we are, and who our patient is. Generally has less focus on the patient details than IMISTAMBO
Example: “Hey it’s Foxy on the Frankston crew, we’re here with a 22 year old female…”
SITUATION –
What is happening right now? Essentially a one-liner – what is the problem?
Example: “She presents today in SVT with a rate of 190 and not responsive to Valsalva”
BACKGROUND –
What is the relevant past history (if any?)
Example: “Patient has previously had SVT requiring Adenosine administration”
ASSESSMENT –
This can be your assessment of what the problem is, although that should have been made clear during your ‘situation’ piece. So it is best to include the relevant findings of your clinical assessment.
Example: “Her current observations are; HR 190 narrow complex, BP 95/40, RR 20, SpO2 98%, GCS 15, pain free”
REQUEST –
The final stage of ISBAR is to make a request – what do you want? If you’re not sure and just need support, that’s okay! However if you know/suspect the patient needs a specific drug, skill or specialty, make that clear. This is particularly important when notifying hospitals, as they made need time to call in or free up the requested resources. Common examples of requests would be blood products, aeromedical support or specialist skill set such as finger thoracostomy.
Example: “Requesting MICA as she likely will require Adenosine again”
De-escalating agitated patients – LEO
LEO is a useful approach for de-escalating majority of agitated patients, particularly when they are agitated due to pain, fear or illness. However it is not as useful for patients with boundary pushing behaviours. Always consider your personal safety before attempting de-escalation and ensure you have sufficient support.
LISTEN –
It’s pretty simple – listen. But don’t just listen to respond… listen to understand. As paramedics we arrive at the peak of chaos, and we often have preconceptions or biases which are wrong. Listen to the patient and bystanders, then explain what you understand of the situation. Make sure you are open to being corrected and clarifying things.
EMPATHISE –
Empathy is the ability to understand and share the feelings of another. Being empathetic requires patience and an open mind. Remember that you don’t have to have been in the exact same position to understand how it might feel. For example, we’ve all felt frightened or alone in our lives – you can use this to consider how the patient is feeling.
Example:
“From what you’ve told me, life sounds pretty distressing right now.”
“What I’m hearing is you are frustrated with the way your partner has treated you today”
“I can’t see or hear what you are right now, but I imagine it would be really scary. You’re safe here with us”
OFFER OPTIONS –
Whilst listening and empathising help us to understand the patient, it will not generally be enough to resolve their crisis. We need to take action. However its vital to respect the autonomy and independence of people suffering mental health crises. Even if the person is on an involuntary order and must go to hospital, we can still respect them and treat them appropriately by offering options. These options might include which support person will come to hospital, offering the patient the chance to have a cigarette before transport or even which hospital they will go to.
Example: “So you understand that we have to take you to hospital for assessment – who would you like to be your support person? Do you need to pack a phone charger?”
“Would you prefer to sit on the chair or on the stretcher whilst we head to hospital?”
Escalating concerns – PACE
A great little reminder to support you when you need to raise a concern with a colleague – particularly around patient safety. The PACE mnemonic allows you to do this in a professional and assertive way. I find it especially useful for junior staff when they are working with a more senior partner.
PROBE –
Ask if the person is aware that what they are doing is incorrect, contraindicated or risky.
Example: When paramedic is drawing up Ceftriaxone “Did you know this patient is allergic to Ceftriaxone?”
ALERT –
A higher level of escalation, if probing has been ineffective or if you feel its not an appropriate option. This is a statement, as opposed to a question.
Example: “This patient is allergic to Ceftriaxone”
CHALLENGE –
The next level of escalation can be more confronting for junior paramedics, as it requires confidence. However if you believe an error is about to occur, and previous probe/alert prompts have not been successful, you must escalate your concern.
Example: “The drug you’re about to give is contraindicated. Do not give Ceftriaxone”
EMERGENCY –
The highest level of escalation, I like to think that you will not need to use this. However sometimes in the chaos of a scene the previous escalations can go unheard. Or you may arrive at a scene as a back-up crew and identify that an error is imminent. One such situation might be that the contraindicated drug has been drawn up, and is being attached to the IV line.
Example: “STOP STOP STOP. The drug you are giving is contraindicated. Do not give that drug.”
A tip about escalating concerns – if you’re ever unsure, or your partner disagrees with your concerns, you should always consult your written guidelines or contact your Clinician.
Major Incident Situation Report – METHANE
Major incidents can occur anywhere, at any time. They are generally defined as situations where the number of patients are greater than the number of paramedics (so typically 3 or more patients). However even single patient events can be considered major incidents, if they involve a large emergency services response, are difficult to reach or are otherwise challenging. Communication between resources on the ground and the communication centre are paramount in ensuring the right resources get to the right patient. With that in mind, the METHANE SITREP is used to succinctly convey all the necessary info.
MAJOR INCIDENT DECLARATION –
Just like it says, you’re starting off your SITREP by declaring a major incident. Using this statement will ensure all ears in the communication centre are on you
Example:
“This is Langwarrin – I am declaring a major incident”
“Lyndhurst – I am on scene at a major incident”
EXACT LOCATION –
It may seem obvious, but confirming the actual location of the incident is critical. Calls to 000 often have incorrect location details for major incidents, as they don’t always happen at addresses with neat signage. Often you will need to rely on landmarks, estimated distances and compass directions. When en route to a case, always reference a map to know where you are.
Example: “Exact location is 200m North of the address given”
TYPE OF INCIDENT –
Clarifying the type of incident will give clues to what additional resources are required, and how unwell the patients may be. For instance, I was once called to a bus vs car collision, with an estimated 40 passengers involved. However on arriving, we found that all the passengers had left the bus uninjured!
Example: “Type of incident is a two car collision approximately 100km/hr”
HAZARDS PRESENT –
Safety is always critical, but even more so at scenes where multiple resources will be backing you up. Although a dynamic risk assessment should constantly be undertaken, it’s important to hand over any identified hazards. Common ones include leaking chemicals, fire, smoke, aggressive people, traffic and unstable structures.
Example: “Hazards include heavy traffic and leaking fuel”
ACCESS AND EGRESS –
In my opinion this is the most poorly conveyed element of the METHANE SITREP, access and egress refers to how backup crews will enter and exit the scene. This becomes particularly important at large, multi-agency incidents, as we want to avoid scene convergence (where emergency resources all flood to the scene and block each other in). This is another time where reading the map becomes critical, as does knowing compass directions. Remember that the way you entered the scene may not be the best way.
Example: “Access from the South via Smiths Rd. Egress to the North via Smiths Rd. The road is blocked from the North so crews will need to divert around.”
NUMBER OF PATIENTS –
Note that we are only now just getting to the casualties. This is because it does not matter how many patients there are if your backup cannot reach you. To accurately gauge the number of patients, the Triage Officer should walk around scene and do a head count on arrival. Ensure that you ask “were you involved in the incident?” to separate bystanders from casualties. If the scene is small enough that everyone can be triaged quickly, they should do so. However at the very least an accurate number of patients should be achieved.
Example: “Number of patients – 8. Two Priority 1, two Priority 2, three Priority 3, one deceased.”
EMERGENCY SERVICES PRESENT/REQUIRED –
The final element is to relay to comms which resources are on scene (such as police and fire) and what resources you are requesting. Don’t worry about requesting specific police or fire resources – just tell them what you want (traffic control, road rescue) and they will work it out. Ambulance resources are a bit different… as a general rule you should request one stretcher vehicle per patient (not counting yourself as a resource). Then consider the need for intensive care paramedics or aeromedical evacuation. Plus its always a good idea to ask for an in-field manager to come to scene and assist with logistics. Always ask for what you need, and if its not possible then work with the communications centre to formulate a contingency.
Example: “Emergency services – fire service currently on scene. Requesting police urgently for traffic control. Require 8 ALS crews, MICA and HEMS, as well as a Health Commander.”
