Introduction: Clear paramedic-physician telecommunications (patches) are critical in systems utilizing on-line medical control. In systems using extensive medical directives individual paramedics patch infrequently. Investigations of specific problem calls indicated that communication problems were more common than believed. Existing literature on this topic is sparse. This project is a quality assurance exercise undertaken to understand the extent and nature of problems in paramedic-physician telecommunications Methods: Retrospective analysis of anonymized transcriptions made from MP3 audio files recorded as part of normal operating procedures by the Central Ambulance Communication Centre during January-March 2014. All calls where telecommunication occurred between paramedics from 4 ambulance services and base hospital physicians providing on-line medical oversight during ambulance calls were included. Transcripts were read multiple times and data extracted onto spreadsheets for frequency analysis. Further thematic framework analysis of emergent themes was done. Results: All 42 patches were transcribed and used for analysis. 36 (85.7%) were for termination of resuscitation orders, 4 (9.5%) were for advice, and 2 (4.8%) were for orders not covered by medical directives. Communication problems were identified in 40 (95.2%) patches. Most had multiple problems. These included disconnections (23.8%), difficulty hearing one another (40.5%) - indicated by phrases such as “sorry?” “what?”, “I can’t hear you” - or caused by individuals interrupting each other (83.3%), and talking simultaneously (47.6%). Signaling the end of “talk turns” - such as “10-4” or “over” - was never used. Instead, terms like “yah” and “OK” were used. When communication went awry, time was spent trying to repair the mis/poor communication. This led to repeating information or attempting to ‘sell’ the case by providing information unnecessary for decision making - such as during a request for termination of resuscitation, “there is vomit on the floor”. Conclusion: Paramedic-physician telecommunication problems were extremely common. They involved technical (mechanical problems) and human factors (disorganized radio ‘technique’). The high incidence of telecommunication problems identified is concerning. Critical clinical decisions (e.g. ceasing resuscitation) depend on clear communication. Further study of these issues is warranted.