In this article, we will present an overview of work in progress on applied informatics necessary for a coordinated emergency response to attacks resulting from weapons of mass destruction (WMD). The emergency responses place large demands on data collection, distribution, and analysis. The information transfer from the field to the decision-makers in the remote Command Control Center (CCC) allows coordination and integration of the responses from local, state, national, and federal agencies. This article will describe on-going federally funded efforts from the Charles McC. Mathias Jr. National Study Center for Trauma and Emergency Medical Systems (EMS) and the Department of Anesthesiology at the University of Maryland to test information transfer, remote diagnosis, and telementoring management that may be useful for future WMD responses.
The integration of medicine, technology, and human factors is critical to successful application of informatics and coordination of information transfer from the field to the CCC. Integration of the different emergency agency responses, triage to appropriate facilities with the necessary resources, and provision of “surge capacity” is determined by the CCC. The Human Factors Research group, including human factors engineers, technologists, and clinicians (www.hfrp.umm.edu) at the University of Maryland, is testing several applications of technology during simulated disasters in the Maryland EMS, and in real life, at the University of Maryland Shock Trauma Center and Medical System. Such enhanced telecommunications for emergency medical care are important for future military and civilian applications, both for disaster management and in response to bioterrorist attacks with WMD.
Current EMS Communication System and Process
Currently, voice communications are available through a microwave network covering 97% of the surface area of the State of Maryland. This communication network allows the pre-hospital field care providers to communicate directly with physicians in trauma centers (known as the Trauma Line) and other referral centers. The Trauma Line information is abstracted, the data are recorded on a whiteboard, and include the vital signs of the patient, estimated time of arrival (ETA), the means of transport (helicopter versus ground), mechanism of injury, level of consciousness, and priority status. The trauma team obtains the summary information from the whiteboard after a group page alerts them to the patient ETA.
This system is relatively inefficient and would be totally inappropriate in a mass casualty incident as the whole trauma team responds to each admission. The voice data can omit useful information because the field care provider may be performing under stress in difficult circumstances. There may not only be a lack of information about the patient, but also a lack of communication about the available information. Reports confirm that observations at the injury scene are communicated only 75% of the time, and additional information is helpful in 52% of cases.1 In a review of EMS voice communications from the field, the receiving team rarely asked questions. The pre-hospital person also spent a lot of time waiting to find the right recipient for information. In one typical example, 205 out of 385 seconds of the communication were spent “on hold.” In disasters with multiple ambulances and field units reporting to multiple hospitals, this kind of delay and lack of communication about available information is unacceptable, and an improved and automated information transfer system is needed.
Novel Approaches to Information Transfer
We sought to improve this process by using a fax linked to a cell phone in the ambulances to send information before the patient’s arrival. When information was faxed ahead, the trauma team was better prepared when the patient arrived. We are also testing a global positioning system (GPS) transponder system for use on ambulances. The GPS transmits a dynamic image of where the ambulance is to the ambulance coordination center, where it is displayed on a map of the state. This facilitates appropriate and efficient dispatch of ambulance units and allows coordination of hospital activities in relation to the predicted time of arrival. Other parts of the system allow the physician at the hospital to look at EKG tracings and vital signs, and to communicate directly with the ambulance. In disaster and terrorist situations, ambulances could be equipped with such a system that could provide information about the incoming workload, the number of patients in each ambulance, and allow for early intervention before arrival, redirection away from overloaded hospitals, and a better sense of the flow of multiple patients enroute to multiple hospitals.
Remote Triage and Diagnosis
The acquisition of rapid multi-patient information from a disaster site is being studied in a project, known as “MobiDoc,” which makes use of next-generation wireless technology to create an entirely mobile telecommunication system. In the size of a briefcase, this communications kit contains 6 cell phones and wireless data-acquisition devices that are connected to the cell phones. A field team can perform multiple charting, vital-signs monitoring, image collection, and other data acquisition tasks on multiple patients. These are then sent securely to the hospital’s intranet, where they can be viewed on a Web browser by CCC personnel. Currently we are able to transmit up to 5 images/second through this system. All of these systems allow patient data, diagnoses, and pre-arrival information to be communicated from the field to a hospital or CCC. The data gathering systems need to be coupled with intelligent algorithms to distribute resources appropriately, e.g., to make sure that all the patients who need a CT scan are evenly distributed among the hospitals that have one.2 Furthermore, while these systems allow us to make more efficient use of existing resources, they also provide information to temporarily increase capacity in a local area.
Use of Telepresence for Lifesaving Procedures in the Field
One benefit of telepresence is the ability to remotely guide procedures such as the emergency airway management of patients poisoned with nerve agents causing respiratory paralysis. The remote airway management model was tested using a task communication algorithm that specified how field personnel should look at the chest, when to listen to breath sounds on the left or the right, and when to check carbon dioxide monitors.3 In an experiment, we used this tool as a way to telementor airway management in a group of trainees who were intubating humans for the first time. One group trained using conventional tools. The other group trained for only 30 minutes (compared to 2 hours and 30 minutes with conventional tools) using the above algorithm with a head camera and communication system that brought the mentor into the process. The group with the telementor took 1 to 2 seconds longer to insert the tracheal tube, but was equally successful. In an animal model of tracheal gas insufflation following tetrotodoxin poison (a good laboratory surrogate for organo phosphate nerve gases), we used percutaneous passage of a circothyroidotomy catheter to maintain oxygenation and ventilation sufficient for neurologically normal survival.4 Insertion of this catheter and attachment of a self-contained insufflation gas supply could be telementored so that a single protected care provider could service multiple casualties with respiratory distress.
Finally, a separate project, funded by the Army Research Institute, is allowing the examination of remote management of trauma cases as a model for remote command and control. In this experiment, trauma surgeons direct the activities of the trauma team when they are remotely situated (50 to 100 feet away) from the resuscitation, but out of direct sight and hearing. Equipment includes a wireless headset for communication with the team leader, a wireless video head camera that transmits the images from the wearer, and a pan tilt-and-zoom camera and an overview camera. We compared the trauma evaluation and management process in this setup to a similar case in which the trauma surgeon was on the scene. When the surgeon was remote, he asked more questions (72% vs. 60% of communications), and gave fewer instructions (28% vs. 40%). These data suggest that the remote surgeons weren’t quite as sure what was going on compared to being on-site, and possibly not quite as confident in their ability to give instructions. The system is nonetheless superior to having no trauma surgeon available at all. So, this holds promise for remote CCC where it is essential that the decision makers be far from the bioterrorist or chemical threat.
Colin F. Mackenzie, MD, is Professor of Anesthesiology and Director of the Charles McC. Mathias, Jr. National Study Center for Trauma and EMS; Yan Xiao, PhD, is Associate Professor and Director of the Human Factors Research Laboratories; and Peter Fu-Ming Hu, MS, CNE, is Director of Technology Integration and Development, with the Department of Anesthesiology, University of Maryland School of Medicine, Baltimore.
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