The evolution of disaster medicine

These novel technologies might revolutionise disaster medicine

in the future

Brent Dibble, MD, MBA; Nadia Elkarra, MD; Megan E Mantaro; and Ian Portelli, PhD, MSc (Member of Crisis Response Journal’s Editorial Advisory Panel)

www.crisis-response.com

Volume 10:1 September 2014

56 Resources, links, pictures, videos and much more are available for subscribers in our digital and online editions www.crisis-response.com

Disasters, regardless of their cause, have devastating effects on the ability of healthcare providers to deliver

medical care to patients adequately. Recent catastrophic events, such as Hurricane Katrina in 2005 and the Fukushima Daiichi Nuclear Power Plant incident in 2011, make healthcare delivery extremely challenging, even in developed countries. Direct damage to hospital systems or issues with overcapacity can cripple healthcare delivery systems in times of the greatest need. As the frequency of natural and human-caused disasters grows, there is an imperative need to develop and implement novel technologies that can assist medical professionals in these situations.

Despite the development of new technology, disaster medicine response teams often rely on relatively antiquated technologies to respond. It is unclear whether this lack of adoption of new technologies is a result of opposition to the effi cacy or ethics of the technology itself,

or if it is related to potential fi nancial burdens. However, as electronic devices continue

to miniaturise, grow more powerful and become less expensive, it is

inevitable that the way disaster

medicine is practised will continue to evolve. Through this review, we hope to

provide a glimpse of the technology that has the potential to revolutionise the way disaster medicine is practised.

Trauma beyond limitsYou are the fi rst responder on the scene following a Category Four Hurricane. The local hospital has signifi cant structural damage and the nearest regional hospital is hours away. You will need to use your basic EMS skills to triage the patients, see that they receive the proper care, and decide which resources will be needed. Initial management in this type of situation requires a solution that is mobile, easily applied, and scalable.

Electronic Triage Tags – Traditional response systems are paper-based, which limits the speed at which information can be collected and the level of detailed information that travels with the patient. For instance, some of the patients in the Haiti Earthquake of 2010 were transferred between fi eld hospitals with only the information that could be written on their casts. Digital technologies present a solution for this type of problem. Their

rapidly increasing computing power has led to their utilisation in the fi eld of medicine through education and direct patient care.

Triaging is a key tenet of any emergency medical response. It involves determining the severity of the injury and the next step of care, and marking the patient according to acuity. Traditionally, this has been completed in the fi eld using paper tags distinguished by colour that are updated as a healthcare worker periodically reassesses the patient. This system, while meeting the basic needs of triage, is ineffi cient, requires additional manpower and does not allow real-time monitoring of patients.

Having access to better technology such as the Electronic Triage System would allow fi rst responders to utilise their time better, as well as to monitor casualties more effi ciently. In this system, the patient is connected to a triage tag, that serves as a central hub for patient care. The tag is connected to remote sensors that can measure the patient’s blood oxygen, blood pressure, heart rhythm (ECG), body temperature, end tidal CO2 and even blood glucose. It reports

The evolution of disaster medicineAs the frequency of disasters grows, novel technologies to help medical professionals in these situations must be developed. Here is a glimpse of some ideas that might revolutionise disaster medicine in the future

57 join the CRJ LinkedIn group follow us on twitter @editorialcrj Crisis Response Journal 10:1

electronically to a central system where the data can be accessed in real-time by computer, mobile phone, or even wearable technology like Google Glass. The tag colour will refl ect the severity of the disease (red = highest, blue = lowest).

The Electronic Triage Tag could provide additional features in

addition to standard triaging functions. Since the tag is connected to the patient’s unique identifi er and is transferred with the patient as he or she moves through the medical system, it can potentially store medical information and avoid the lack of data transfer seen in the Haiti Earthquake response and which is experienced during most disasters. Moreover, the tags can also have geographic information system (GIS) capabilities, allowing patients to be

future technology

tracked as they move through the system. This provides a more complete picture of the scope of damage and precise localisation of patients as supplies are delivered. First responders can utilise real-time technology to enable better assessment of patients, as well as establishing remote assistance on patient status. This can further provide a more sophisticated system for transferring high-risk patients to the appropriate healthcare facility.

Telecommunications and mobile phones – as the triaging process continues, physicians or other healthcare workers may need to visualise a patient’s wounds. This can present

a serious problem during situations in

which it is too dangerous to bring additional healthcare workers to the scene. Telemedicine, or the use of telecommunication to provide healthcare, has become an important tool for physicians. Whether for astronauts in space or patients at a disaster scene, telemedicine is sometimes the only means for physicians to provide their care and expertise. It allows for medical care to be delivered no matter how remote casualties may be.

Some of the aforementioned Electronic Triage Systems can transmit live video or

still photographs of patients, but there is a far more ubiquitous technology that can provide this type of care. With over 6.9 billion mobile phone users and 2.3 billion

mobile broadband users globally, personal mobile technology is far more widely available than electronic triage tags. Applications such as FaceTime, Google Hangouts, and Skype allow patients and fi rst responders to transmit live video to remote physicians who can help with initial triage, diagnose and assist with treatment. This technology also presents an opportunity for EMS to deliver updates and live video streams to emergency departments as

58 Resources, links, pictures, videos and much more are available for subscribers in our digital and online editions www.crisis-response.com

patients are being transferred from the fi eld to the hospital. In addition to video conferencing applications, a plethora of decision-support applications that have been developed to assist healthcare workers in every day practice can also help during disaster management. Applications such as PalmEM have built-in scoring systems that can be used to assist with triage and management decisions.

Mobile applications can also communicate with devices to help deliver care. For instance, as Electronic Triage Systems become more widely used, one can expect synchronisation programs to be developed that allow healthcare workers to follow the status of patients on their mobile devices.

We have also seen the development of portable, handheld ultrasound machines that can be used to check for internal bleeding and assist with diffi cult line placement – these images can be transmitted to a physician via a mobile phone.

As these portable systems continue to become more advanced, perhaps we will see the introduction of High Intensity Focused Ultrasound (HIFU), a tool that has been used in hospitals to focus ultrasound beams to vaporise tissue or stop bleeding. This would be an incredible asset that has great potential to save lives in the fi eld.

Google Glass – in addition to devices that sync with mobile phones, freestanding wearable technologies such as Google Glass are beginning to have a greater effect upon the way medicine is practised. Google Glass has been integrated into medical education and piloted in a busy Boston emergency department with great success.

The potential to use this technology successfully in disaster response is still being explored. As with mobile phones, Glass can use video conferencing to obtain triage and diagnostic support from remote healthcare providers and to document patient care as the patient eventually arrives at the hospital. Since they are ‘glasses,’ the person on the other end sees exactly what the user does and can guide them through procedures in the fi eld or en route to the hospital. Moreover, the Glass’s wearable design allows the user to keep both hands free to treat the patient and keeps the Glass from coming into contact with multiple surfaces like a phone or tablet would. Thus, Glass is a much more sanitary and easily applicable solution when performing procedures than other mobile devices.

Google Glass technology still remains in its infancy and is, at the time of publication, only available to Beta users. However, developers

have begun to create healthcare applications with potential disaster response uses. For example, the University of California (UCLA) has developed an application that allows Glass to perform instant, wireless diagnostic testing for a wide range of diseases including HIV, malaria, TB, and syphilis in as little as eight seconds using rapid diagnostic testing strip technology. While this technology may seem like more of a non-emergent diagnostic tool, it is possible that strips can be developed to test for chemical poisoning or exposure.

In addition to diagnostics, developers have created applications that enable users to treat patients. For instance, an application called CPRGLASS can guide rescuers through step-by-step CPR while contacting emergency medical services. Another complementary application

called AED4.US allows Glass users to locate the nearest Automatic External Defi brillator in the event that a patient undergoes cardiac arrest.

Trauma care & transportYou have successfully completed the initial triage. You have found that 15 patients are in critical care condition, requiring ICU level care, and one patient requires emergent surgery. The rest of the patients require only basic level fi rst aid care. In addition, volunteer staff on the ground need additional basic medical supplies and everyone needs more food and clean water.

The next step in the management of this situation depends on the scope of destruction caused by the disaster. If there is widespread damage, there may not be a hospital within a reasonable distance to which patients could be

Using Philips and Accenture’s proof-of-concept demonstration using a Google Glass head-mounted display, a physician could monitor a patient’s vital signs remotely or enlist assistance from doctors in other locations

Philips | Accenture

As medicine is always evolving, it is crucial for disaster medicine to apply technology not as an exception, but as a necessity

59 join the CRJ LinkedIn group follow us on twitter @editorialcrj Crisis Response Journal 10:1

airlifted. Even if a hospital is nearby, healthcare providers may not be able to bring patients there, as the site may still be too dangerous. Scenarios such as this are commonplace in the military, but could also involve situations such as a nuclear reactor meltdown.

Life Support for Trauma and Transport (LSTAT) – one of the biggest challenges in disaster medicine is the treatment of patients who require an intensive level of care. In the 1990s, the Defence Research Projects Agency sponsored a collaborative project between Northrop Grumman and the Walter Reed Army Institute of Research (WRAIR) to develop the LSTAT system. The current version, sold by Integrated Medical Systems (a Northrop Grumman company), is an all-in-one portable solution for trauma treatment. It features a ventilator with on-board oxygen delivery, fl uid/drug infusion, suction, defi brillator, blood chemistry analysis, patient physiologic monitoring, data logging with communications connectivity and power, and system data management. The system provides intensive care from the initial injury through transport to a high acuity medical centre with the potential to reduce morbidity and mortality.

ICU in a Can – the LSTAT system is quite useful for initial trauma care and transport, but patients in the fi eld may also require long-term ICU care. If local infrastructure has been destroyed, medical providers will need to build or import additional structures. To this end, a designer named Kukli Han has developed a ‘mobile hospital’ system based on the overwhelming success of the Mobile Army Surgical Hospital (MASH) systems. The hospital comes ‘packaged’ in a shipping crate-like structure that unfolds into a multi unit fi eld hospital equipped with examination rooms, inpatient hospital rooms, an x-ray facility, and even an operating room. Conveniently, the entire hospital can be moved by most common routes of transportation including ship, train, or helicopter, and can be customised with as many units as are needed to develop the capacity necessary for proper response. Currently, the project is still a concept but, if developed further, it has the potential to improve patient care greatly in these types of situations.

Drones – fi eld hospitals cannot function without suffi cient resources. Trucks and helicopters typically deliver medical supplies following disasters, but these methods prove problematic if the transportation infrastructure has been damaged. Furthermore, delivery by these methods can be incredibly slow and ineffi cient in large-scale disasters. A tailored approach to resource management may be far more effective in such situations.

Non-military use of drone technology is a recent phenomenon that has been used in various ways. In a disaster, drones could provide a portable and cost effective option for short distance use in life threatening situations and can enter dangerous situations without putting additional lives at risk. This could have huge implications for disaster response situations, particularly where traditional infrastructure has been destroyed.

Drones could be used to deliver medical supplies, food, lab tests, and other resources. Moreover, with new technology, they can be used to track heat signals to identify survivors, detect chemical levels, measure radiation, and survey the scenes for safety. As is the case with many of these technologies, drones are becoming less expensive to manufacture. In fact, engineers at Sheffi eld University in the UK have built a 3D-printed drone using roughly $9 (€6.70) worth of materials.

However, drones do have a major limitation – the amount of supplies that they are able to transport. For instance, the octocopter drones proposed for use by Amazon can only carry just over fi ve kilos of supplies.

To overcome this obstacle, companies like Matternet are trying to develop large-scale drone infrastructure that can meet the capacity needs of traditional delivery services. Matternet has already carried out test runs in Haiti and the Dominican Republic, and plans to set up a drone infrastructure in Lesotho. Andreas

Raptopoulos, CEO of Matternet, revealed in his TED talk that setting up a network in Lesotho, an area spanning 138km2, will cost $900,000. This money will allow the company to build 150 vehicles and 50 stations. Upon completion of the network, the cost for each drone to carry a two-kilo load over 10km will be nominal.

Ideas such as Matternet’s are based on the belief that one can use a large number of drones to deliver the same amount of supplies that a standard helicopter can transport, but with a more personalised and effi cient approach. Furthermore, the utility of these products will improve continuously as the weight-bearing capacity of drone technology continues to increase. Political views aside, drones have the potential to truly affect the allocation and management of resources during disaster response.

As state-of-the-art technology is widely adopted in many fi elds of medicine, the time has come to integrate such technologies into disaster medicine further. Innovative measures on how to apply easily accessible technology can lead not only to sophisticated and highly effi cient services that can enhance healthcare delivery, but may also further improve survival outcomes. As medicine is always evolving, it is crucial for disaster medicine to apply technology not as an exception, but as a necessity. GIS, mobiles, tablets, and other such devices are widely utilised in many medical specialities. Disaster medicine should be at the forefront of this utilisation as space and information technology is now so readily available that not applying it to healthcare services in a disaster situation is defi nitely a disadvantage to both healthcare providers and patients. CRJ

AuthorsBrent Dibble, MD, MBA; Nadia Elkarra, MD; Megan E Mantaro; and Ian Portelli, PhD, MSc (Member of CRJ’s Editorial Advisory Panel)

future technology

Dr David Feinstein, Assistant Professor of Anaesthesia at Harvard Medical School, tests out Google Glass before entering the Philips and Accenture OR simulator lab

Philips | Accenture

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RESILIENCEVisionary crisis leadership

EVOLUTIONFuture disaster medicine

SENTIENCECities empowering people

CRISIS | RESPONSE

WE ARE ENTERING our tenth volume of CRJ, which was

launched a decade ago. The nature of the publication means celebration is inappropriate; too many incidents have occurred over this time, too many lives lost. But it is, nonetheless, a gratifying milestone.

Our founding ethos still holds true: to bridge any institutional, organisational and national gaps, to share information, enhance partnership working and improve communication. It has been good to see how dialogue between various disciplines and organisations has evolved, as shown by the increasing diversity of actors and stakeholders who have become involved in the conversation through our pages.

Despite this, in many ways the world feels no safer. The Hydra of wicked problems sometimes appears invincible, the same incidents repeating themselves, locked in a dispiritingly familiar cycle. Each time we absorb the horror of a disaster or terrorist attack, a bigger, more destructive one seems to surpass it.

The risk landscape has shifted in a decade: climate change has been added to the list of threats, exacerbating existing hazards. But the response, resilience and emergency planning community has developed accordingly in terms of leadership acuity, interagency co-operation, mutual assistance and business continuity.

And it is fascinating to observe the proliferation of emerging technology – ten years ago we hadn’t heard of Twitter, YouTube, the Internet of Things, smart cities… Of course, these bring their own vulnerabilities and can be exploited to cause harm, but their potential for improving safety and resilience should not be overlooked.

So is with gratitude that we thank our sponsors, many of whom helped to launch CRJ ten years ago. Thanks also to our Editorial Advisory Panel – those who have been with us since the start and those who joined us along the way – and to the writers who have generously shared their thoughts, knowledge and experience. And an immense thank you to our subscribers.

To paraphrase Camus, most people are good rather than bad; it is usually ignorance that causes harm, despite good intentions. And this is why sharing experience and information is so vital: you are all working to eradicate ignorance and make the world a safer place.

It is a privilege to observe and report on this. Emily Hough

comment

@SyriaCivilDef Keryn van der Walt | National Sea Rescue Institute

Rescue in conditions of war p70 Bhopal 30 years on p81

contents Cover story: CRJ’s Tenth anniversary

Main artwork: Neil Webb Inset images: Eureka Entertainment | Shutterstock

A look at Johannesburg.................................46Is Johannesburg a world-class African city? Yes, and no, according to Hilary Phillips

A living laboratory.........................................50The campus of Lille University in Northern France has been turned into an experiment to demonstrate smart city concepts, write Isam Shahrour and his team

Future technologyEmpowering people ......................................52The day when cities become smarter than their citizens are approaching, according to Robert Ouellette

Spatial services ............................................55Dr Hervé Borrion says spatialised social networks might protect people and provide help in emergencies

Evolution of disaster medicine ......................56There is an increased imperative to develop and implement novel technologies to help medical professionals in disaster situations. Here’s a glimpse of the future

Emerging technologies .................................61J P Vielleux describes real-time innovations in disasters

Human-agent collectives ..............................62David Jones describes a project that looks at forming symbiotic relationships between increasingly independent computer systems and user communities

Unleashing the power of UAVs ......................64Glenn Smith joins the debate, exploring the positive potential of drones in emergency situations

Earth observation ......................................... 66The potential contribution of space-based information to disaster risk management is not being fully exploited, say Antje Hecheltjen and Anne Pustina

In depthBusiness excellence and new technology .....68Mike Hall says it is time to embrace the business benefi ts that emerging technology can bring

USAR in an active war zone ..........................70James Le Mesurier looks at how community responders in Syria are being trained in urban search and rescue

Beyond the resilience apex ...........................72Brett Lovegrove refl ects on how leaders need to think more differently today than ever before when approaching business resilience and continuity

Facing biological risk ....................................74Nicolae Steiner looks at the twin threats of biological attacks and of increasing bacterial resistance to antibiotics, and the prospect of an interaction between the two

Civil protection in Georgia ............................76The Republic of Georgia is the fi rst country to be profi led by this new series on the International Civil Defence Organisation and its members

RegularsEvents ...........................................................78EU response to Balkan floods .......................80Looking back: Bhopal ....................................81Frontline ........................................................82

3 Crisis Response Journal 10:1

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September 2014 | vol:10 | issue:1

Earth observation p66Search & Rescue in Iran p24

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CRJ’s Sponsoring Partners are leading specialists in the crisis, security and emergency response disciplines

contentsNews ...............................................................4News extra ......................................................8Comment ......................................................10Tony Moore takes a comprehensive look at the incidents that occurred in the year of CRJ’s launch – 2004

AnalysisCompulsive un-safety ...................................16Satish Kumar Dogra examines why safety limits are being stretched in India

‘Green’ rescue kit ..........................................19One of our sponsoring partners, Holmatro, introduces its latest rescue tools

Climate change and the Fire Service ............20Shan Raffel describes a co-ordinated approach to manage the effects of climate change on emergency response provision in Queensland, Australia

Resilience peer review .................................22Helen Braithwaite leads us through a journey of discovery into the world of resilience partnership peer review

NGOsSearch and rescue in Iran .............................24Emily Hough speaks to Behrouz Moghaddasi, Head of Iranian SAR, about how he has helped to establish volunteer teams across the country

Volunteer searchers ......................................26Rachel Good and Andy Marshall take a closer look at the work of the Staffordshire Search and Rescue team in the UK

New team helps after disasters ....................28Alois Hirschmugl describes a new European team formed to help citizens when they are stranded in large-scale emergencies abroad

Exercise Angel Thunder ................................30In May 2014, Rescue Global took part in Exercise Angel Thunder, the world’s largest interagency search and rescue exercise, writes David Jones

Terrorism & securityGender-based violence .................................32Lina Kolesnikova reports on an increasing trend whereby some militant organisations are using gender-based violence as a terrorist tactic

Mapping out terrorism in Pakistan ................34Pakistan is home to many more terrorist organisations than the Taliban, says Luavut Zahid

Chemical potential ........................................38The perceived threat from terrorists using chemical weapons had declined in recent years. Dave Sloggett questions whether that is still the case

Smart, resilient cities Propelling us into the future ..........................40Emily Hough speaks to Sir David King to fi nd out more about the Future Cities Catapult initiative in the UK

Building city resilience ..................................45Applications closed for the next candidate cities in the 100 Resilient Cities Challenge in September 2014, writes Emily Hough. Which cities will make it onto the list?

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