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Terrorism: Reducing Vulnerabilities and Improving Responses - U.S.-Russian Workshop Proceedings APPENDIX G Proposal for a Chem-Bio Attack Response Center (CBARC) for Chicago, Illinois, U.S., 2003 Russ Zajtchuk, M.D. Chicago Hospitals International Joe Petrovic InteleDatics, Inc. BACKGROUND Civilian and military trauma care systems in the United States need a support framework for managing chemical and biological (chem-bio) emergencies. The continuing proliferation of chemical and biological weapons throughout the world poses an increasing threat, as demonstrated by the 1995 sarin attacks in the Tokyo subway, which injured more than 5,000 people. To prepare for and defend against such threats, sophisticated sensor and emergency telemedicine networks must be extended in capability to support identification, containment, and emergency medical care if a chem-bio emergency occurs. This paper proposes a plan for the creation of a center in Chicago, Illinois, to develop response techniques and technologies for advanced trauma care of victims from chem-bio attacks that will support government and private medical groups and first responders. Tasks conducted under this center will involve collaboration between technical research and development companies and schools, and tertiary health care providers and their affiliated hospitals, clinics, and medical schools. OBJECTIVE The objective of this program is to establish a center for the development of advanced emergency medicine for application in response to a chem-bio attack. The center is configured as a virtual institute, including several organizations involved in the technical and clinical aspects of advanced emergency medicine and chem-bio environments. Functions performed by the center include information and research services and an advanced emergency medicine test bed to
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Terrorism: Reducing Vulnerabilities and Improving Responses - U.S.-Russian Workshop Proceedings gauge the technical effectiveness and clinical efficacy of advanced procedures and technologies. Near-term achievements involve a review and assessment of current telecommunication, medical informatics, and medical procedures as applied to chem-bio emergency medicine. Long-term goals include the development, testing, and deployment of advanced telecommunications, for example, high-bandwidth wireless system, sensors for identification of agents, medical informatics as applied to chem-bio emergencies and advanced trauma care, and chem-bio protection and isolation equipment. PARTICIPANTS The proposed approach for a nationwide (and global) program for improving emergency medical service for chem-bio incidents is to establish a Chem-Bio Attack Response Center (CBARC). This would be a virtual institute involving organizations specializing in advanced medicine, telecommunication technology, sensor technology, medical informatics, and chem-bio response procedures and equipment. To be compliant and integrate with the general area of advanced medicine, the CBARC must be embedded into a complete telemedicine architecture where all components of telecommunications and medical informatics are involved. The specific types of organizations to be included are tertiary health care providers affiliated urban hospitals and clinics, including primary care providers primary care emergency rooms medical schools and universities technical research and development companies local fire departments national guard units federal government (Department of Defense [DOD], National Institutes of Health [NIH], and so forth) FUNCTIONS CBARC will provide advanced emergency medical expertise, software development and engineering services, and equipment in the following categories: Information Services—These services are focused on the collection, analysis, processing, and dissemination of telecommunication and clinical data relevant to emergency telemedicine and medical informatics in a chem-bio environment. Information will include results of efficacy studies, telemedicine hardware configurations, chem-bio protection and isolation equipment, cost-benefit analysis, and other data compiled in databases that are available for access and search via the Internet.
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Terrorism: Reducing Vulnerabilities and Improving Responses - U.S.-Russian Workshop Proceedings Research Services—These services are focused on unbiased, highly technical research and engineering in applying existing technologies, emerging technologies, and basic research in the areas of chem-bio sensors and sensor networks, medical informatics, clinical techniques, clinical efficacy studies, chem-bio protection and isolation equipment, data formatting and compression, and telecommunications as applied to chem-bio emergency telemedicine. Chem-Bio Attack Response Test Bed—This function includes establishing a Chicago-area test bed for testing emergency medicine concepts using the large trauma center at Cook County Hospital to gather data, Rush-Presbyterian-St. Luke’s Medical Center to conduct efficacy studies, and InteleDatics, Inc., to provide technological solutions to emergency telemedicine problems. IMPLEMENTATION The specific organizations proposed for CBARC are all located close together in Chicago, Illinois, and include Rush-Presbyterian-St. Luke’s Medical Center (RUSH) Cook County Hospital Emergency Services (CCH) InteleDatics, Inc. (IDI) Chicago Fire Department (CFD) University of Illinois at Chicago (UIC) These organizations provide the expertise to develop and operate CBARC and have already established working relationships through present and past programs and contracts with industry and government. Rush-Presbyterian-St. Luke’s Medical Center is a tertiary care provider. It is the central component of the Rush System for Health, a comprehensive, cooperative health delivery system designed to serve 1.5 million people in northern Illinois and Indiana through its own resources and in affiliation with seven other Illinois hospitals. The Rush System for Health is vertically integrated, with an academic health center (Rush-Presbyterian-St. Luke’s Medical Center, Johnston R. Bowman Health Center for the Elderly, and Rush University), a teaching hospital, community hospitals, and managed care offices that serve Chicago-area communities of diverse socioeconomic and cultural backgrounds. A major component of RUSH comprises a system of 49 advanced life support ambulances covering 240 sq mi. These ambulances relate to five level-1 trauma units. Cook County Hospital, which has an academic affiliation with RUSH, is centrally located within the city and is close to Rush Medical Center. It is a world-renowned academic medical center that has one of the world’s largest and busiest emergency departments. More than 120,000 adults, 45,000 children, and 4,500 major trauma patients are treated per year. CCH would be the primary trauma center for victims of a terrorist attack in the Chicago area, and its emer-
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Terrorism: Reducing Vulnerabilities and Improving Responses - U.S.-Russian Workshop Proceedings gency physicians are acquainted with treatment procedures for people exposed to chemical and biological agents. InteleDatics, Inc., is a small business providing high-technology consulting that helps hospitals and physicians project their expertise to distant locations and creates innovative devices and software applications that extend the forefront of medical specialties. The current staff of IDI has many years of experience from previous employment at research institutes, technical schools, and medical-related companies. This staff brings cutting-edge technology in the areas of telecommunication systems, integrated wireless sensor networks, and medical informatics. The Chicago Fire Department will be one of the first units to respond (first responder) to a chem-bio attack. It is the largest fire department in the Midwest, serving a population of 3 million, with response procedures for hazardous materials and emergency medical services, including those for a chem-bio attack. The CFD would notify the Illinois National Guard of a possible emergency and would be the primary city service directly in contact with the victims. The primary support to the local first responder will be the Illinois National Guard RAID (Rapid Assessment and Initial Detection) element. The RAID element will have the principal role in assisting the incident commander, for example, the fire chief, in providing early assessment, initial detection, and technical advice in response to a weapons of mass destruction (WMD) incident. Local response to an emergency may not be enough, and the incident commander may request state or regional assets through the State Office of Emergency Services. The RAID element is the military first responder with the goal of a four-hour response time. The RAID element will also have the necessary equipment for a large WMD incident with the capability to conduct reconnaissance; provide medical advice and assistance; perform detection, assessment, and hazard prediction; and provide technical advice concerning WMD incidents and agents. The University of Illinois at Chicago is the largest institution of higher education in the Chicago area, is one of the top 100 research universities in the United States, and is dedicated to the land-grant university tradition of research, teaching, and public service. It has 13 academic colleges and professional schools and offers 92 undergraduate, 85 master’s, and 55 doctoral programs in architecture, art, associated health professions, business administration, dentistry, education, engineering, humanities, kinesiology, mathematics, medicine, nursing, performing arts, pharmacy, public administration, public health, sciences, social sciences, social work, and urban planning. UIC has an enrollment of 25,000 students, including more than 8,000 graduate and professional students. It has an excellent engineering school and a state-of-the-art Microfabrication Applications Laboratory for support of CBARC science, technology, and engineering tasks. The proposed program plan is based on the use of a networked health care test bed involving representative components of the entire telemedicine and chem-bio environment. This test bed allows for testing of maturing telemedicine
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Terrorism: Reducing Vulnerabilities and Improving Responses - U.S.-Russian Workshop Proceedings systems, techniques, and procedures in a civilian application. The chem-bio Attack Response Test Bed (CBART) includes a network of community hospitals affiliated with a tertiary care institution and a mobile paramedic system and first responder unit linked to a level-1 trauma unit. In this environment, physicians caring for victims of a chem-bio attack can transmit information and communicate with physicians in a tertiary care hospital without being exposed to chemical or biological agents. The test bed provides a stable and controlled link between all components. The network of hospitals is widely dispersed throughout the urban and rural areas and can be linked through either wired or wireless communication networks. Following is a typical configuration for a chem-bio environment. A terrorist attack occurs in the subway system and the first responders (local fire department and National Guard RAID teams) start to evacuate the victims. The victims are provided with special equipment that will isolate them and contain the chembio agents as they are taken to a nearby transfer zone. In the transfer zone the isolation gear is decontaminated, which allows for the contaminated victims to be placed in clean vehicles (ambulances and helicopters) for transfer to local hospital emergency rooms or a designated, contained treatment facility. The Chicago CBARC will allow for the development of equipment and procedures involved in all elements of the chem-bio scenario. In an actual attack, several such sectors will exist for rescuing victims and safely transferring them to medical emergency rooms without exposing the clinical staff to the chem-bio agents. Using the CBARC sector as a test bed (CBART) will allow for the development of advanced chem-bio response techniques and technologies that can be transferred and applied to other locations throughout the world in addition to the system assembled for use in Chicago—one of the top three target areas identified in the United States. TECHNICAL APPROACH Technical Areas Information Center There is a need to establish a Chem-Bio Attack Response Information Center (CBARIC) for the purpose of collecting, analyzing, synthesizing, and disseminating worldwide scientific and technical information on emergency telemedicine, medical informatics, and medical response procedures for chem-bio attacks. The CBARIC would be a mechanism to prevent duplication in studies, enhance the effectiveness of current studies, and centralize information for use in studies and for distribution. Also, such a center would work to promote and oversee standardization of equipment and techniques. IDI’s extensive experience with DOD Information Analysis Centers (IACs) will be applied directly, which will eliminate start-up labor costs. The CBARIC will leverage off IAC information technology developments, provide a reposito-
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Terrorism: Reducing Vulnerabilities and Improving Responses - U.S.-Russian Workshop Proceedings ry for data, and develop standards for chem-bio telemedicine for the community. The latest information retrieval techniques will be used to allow users to search massive text databases and retrieve relevant information. Wireless Sensor Networks The use of sensors in an emergency telemedicine environment and their interface to telecommunication systems are a required element of advanced trauma care. Sensors may be used for monitoring critical patients and for monitoring casualties in the field at all times. Networks of sensors will need to be deployed soon for chem-bio defense and will need to be assembled in civilian and military areas where there is a potential threat, such as subway stations, airports, office buildings, and convention centers. These sensor networks will transmit alarms following the detection of a chem-bio agent and will need to be networked into an emergency telemedicine infrastructure in order to disseminate this information to appropriate emergency response authorities and trauma centers. The design of a telecommunication infrastructure will need to consider the integration of sensor networks into that infrastructure in order to enhance the current emergency telemedicine environment with new technologies and capabilities. Telecommunications A telecommunications infrastructure must be established for use in emergency telemedicine. Rural, disaster, and terrorist-invoked emergency telemedicine will require systems that use mobile satellite and cellular telecommunications for video, voice, and telemetry data transmission from an emergency site or vehicle to a trauma center. Telemetry systems need to be designed for various emergency instrumentation that does analog-to-digital (A/D) conversion and uses telecommunications to transfer vital signs data from a forward emergency area and during transit. Also, video, voice, and data need to be transferred from emergency room personnel to a forward-area vehicle or site. The forward-area vehicle would provide the long-range telecommunications link to a trauma center. Chem-bio emergencies will require satellite, cellular, and other wireless technologies to provide links to an emergency area and to communicate with sensor networks that monitor an area for agents. A primary source of telecommunications technology that will be used in this subtask is the Fly-Away Package (FAP). Various sections of the FAP relate directly to the communications need for mobile emergency telemedicine communications. The overall objective in conducting the FAP task is to experimentally verify the ability to assemble a full-service communications system that can support requirements in remote as well as developed areas. This support includes the proper transfer of data for successful operation from the point of view of total situation awareness and information dominance. Achievement of these objectives calls for a
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Terrorism: Reducing Vulnerabilities and Improving Responses - U.S.-Russian Workshop Proceedings communications system having multiple voice channels, video conferencing, and high data rate transfers. Seamless connections to private telephone networks, mail systems, commercial telephone systems, various dial-up services, and the Internet are the required service goals in the design of the system. To increase the amount of information transmitted over telecommunications channels, data must be formatted and compressed. In a military environment, the communication bandwidth (bandwidth here denotes transmission capacity rather than the width of a frequency band) necessary for the timely, secure, and reliable transport of information is scarce. In a civilian environment, high communication bandwidth for mobile wireless communication is relatively expensive in equipment cost and service rates. Thus, to bring tangible improvements in battlefield and civilian medical care, telemedicine information services must be carefully designed and deployed. It is important to prioritize these services and to design them to operate flexibly and degrade gracefully so that telemedicine operations can adapt to constraints imposed by the dynamic environments. Since telemedicine services are based on the processing, transmission, storage, and retrieval of information (signals, digital data), it is essential to represent and organize the information efficiently and flexibly. To enable the delivery of the best grade of telemedicine services, the information must be represented (coded) to furnish various properties such as compactness, error tolerance, non-decipherability, scalability, modularity, extensibility, and openness. Many of these properties are essential to any open-architecture system. A compact representation conserves transmission bandwidth and can be achieved via compression or source coding. An error-tolerant representation can be achieved by means of channel coding; privacy of data, using public key encryption; integrity of data, using message digest calculation; and authentication, via digital signatures. Current clinical information systems are mostly text based, with image and other signal data relegated to separate archives, for example, Medical Diagnostic Image Support System, or MDIS. The plethora of proprietary clinical information systems presents a major obstacle to inter-networking. To aid the trend of harmonizing diverse systems through the implementation of common interchange formats, for example, Digital Imaging and Communication in Medicine (DICOM), and protocols, focus will be placed on developing and applying coding algorithms that are based on standards that are or are likely to be widely accepted. Most coding standards do not specify exactly how to encode a given type of source signal. These standards can be regarded as “toolboxes” or as precisely defined languages that can be used to tackle a range of applications. For a specific application, there is usually substantial latitude allowed for designing and optimizing a coder algorithm conforming to the standard. Thus, considerable effort must be devoted to designing, applying, assessing, optimizing, and extending or enhancing standard-based coding algorithms, for example, JPEG, H.261, H.263, MPEG, and JBIG, to compress radiological images and image sequences.
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Terrorism: Reducing Vulnerabilities and Improving Responses - U.S.-Russian Workshop Proceedings Medical Informatics To enhance the quality and timeliness of emergency care via telemedicine, information required for emergency care will need to be provided to the caregiver from historical records and from real-time data about the trauma victim. Data sent over telecommunications channels may be (1) near-real-time data gathered in the field that must be received by the trauma center and stored in the appropriate databases associated with the patient, (2) patient history data sent from the trauma center to the field, and (3) voice and video feeds between the remote site and trauma center. These data modalities will require software interfaces between existing databases and the telemedicine system, data transmitted to be secure, and new databases to be built for telemedicine session information. The current state of storing patient information falls short of a single unified patient record. A number of systems are working toward unifying information that is scattered across many databases. The Defense Advanced Research Projects Agency (DARPA) has funded programs to address unifying a patient record. These systems had to devise their own formats for specific systems, such as the Trauma Care Information Management System (TCIMS). Those working on other government thrust areas, such as the Expert Tertiary Care Host, are attempting to deploy systems to project medical expertise forward to the battlefield. To enhance emergency medicine, a Computerized Patient Medical Record System (CPR) must be used. The system should be able to work over a hospital intranet and possibly the Internet and preferably have a browser-based user interface. The emergency telemedicine user interface must be able to handle multimedia formats for video, voice, and data. It must interface with the patient medical record, various disparate hospital databases, and the live link to the field and bring all these sources of information together in a clear priority-oriented format that is easily interpreted by the emergency room physician and other personnel. Also, the paramedics in the field will need a user interface that will provide multimedia capability to display information sent from the hospital to the field. This may include patient record information, images, and video of the emergency room physician. If a communication or hardware problem occurs, these user interfaces must be easy to use, control, and start. The patient record will also be stored on a Personal Information Carrier (PIC) that will be on the patient at all times. This device will hold the patient medical record, including images, lab tests, and audio up to 80 MB on a dog tag-like device that can be worn on a chain around the neck or on the wrist or carried with the patient on a key chain. The device, called a Medi-Tag, will interface with the CPR system, and patient record data will be able to be downloaded onto the storage device or uploaded into the CPR. The Medi-Tag is a rugged, durable, and hermetically sealed device that can withstand shocks, tolerate extreme temperatures, and be sealed against water, fuels, and other harmful fluids. It is also resistant to wind-
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Terrorism: Reducing Vulnerabilities and Improving Responses - U.S.-Russian Workshop Proceedings driven dust and sand and is not affected by saltwater, rain, or ice, making it an ideal device for use in a emergency situation anywhere in the world. For disaster-related emergencies, including a chem-bio attack, an information infrastructure must be in place to disseminate and update information about the emergency. Emergency information must flow from a disaster site via a telemedicine network for treatment purposes and to disseminate alerts and emergency information via a networked infrastructure. Network Surveillance for Chem-Bio Attack The first priority in defense against weapons of mass destruction is the early detection of mass exposure. Whether the agents used are chemical or biological, there is currently no reliable method for early detection of victims with unsuspected agent exposure. One of the most fearsome events is occult attack, where victims who become contaminated at a scene do not exhibit symptoms until much later. They may be widely dispersed geographically by the time they feel sick. This is usually from exposure to a biological agent. The protection of the populace will require more than sensor use. This is especially true for a silent, unsuspected biological agent exposure. Because most biological agents have initially mild or subclinical symptoms accompanied by their communicability, the threat is devastating. The subsequent crippling of urban infrastructures, for example, hospitals, in this type of event is easily possible, resulting in marked limitations in the ability to provide health care to the populace. In addition to detection by environmental sensors, another key protective mechanism that should be in place is the detection of exposure victims as they present to local area emergency departments. Unfortunately, current surveillance systems of population diseases have not kept pace with present-day information technology. Monitoring of these occurrences is done in a retrospective fashion. Even infectious disease surveillance of reportable conditions is limited to phone, fax, or mail communication from treating physicians to local public health departments. It is also dependent on recognition of the disease by the treating physician, which may be limited when considering rare, unfamiliar diseases such as anthrax or botulism. Processing and review of health surveillance information in this fashion offer no potential for rapid early detection and intervention if there is mass exposure to a biological or chemical agent with delayed symptoms. A surveillance network capable of real-time detection of disease patterns suggesting unrecognized exposure to chemical or biological agents would address all these threats. The victims of exposure to biological agents with delayed effects frequently suffer symptoms that are first mistaken for unusual variants of such common diseases as influenza. Even when there are many patients in a geographic area, each health care worker in area emergency departments may see only one or two. Current detection of a mass exposure depends on an alert
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Terrorism: Reducing Vulnerabilities and Improving Responses - U.S.-Russian Workshop Proceedings health care worker noticing an unusual but small increase in suspicious cases. Nobody will suspect a common exposure until a cluster of similar cases is noticed. To avoid losing valuable time, a real-time Internet-based surveillance system is proposed. This system will create a single database linking the clinical details of patients from the many hospital emergency departments of a geographic region. By combining the simultaneous experience of many health care providers, this system will be capable of rapidly detecting significant but small increases in patients treated for medical problems consistent with biological or chemical weapons exposure in a defined geographic area. ATLS-Compatible Chem-Bio Protection and Isolation Equipment Equipment must be designed and created that can be used for evacuation of chemically and biologically contaminated victims and provide isolation of victims and allow for trauma care to be administered. Some of the equipment must be able to provide for full ATLS (Advanced Trauma and Life Support) intervention while maintaining isolation of the victim. Equipment must be designed for mass casualties that can be used under severe environmental conditions of extreme hot, cold, dry, humid, and rainy conditions. Internet-Based Training Course One of the cornerstones of domestic preparedness against an attack by weapons of mass destruction will be coordinated, well-trained emergency response teams and hospital personnel. Although the U.S. Domestic Preparedness Program provides for low-cost training packages via CD-ROM and other inexpensive media, there exists no comprehensive, customized web-based program for use by first responders and medical staff. The current instructional process is accomplished using traditional teaching models such as lectures, slides, and video. This type of training has several limitations. First, there is rapid decay in knowledge on subjects rarely encountered, such as a nuclear, chemical, and biological weapon attack. Second, the multitude of possible agents and the enormous volume of information mean that most students will not absorb all the material on the first exposure. Third, there is an inherent difficulty in standardizing this type of presentation, since there are multiple trainers, each with a different background, experience, and style. There is also the difficulty and expense in meeting the need for mass training and periodic retraining. Last, updating traditional materials based on new knowledge or a detected weakness is expensive. The design of a web-based, comprehensive interactive training program in nuclear, chemical, and biological weapons will address the problems given above. The features of this training program are as follows:
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Terrorism: Reducing Vulnerabilities and Improving Responses - U.S.-Russian Workshop Proceedings The web-based format will allow students to retake part or all of the course at will without increasing costs. The multimedia interactive environment will engage student interest and increase active participation, leading to better learning. The variability in course presentation because of multiple instructors is reduced to nil. Anyone can take the course at any time. This relieves pressure on rescue and hospital departments who must release personnel simultaneously for traditional course presentation. This ensures that all target trainees can receive instruction without disrupting important department functions. Computer-based teaching materials are more easily and cheaply updated. In the traditional model, testing follows instruction. This mutes the learning advantage that can be received when immediate feedback is given for wrong answers. The student is no longer vested in the topic by the time a failing grade is returned. A second chance to reassess and correct deficiencies may be long delayed until the next course is offered in the geographic area. The proposed course will immediately recycle students through topics where they are weak to ensure the best trained personnel possible.
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Representative terms from entire chapter: