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TECHNICAL REPORT

MASs-casualties and Health-care following the release of toxic chemicals or radioactive materials

Report on recent ICT advancement applicable to mass emergencies

Elaborated

Date: May 2010

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1 GLOSSARY AAP Assistance Action Plan AES Advanced Encryption Standard AFH Adaptive Frequency Hoping APCI Atmospheric Pressure Chemical Ionisation ARP Address Resolution Protocol CBRN Chemical, Biological, Radiological and Nuclear CDSS Clinical Decision Support System CDU Control Display Unit CSMA-CA Carrier Sense Multiple Access with Collision Avoidance CWA Chemical Warfare Agent DAN Disaster Aid Network DHCP Dynamic Host Configuration Protocol DIR Dispersive InfraRed DNS Domain Name System DZ Danger Zone ECG Electrocardiogram ECDC European Center for Disease prevention and Control ED Emergency Department EEA European Environment Agency EFSA European Food Safety Authority EHE Environmental Health Emergencies EMC Emergency Medical Chief EMCDDA European Monitoring Center for Drug and Drug Addiction EMEA European Medicines Evaluation Agency EMS Emergency Medical Services EMT Emergency Medical Technician ENP European Neighbourhood Policy EPCIP European Programme for Critical Infrastructure Protection ETSI European Telecommunications Standards Institute EWRS Early Warning and Response System FAO Food and Agriculture Organization FAT Field assistance Team FPD Flame Photometry Detection FRT Field Response Team FTIR Fourier Transform InfraRed Spectrometry GPS Global Positioning System GUI Graphical User Interface HAZMAT Hazardous Materials HCC Hospital Communication Center IAEA International Atomic Energy Agency IASC Inter-Agency Standing Committee

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ICT Information and Communication Technologies IDT InterDigital Transducer IDZ Injured Deposition Zone IEC Incident and Emergency Center IEEE Institute of Electrical and Electronics Engineers IMS Ionic Mobility Spectrometry ITER International Thermonuclear Experimental Reactor ITT Intelligent Triage Tag JAT Joint Assistance Team LAN Local Area Network LED Light-Emitting Diode LCD Liquid Crystal Display MAC Media Access Control MANV Massenanfall von Verletzten MBQ MegaBecquerel MCE Mass Casualty Event MCI Mass Casualty Incident NAC National Assistance Capabilities NATO North Atlantic Treaty Organization NDIR Non Dispersive InfraRed NWP National Warning Point OOC On-site Organization Chief PDA Personal Digital Assistant PID PhotoIonization Detection PPB Parts per billion PPM Parts per million RDU Remote Display Unit RFID Radio Frequency Identification RIP Reactant Ion Peak RNWG Radio Nuclear Working Group RSSI Received Signal Strength Indicator SARS Severe Acute Respiratory Syndrome SAW Surface Acoustic Wave SNR Signal to Noise Ratio SSID Service Set Identifier START Simple Triage And Rapid Treatment TCP/IP Transmission Control Protocol/Internet Protocol TDRU Tracking Data Relay Unit TIC Toxic Industrial Compound TIM Toxic Industrial Material TRZ Transport Zone TZ Treatment Zone UDP User Datagram Protocol USB Universal Serial Bus USD United States Dollar

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UWB Ultra Wideband WAN Wide Area Network WHO World Health Organization WMD Weapons of Mass Destruction WPAN Wireless Personal Area Network WSN Wireless Sensor Network

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2 TABLE OF CONTENTS

1 Glossary .......................................................................................... 3

2 Table of contents ........................................................................... 7

3 Table of Figures ............................................................................. 9

4 Introduction / Background .......................................................... 11

5 ICT in crisis response .................................................................. 17

5.1 The role of IT .................................................................................. 17 5.2 Difference between ED and EMS levels of IT use .......................... 19 5.3 Communication tools more important than information tools .......... 19 5.4 Extraction of Information depends on individuals ............................ 20 5.5 ICT is equal to IT+CT? ................................................................... 21 5.6 Design Requirements ..................................................................... 22 5.7 Conclusions .................................................................................... 23

6 Communication systems ............................................................ 24

6.1 Victim identification ......................................................................... 24 6.2 Triage systems ............................................................................... 25 6.3 Triage tags ..................................................................................... 25 6.4 Disaster Aid Network ...................................................................... 30 6.5 MAETTS ......................................................................................... 36 6.6 WIISARD ........................................................................................ 46 6.7 Wista .............................................................................................. 54 6.8 Codeblue: Wireless Sensors for Medical Care................................ 68 6.9 The ISCRAM Community ............................................................... 79

7 Information management ............................................................ 85

7.1 Radiation Emergency Medical Preparedness and Assistance Network (REMPAN)..................................................................................... 85 7.2 Response Assistance Network (RANET) ........................................ 87 7.3 EU Health security committee ......................................................... 94

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8 Research ..................................................................................... 102

8.1 Second generation locator for urban search and rescue operations (SGL FOR USAR) ..................................................................................... 102 8.2 Seamless communication for crisis management (SECRICOM)... 104 8.3 The Integrated Mobile Security Kit (IMSK) .................................... 107 8.4 EUropean software defined radio for wireless in joint security operations (EULER) .................................................................................. 109 8.5 Network of Testing Facilities for CBRNE detection equipment (CREATIF)................................................................................................. 111 8.6 Identifying the needs of medical first responder in disasters (NMFRDISASTER) .................................................................................... 113 8.7 Common operational picture exploitation (COPE) ........................ 115 8.8 Developing a crisis Communication Scorecard (CrisComScore) .. 116 8.9 Real-time On-line DecisiOn Support (Rodos) ............................... 118

9 References .................................................................................. 123

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3 TABLE OF FIGURES

Figure 1 – Patient flow at the disaster site ........................................................................ 31

Figure 2 – OCC drawing manual map .............................................................................. 32

Figure 3 – Disaster Aid Network architecture ................................................................... 33

Figure 4 – Mobile Agent Electronic Triage System .......................................................... 38

Figure 5 – Calmesh wireless networking node ................................................................. 47

Figure 6 – WIISARD architecture ..................................................................................... 48

Figure 7 – Intelligent Triage Tag (ITT) .............................................................................. 49

Figure 8 – WIISARD iMOX device .................................................................................... 50

Figure 9 – WFR screen ..................................................................................................... 51

Figure 10 – Command Center system .............................................................................. 53

Figure 11 – WISTA system architecture ........................................................................... 56

Figure 12 – Software architecture at control center ......................................................... 59

Figure 13 – Software architecture at local server ............................................................. 60

Figure 14 – Text patient information on PDA ................................................................... 62

Figure 15 – Layered structure ........................................................................................... 64

Figure 16 – Real-time patient information is shared between responders at the disaster

scene, hospitals and ambulances ..................................................................................... 69

Figure 17 – USB receiver is used to communicate with the miTags. Patient monitoring

software sorts patients by triage priority, displays real-time vital sign trends, and

processes patient data for alerts. ...................................................................................... 70

Figure 18 – The miTag supports a variety of sensor add-ons. ........................................ 71

Figure 19 – Server hosts information to the web, and is accessible from the web

browsers of both handheld devices and computers. ........................................................ 75

Figure 20 – Example of two teams: Team A using miTags and Team B using traditional

tools. .................................................................................................................................. 78

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Figure 21 – Outline of the RANET concept ...................................................................... 89

Figure 22 - The concept of an Assistance Mission ........................................................... 91

Figure 23 – The concept of the Joint Assistance Team ................................................... 92

Figure 24 – RODOS system ........................................................................................... 121

Figure 25 – RODOS centre............................................................................................. 121

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4 INTRODUCTION / BACKGROUND

Mass emergencies involving toxic chemicals and harmful radiological material will impose an overwhelming burden on the health care system. The MASH project deals with the early phases of this care-taking process. The general objective of MASH is to substantially improve today’s over-all capacity to deal with (i.e. register and document, prioritize, communicate about, decontaminate, treat, transport, trace and receive at the hospital) intoxicated and/or contaminated patients.

Together with representatives of the EU 27, MASH will elaborate and define generic scenarios of mass emergencies following the exposure to toxic chemical and to dangerous radioactive material. These generic scenarios will thereafter become the common basis for discussions of preparedness planning throughout the project. MASH will survey the preparedness planning of the member states and through discussions with representatives for the EU 27 contribute to define today’s best practice models to be used for generic preparedness planning. In addition MASH will perform a foresight study considering in which today’s shortcomings will challenged by edge technologies from biotechnology and ICT. Following discussions with the EU 27 this forecast will lay the ground suggestions of tomorrow’s improvements to the generic preparedness planning models.

The long-term objectives of MASH is to mitigate the impact of mass emergencies on the health care system by contributing to an improved generic preparedness planning for medical situations involving mass emergencies and requiring rapid interventions.

MASH concerns the early, pre-hospital, phases of medical treatment following severe accidents or acts of terrorism which involve toxic chemicals and/or radioactive material. It adheres to the idea expressed by the European Commission, COM(2005) that generic preparedness planning and interoperability are key elements in mitigating the impact of mass emergencies.

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The procedure of prioritizing, treating, documenting, communicating, tracing, transportation and receipt of patients at the hospital in a mass emergency involving toxic chemicals and harmful radiological material will be overwhelming to the local health care system. The objective of MASH is to contribute by improving today’s competence and capability to deal with exposed patients. This will be achieved using methods as scenario-derived discussions, surveys, interviews, reviews, systems analysis, forecasting and critical seminars.

Chemicals, that produce harmful effects on people, can spread over a large area after an accident of railroads or other kind of accident as well as after a chemical attack by terrorists. Effective management systems are needed to take care of the patients.

Mass emergencies involving toxic chemicals and harmful radiological material are likely to cause an overwhelming burden on pre-hospital care systems. This project deals with the early phases of care-taking process. Scenarios describing medical emergencies following the release of chemical or radiological agents are an important part for successful handling of such an event.

Mass emergencies due to toxic chemicals or radioactive materials are complicated since exposures can result in effects which are not immediately obvious in the traditional triage and evaluation of patients immediately following the incident. Management of the incident scene and how victims will be taken care of varies in different countries throughout the world and is based more on dogmas than scientific data. The final outcome making early diagnostic assessments difficult due to symptoms correlation with exposures are not obvious. People acutely affected from toxic exposures or from radiation need early medical interventions and at the same time, decontamination of patients if relevant should be performed early in the response efforts, preferably on the scene, to prevent spreading of contamination in surrounding areas, transportation vehicles, and health care facilities. A large number of persons whether seriously affected or not will be seeking medical attention out of fear and anxiety, thus the local health system will be overwhelmed by numerous patients demanding attention. In the Tokyo incident involving the release of the nerve agent sarin into the underground, an estimated 688 of more than 4000 of

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the patients were transported by ambulance or first responders, the rest were self-evacuated, seeking care.

Insufficient research has been conducted in addressing issues on management of mass casualty incidents, especially those involving chemical agents or radiological material. It can even be argued if the term “mass casualty” has been properly defined. Mass casualty accidents require different approaches than those used in routine emergency response. A large number of affected persons present many logistical problems for both triage and decontamination, many of which impact and overlap the work required for each category of personnel.

For triage, a reliable scheme for categorizing patients according to urgency and type of care is required. However, no gold standard for mass casualty triage scheme is available to date. In fact, under normal circumstances, triage decisions are estimated to be only about 80% accurate. There are no consensus triage systems today that include evaluation of CR-effects.

According to the data and information issue the automatic interpretation of sensor readings in the context in which they are obtained would considerably benefit the operator trying to make sense of the situation. If a human is interpreting a raw data, soon this becomes overwhelmed and a computer-based algorithm which can assimilate data and context would be of significant assistance to the user. The tempo of interpretation is an important factor in situational assessment. In addition, data and information can have significantly different periods of validity, can arrive at irregular intervals or even in a non chronological order and any interpretation of such data has to be sensitive to these issues.

In the first instance, the most obvious challenge is to develop improvements in temporal and spatial fusion of data and information in order to present the maximum amount of useful information to a variety of users. Further to this, reconfigurable sensor systems, can take account of the currently assessed situation and can autonomously react in order to gather data in the optimal manner to provide an optimal situation.

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Specifically to CRN detection, how can the lessons learned over many years of experience from domain experts and knowledge archives be applied to improve future CRN detection systems? The first stage is articulating and recording available knowledge from each source; once this is done, rationalizing the formal and informally stored knowledge in all these islands of excellence would greatly assist a robust and unified approach. An additional factor would be the normalization of individual existing knowledge repositories or expert-elicited knowledge. The progression of data and information processing techniques should provide additional benefit decision makers at all stages of a CBRN response. Many, if not all, of the points raised are applicable to biological and even explosive detection.

Computer based decision-making is well suited to low cost decisions such as re-configuring a sensor array. Other, higher risk decisions are more appropriate to decision-aiding, where the computerized process might assist the user by presenting the decision options with their associated utility and the information which is required for making the decision but where the human decision maker makes the final choice. The decision taken may well depend on factors which are external to the process of assessing the situation. For instance, the tempo of the situation may influence the decision; a rapidly deteriorating situation might force more extreme options to be considered more readily in order to stem the tide of the event, in this same situation, reconfiguring a sensor array to obtain more (or more accurate) data might be an undesirable decision as the situation degrades further. This last scenario poses the question ‘how much information is enough to make an adequate (but perhaps sub-optimal) decision?’ which has been considered in much research on the subject. Decisions lead to actions. An action, taken in an operating environment will probably affect the situation, which will have to be re-assessed in the light of the changed state. For instance, as people are evacuated the ‘number of people affected’ parameter in any model will change, thus changing its output.

In any CRN detection system, the integration of an essentially passive output and an active detection system would require theoretical research and validation in the field to optimize its efficiency.

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The needs for different actors, such as fire fighters, special units medical support units etc, in different situations are summarized. The primary need for the fire fighters or rescue operators is warning in order to take necessary actions for their own protection and monitoring and area survey capability in order to decide for a possible evacuation. One must remember that in most cases it is not obvious at the turnout situation what has happened and what the hazards could be. If there is a known threat of a release of some kind and there are no other suitable Units available, the task might fall on the rescue operators to detect and warn for it and hence an early warning capability would be desirable.

Contamination control is a delicate thing to do and requires skill, suitable equipment and it takes time. Therefore this should be avoided. In for instance a mass casualty situation, where most of the persons are expected to be contaminated no time should be spend on finding out if there are some that do not need to be decontaminated. The limited resources are most likely better used if all are decontaminated, even if there are a few that do not need it.

Rescue operations and other operations by Special units: the tasks and therefore the needs for special units could be considered as extended from the fire fighters or rescue operators. If there are special units available they will have the task to arrange systems for early warning.

Rescue operations Medical units: in the field all detection tasks will be performed by either fire fighters or, if available, special units. All casualties that have passed through the system of evacuation, decontamination/triage etc, should be possible to handle by the medical personnel. A small fraction of possibly contaminated persons might arrive at hospitals on their own and hence there is a need for a decontamination capacity in connection to the entrance of the emergency ward. Depending on the procedures, there is a need for confirmation of absence of contamination before letting people into the emergency ward.

This project is set up to improve the knowledge around mass casualties’ management system and health care after an incident with chemical agents and

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radioactive substances. Particularly this part of the project (WP8) will describe how Information and Communications Technologies are responding to such scenarios and will give some suggestions for the future.

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5 ICT IN CRISIS RESPONSE

Information and communication technologies (ICTs) play a vital role in coordinating crisis response between pre-hospital services and emergency departments of hospitals. In spite of the advances in these technologies, there remain a variety of challenges to their usage during a crisis. To identify these challenges, the College of Information Sciences and Technology of the Penn State University and the Department of Emergency Medicine of the Hershey Medical Center conducted in 2008 focus group interviews with emergency department (ED) and emergency medical services (EMS) personnel [1]. They found that ED and EMS personnel have widely varying perceptions about the usefulness and ease-of-use of information tools and communication tools used in crisis management. They discuss the importance of bringing together communication and information tools into integrated networks of ICTs for effective crisis response and they highlighted design features of ICTs which can support seamless and effective communication and coordination between ED and EMS teams.

Some of the conclusions are brought to this report in order to give a glance of the perception of those agents.

5.1 THE ROLE OF IT

Physicians were not sure exactly what role IT would play during a mass casualty incident. One physician said “My prediction, and it’s purely conjecture on my part, is that IT will go right out the door the moment this happens”. We found residents, given their lack of experience with crisis management, to be particularly unsure about the role of existing computer-based systems in the event of a crisis. When a resident answered our question as to what role their electronic medical records (EMR) would play in the given scenario, other residents asked him “but how do you know that, in a disaster situation, do they still use computers?” When asked whether they would use electronic records for admission during a mass casualty incident, one resident admitted “We don’t know for sure”.

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Under normal operation of the ED, every patient’s information is entered into the EMR at triage. However, physicians felt that if there were a deluge of patients over a short amount of time, they would go “low-tech” and switch to paper-based mode of operation. Only after the crisis was over would they transfer the information collected on paper to the EMR system. Given a large number of patients coming into the ED rapidly, a resident said, “Once patients come in they will be assigned a number and that’s how you would take care of them until someone from registration will come around, get their name, and then get it into a computer.” Thus, in an emergency, verbal communication of care-related information would take precedence over entering information into the computer. Thus, the computer system would be relegated to a mere record-keeping tool as opposed to a tool actively used to manage the mass casualty incident.

Both ED and EMS staff felt that using current IT systems would constrain them in a disaster situation and they would prefer using paper to computers. One physician said, “Paper is so much better than the computer. Because in a situation like this is the time when the IT system gets overwhelmed.” Also, with respect to getting back lab results in an MCI, “the current IT system would be completely unworkable”.

EMS personnel were also skeptical about how useful technology would be given that “it takes time ...things are happening on scene so quickly”. They said, “...things can escalate rather quickly, so if you take time to start playing with the PDA, you can lose track. Maybe paper would be quicker; you can jot notes, your short notes, short hand...” In spite of their heavy reliance on communication tools like cell phones and pagers, care providers were not satisfied with the usefulness of these tools. Given their experience with not having cell phone coverage in remote locations, paramedics pointed out that “technology is good except when you are in the middle of the boon- docks”. Instead, paper seemed to be the most easy to use in crisis situations. EMS and ED staff both mentioned that they would exchange information using “yellow sheets” which are casualty triage forms used to note patient information in mass casualty incidents.

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The communications center (CC) is located in the ED and its role is to convey information between EMS units and the ED. Currently, operations of the CC depend mainly on radio, paper and the phone. CC personnel note information given by EMS units on paper and for incoming ambulances they have “sheets to be filled out”. They use computers to track the helicopters and ground transport units, but rarely for information storage or retrieval. The various information exchanges, such as EMS to CC to charge nurse, are not stored electronically. One of the CC staff said he was most comfortable with paper because he “...grew up with it at the county level where we did not have the computer aided dispatch system”.

5.2 DIFFERENCE BETWEEN ED AND EMS LEVELS OF IT USE

Computers are extensively used by the ED staff. A physician said, “All our orders are on computers. There is Internet and all that on computers.” While the ED uses an EMR and a CPOE, EMS personnel do not carry computers on ambulances or helicopters, and hence do not have on-board access to the EMR or computerized provider order entry (CPOE). The EMS teams expect to install laptops in the near future; however, the laptops will primarily be used for wireless and radio communication. Paramedics said that while they were considering installing laptops on-board, “the information is usually available on-site or through the communication center. You will call the communication center and say ‘this is command such and such, we need to know such and such...’”. EMS teams exchange information primarily through communication technologies and do not perceive IT tools to be particularly important for their information management needs.

5.3 COMMUNICATION TOOLS MORE IMPORTANT THAN INFORMATION TOOLS

Both ED and EMS personnel mentioned the use of pagers, cell phones, walkie-talkies and radios multiple times during the test. However, they rarely mentioned using the EMR or the CPOE and did not envision it to play a major role. Interestingly, there was no mention of using information tools to communicate information between different actors; communication tools would

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be the sole means for exchanging information during a crisis. CC personnel said that they receive patient information from EMS and “page the trauma responses and put it up on the trauma recorder so all the trauma teams that respond call a certain number and listen to what’s coming”. Thus important information is disseminated via recorders and phones instead of centralized information systems.

In spite of the heavy reliance on conventional communication devices, participants complained about their severe limitations. Residents admitted that even though the primary means of communicating a disaster alert to them was the paging system, outside the hospital “at least half or may be a majority of us don’t have our pagers on”. The cell phones used by ED and EMS personnel hit dead spots and the 2-way radios fail because of mismatch of frequencies between counties.

5.4 EXTRACTION OF INFORMATION DEPENDS ON INDIVIDUALS

Currently, ICTs do not ‘push’ relevant and timely information during a crisis to actors who need it. Actors need to actively ‘pull’ information. Therefore, the quality and timeliness of information extracted depends on an individual’s motivation, skills, and training. Given the limited information available in the early stages of our scenario, some residents would go to the CC and ask for more information, but not others. CC personnel listen to various frequencies of the surrounding counties and reporting frequencies of the Life Lion helicopters and ambulances. From experience they have learnt to extract relevant information when listening to numerous frequencies and pass on required information to ED and EMS teams. When asked whether they get overwhelmed with the amount of information on the various frequencies, they said, “...with the amount of experience, you learn what to listen to and what just to tune out.” However, individual motivation and experience determine the quality of information extracted by CC personnel from these communication channels. EMS personnel said about CC staff that “some listen [to the radio frequencies] more than others...” and so the amount and quality of information passed on to them “depends on who’s there, depends on their mood”. On occasion,

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depending on who is working in the CC, EMS units have received inaccurate information and reported to wrong hospitals for patient transfers.

5.5 ICT IS EQUAL TO IT+CT?

The term ICT implies the integration of information and communication technologies such that the whole is greater than the sum of the parts. IT and CT need to be seamlessly integrated to leverage processes of care. However, the study revealed that there is a clear distinction in the roles and uses of IT and CT for emergency response. For instance, EMS personnel verbally communicate patient information to the CC which in turn pages or calls the charge nurse in the ED. However, the ED primarily manages patient information electronically using the EMR.

They found that current ICT usage is divided into two distinct domains – the IT domain that contains computer-based systems and the CT domain that contains communication devices. CT enables communication of unstructured information in the form of natural language. IT forces us to convert our verbal communications into structured information to fit into the schema of underlying databases. An ideally integrated ICT environment should enable unstructured communication to flow easily into the structured domain of information systems and vice versa. However, current ICTs do not facilitate seamless information flow between the CT and IT domains; this task is left to the human actor.

In situations where users are unable to extract structured information from unstructured communication, they prefer paper and verbal communications to IT tools. When users are overloaded with verbally communicated information, and where CT are not integrated with IT, users switch to low-tech methods such as paper which provides unstructured information management. Therefore, we need to develop means of real-time integration of CT and IT such that information can flow seamlessly between them. Integrated networks of ICTs should enable unstructured verbal communication to be automatically converted to structured information for insertion into information systems. In the next section, we highlight some of the design requirements for these types of systems.

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5.6 DESIGN REQUIREMENTS

5.6.1 Easy conversion of unstructured to structured information

EMS personnel find it difficult to use hand-held technology that constrains free-form data entry for the same reasons that ED staff in the study found the EMR unusable in disaster situations. Therefore, it is need to design technologies that automatically convert unstructured information into structured information suitable for computer-based systems. For instance, verbal communication devices can be designed to transmit EMS information to speech-to-text systems which extract relevant information and populate EMR databases that can be accessed in the ED.

5.6.2 Interoperability and standardization

Standardization of emergency response information systems is important so that different hospitals and EMS units can exchange information about resource availability, number and types of injuries, presence of decontaminants etc. during a disaster. To complement ED usage, access to the EMR should be made available to EMS personnel on-site [[2]]. During emergency situations, where existing technologies do not provide support, there is often a mixing and matching of diverse ICTs[[3]]. Hence, there is a need to ensure interoperability between ICTs used by different agencies and across regional boundaries. Multi-organizational radio interoperability issues have long been cited as an obstacle to communication during response. Potential solutions to such technical problems include designing dual-use technology which allows both normal and emergency modes of operation and built-in architectural and protocol redundancy in tools [[4]].

5.6.3 Information ‘push’ model required

For EMS, the “information pull” model of seeking relevant information by listening to various frequencies is grossly inefficient. Technologies need to be developed that can eliminate waste of bandwidth used to seek information by “pushing” relevant incident information to EMS units. This will also ensure that

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all actors, regardless of their background and experience with IT usage, consistently access accurate information.

5.6.4 Training and awareness about ICT usage

Training and awareness about ICTs will increase readiness of EMS and ED staff to respond when faced with a crisis. Even as more and more IT tools are being incorporated into EDs and EMS, it is not clear to users what roles these systems will play in situations that they are not primarily designed to support. Hospital management must train staff about the capabilities and benefits of these technologies for dealing with MCIs. For instance, they found that residents were not formally educated about the usage of IT systems during an MCI. Prior ICT use determines, to some extent, how open and enthusiastic care providers are about using IT. CC personnel with prior experience with using computer-based systems were more comfortable with using the computer-aided dispatch system as compared to others who “grew up” using paper. This led to inconsistent methods and media for recording information. Therefore, training is crucial to ensure equal levels of comfort with technology use.

5.7 CONCLUSIONS

The study highlights the various perspectives on usefulness and ease of use of ICTs during a crisis. They found that even among the ED and EMS teams of a hospital with above-average ICT usage, there were more negative than positive views about the role that ICTs would play during a crisis.

There are two important steps that can take to address these issues. First, there is a need to develop integrated systems that support the seamless flow of information between structured and unstructured forms. Second, there is a need facilitate ‘emergent interoperability’ between ICTs [[3]] through focusing on real-time integration of information and communication technologies.

ICTs are a crucial component of emergency crisis response. However, for these technologies to be successful they must support both pre-hospital and hospital sides of the crises response.

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6 COMMUNICATION SYSTEMS

This chapter covers the communication systems proposed actually for mass casualty incidents. It is not a historical review of the systems used in these applications, but a state of the art of how the last generation communication technologies have been adopted and their benefits.

The adoption of these technologies is not still generalized; they are prototypes that have been tested in practices successfully in different countries but without a regulatory institution.

There are three topics closely related to a triage system: victim identification (assigning a temporary identifier for further reference), a medical classification system (common criteria for objectively deciding the status of victims), and a physical support to make all this information available (generally, triage tags). This introduction will go into these aspects [5]

6.1 VICTIM IDENTIFICATION

The first requirement for any emergency triage system is having a mechanism for the unique identification of victims. Bar codes have replaced plain numbers in this task, especially in medical environments, thus facilitating mechanical reading (Neuenschwanderetal.,2003). Bar codes are easy to create (they can just be printed on paper using a standard printer), but the optical reader needs to be very close to get the information. Furthermore, only one bar code can be read by a reader at a time, and no additional data apart from the identifier can be stored in it.

Recently, two-dimensional bar codes are being introduced in different fields (Gaoetal.,2007). This technology is based on dots instead of bars, allowing more bits of information to be included in the code. It can also be used for victim identification, and even additional information, such as patient data, can be stored on it. Unfortunately, this mechanism also requires readers to be placed in front of the bar code, only one code can be read at a time, and a new code must be printed again if the information in it has to be updated.

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RadioFrequency Identification (Inoueetal.,2006) is another technology that can be used for victim identification. A unique identification number is stored in a RFID tag, and a wireless, contact-free, low-to-medium-range reader communicates with it using radio waves to get this information. Two types of tags exists, passive tags, that use the energy received from the reader to send the identifier, and active tags, that include a battery to increase its distance range.

In spite of requiring special hardware tags, this technology is very interesting for emergency systems because it supports the simultaneous identification of several elements from a medium range distance.

6.2 TRIAGE SYSTEMS

The first medical step in the aftermath of a crisis is the triage of the victims, which is required for an initial evaluation of their health status. This process, called triage, must observe a strict, non subjective procedure following standard criteria. Several triage systems exist, such as the world-wide used Simple Triage and Rapid Treatment (START) (Super, 1984), the more complex and complete Manchester Triage System (MTS) (Mackway-Jones, 2006) widely used in UK, Europe and Australia, the points-based Glasgow Coma Scale (GSC) (Teasdale and Jennett, 1974), only centered in the conscious state of the victim, or the two-step Triage Sieve and Sort (Wallis, 2002). Most of these systems are based on the rapid analysis of the breath status and rate, pulse rate, patient ability to follow simple commands, or eye, verbal or motor response. After the triage, victims are usually classified in to four injury level categories, each one associated with a colour: Minor (green), Delayed (yellow), Immediate (red), and Deceased (black). Furthermore it has recently being introduced a new category, violet, for victims in a very critical status, which are very likely to be casualties in a short time.

6.3 TRIAGE TAGS

Once a victim has been triaged, one of the four colours associated with the injury level is assigned to them together with an identification number. The medical data obtained from the triage, as well as non-medical in formation that

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may be obtained from the victim, may also be vital for later treatment. For the visualization of the colour associated with the injury level, easy methods are used such as the Flagging tape, a simple colour on-adhesive PVC or vinyl tape. More complex paper tags, known as triage tags, are also widely used. These triage tags include the colour associated with the injury level, the victim identification number, and additional medical and non-medical information that may be useful for the medical personnel to assist the patient later (seeFig.1). Examples of them are the original (METTag), the foldable SmartTag (TSGAssociates), the big-sizecross-shaped foldable Cruciformtag (CWC-services), or the military Smart Incident Command System (SICS) (TSGAssociates). Using these traditional paper triage tags the information written on them remains near the patient. Nonetheless, additional steps are required for the medical personnel if this information must be received in advance to attend the patient later on, or if this information must be introduced and managed in a computer system.

The next table shows at a glance the main contributions to the state of the art within the ICTs applied to mass casualty incidents. Note that the applications covered by those systems can include the CBRN cases, even they do not specify.

.

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Germany Disaster Aid

Network Institute for Information Processing Technology, University of Karlsruhe 2008 [6]

Spain MAETTS Department of Information and Communications Engineering, Universitat

Autònoma de Barcelona 2009 [5]

California WIISARD California Institute for Telecommunication and Information Technology &

University of California San Diego 2005 [7]

Massachusetts WISTA Multimedia Networks Laboratory ECE Department. University of

Massachusetts. 2007 [8]

Maryland CodeBlue Harvard Sensor Networks Lab 2008 [9]

Connecticut SALT Division of EMS, Section of Emergency Medicine, Yale University 2008 [10] [11]

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The next sections try to explain more in detail references from the table above: Disaster aid Network, MAETTS, WIISARD, WISTA and CodeBlue will be introduced as good representative cases. For more details just refer to the bibliography.

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6.4 DISASTER AID NETWORK

Wireless sensor networks (WSN) based emergency response is introduced in this section as an example of how ICTs could help in such situations [6].

WSNs are perceived as dynamic, ad-hoc networks with thousands of sensor nodes communicating over radio channels, performing data sensing and collaborative processing. However, some important challenges must be noted:

Self-Sufficient operation: The sensor nodes are battery powered and left unattended at deployment site.

Self organization: The ability of the sensor nodes to spontaneously create an impromptu network, configure the network, dynamically adapt to device failure and degradation, manage movement of sensor nodes, and react to changes in task and network requirements.

Scalability: A WSN should be able to adapt itself to the insertion of new nodes.

The ZigBee standard offers new opportunities for many new applications, because of its properties as short range, low power and low rate.

6.4.1 Disaster management scenario

The emergency response system is based on the disaster management strategy followed in Germany, but it can also be adapted to other disaster management strategies. Mass Casualty events-“Massenanfall von Verletzten” (MANV) is the widely used process for handling disasters in Germany. The on-site organization chief (OOC) designates the disaster site into four care zones as shown in the following figure and the chief emergency doctor plans for triaging the patients.

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Figure 1 – Patient flow at the disaster site

Danger Zone (DZ): This is the zone where the actual disaster takes place. The search and rescue of the injured patients is carried on here.

Injured Deposition Zone (IDZ): The rescued patients are gathered and triaged.

There are four different classes of triaging:

Red: patients who require immediate attention

Yellow: patients who require delayed attention

Green: patients with light injuries

Blue: patients with no hopes of survival

Black represents patients who are dead and is not a triage class

Treatment Zone (TZ): The triaged patients are treated based on the short diagnosis in the triage and first aid.

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Transport Zone (TRZ): The ambulances are present here to transport the patients from the disaster site to the hospital. The red triaged patients are moved to the Transport Zone first, followed by the yellow ones.

6.4.2 Field study

A disaster simulation drill was conducted by state fire department Bruchsal, Germany and the MANV based emergency response for a train-bus collision was simulated. The drill comprised of around 60 patients, 35 emergency doctors including the paramedics, fire fighters and the Organization group. The OOC charted out a plan based on the resources available and the victim count. He manually drew a map and accounted the details of the number of medical responders, transport vehicles, care zones (Figure 2).

Figure 2 – OCC drawing manual map

The zones can be nearby or far away and may even overlap one over the other. The manual mapping done by the organization chief was time consuming, complex for updating real time changes and the resource estimation was hindered. Medical responders conduct initial triage and then call their emergency medical chief (EMC) using their handheld radios, and verbally report the patient count. The officer manually tallies the patient counts on clipboards and verbally reports the patient count to transportation coordinators and requests for the necessary number of ambulances. After initial triage, patients wait at the scene until their ambulance arrives. With a resource limited response

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team, patients often wait for an extended period of time before transport. During this waiting period, patient conditions may deteriorate. Secondary injuries such as hypoxemia, hypotension, and cardiac tamponade can become life-threatening if not treated immediately. There is no continuous patient vital sign monitoring currently used. The paper based triage is a bottle neck and makes the re-triaging difficult. Patients with minor injuries often depart the scene without notifying the response team, thus creating an organizational headache for EMC/OOC who is responsible for tracking the whereabouts of each patient.

6.4.3 Disaster Aid Network (DAN)

An emergency response system is proposed based on the DAN to solve the following main problems:

no real time patient tracking and vital sign monitoring

triaging is a bottleneck

manual resource estimation is time consuming

extended patient wait time before transporting.

Figure 3 – Disaster Aid Network architecture

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The DAN architecture consists of hundreds of nodes distributed in a disaster site and wirelessly interconnected through the new low-power ZigBee technology to form a mesh network. The DAN ZigBee network uses the 2.4GHz band which operates worldwide, with a maximum data rate of 250Kbps. ZigBee is chosen because it’s a low power, low cost technology for sensor networks. ZigBee network can access up to 16 separate 5MHz channels in the 2.4GHz band, several of which do not overlap with US and European versions of IEEE 802.11 or Wi-Fi. It incorporates an IEEE 802.15.4 defined CSMA-CA protocol that reduces the probability of interfering with other users and automatic retransmission of data ensures robustness. It enables the mesh network to be formed by itself thereby enabling the network to be easily scalable. Its Self-healing mesh network architecture permits data to be passed from one node to other node via multiple paths. Its security toolbox ensures reliable and secure networks. The MAC layer uses the Advanced Encryption Standard (AES) as its core cryptographic algorithm and describes a variety of security suites that use the AES algorithm. These suites can protect the confidentiality, integrity, and authenticity of MAC frames.

There are three logical device types in ZigBee:

The Coordinators

Routers

End Devices.

The Coordinator initializes a network, manages network nodes, and stores network node information. The Router node is always active and participates in the network by routing messages between paired nodes. The routing is based on the simplified Ad-hoc on demand Distance Vector (AODV) method. The End Device is the low power consuming node as it is normally in sleep mode most of the time. It can take 15ms (typical) to wake up from sleep mode. DAN is a heterogeneous network formed with the following type of nodes:

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Patient bracelet node (End Device): Minimized electronic triage tag, localization support, ZigBee mote, vital and activity sensors, RFID tag, localization.

Emergency Doctor´s bracelet node (End Device): Localization support and ZigBee mote.

Monitor station (Coordinator): Collector node running a visualization software that displays the disaster site map with location, triage information and used by the EMC/OOC.

Router nodes: ZigBee motes with known location coordinates that can be deployed at the site ( ex: attached to tents, ambulances)

Emergency doctors PDA: For patient monitoring and data recording.

Based on the instantaneous need during the emergency response the concerned nodes can form a Mobile Ad-hoc network (MANET) for accomplishing a specific task.

The main functionalities of the Disaster Aid Network are efficient logistics at the disaster site and patient monitoring. The physical and physiological parameters are sensed, collected from the mesh network and displayed at the Monitor Station for continuous patient monitoring. If there is a change in patient status the EMC is informed at the monitor station and treats the corresponding patient swiftly. A passive RFID tag is integrated into the bracelet for patient identification.

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6.5 MAETTS

6.5.1 Mobile agents

The system proposed is based on the use of mobile agents for emergency situations [5]. Agents are autonomous software entities with a set of tasks, reactive (i.e., react to their environment changes), proactive (i.e., change their environment), and social (i.e., interact with other agents). Mobile agents have the additional ability to move to different network locations. Agents dwell in agent platforms, which are frameworks where they are executed.

In order to allow agents to collaborate among them selves, when they are originated in platforms using different technologies, a standardized way to interoperate is required. Nowadays, the standards specified by the IEEE Foundation of Intelligent Physical Agents (FIPA), both for agents and for agent platforms, are the most widely used.

6.5.2 MANET networks

In most emergency situations no communication infrastructures exist. It is in this case where wireless ad hoc networks have an important role. These networks are formed connecting the different systems without using any intermediate access point. A specific case of wireless ad hoc networks are mobile ad hoc networks (MANETs), where nodes move and dynamically change the structure of the network.

In MANETs, research has mainly been done on the optimization of routing algorithms, which are focused on different objectives: load balancing, energy efficiency, distance vectors, or the link state.

6.5.3 Bluetooth

Bluetooth is a radio frequency wireless technology for connecting devices in a short distance set to replace cables. It is designed to use very low power, making it suitable for portable devices, but limiting the data transfer speed. One

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of its features is the possibility to deal with several devices connected over a single link without being in line of sight of each other.

6.5.4 The Mobile Agent Electronic Triage Tag System

The main objective of this proposal is the specification of the Mobile Agent Electronic Triage Tag System, an innovative triage system for using in emergency situations. The system is an improvement of current electronic medical triage systems, which takes advantage of mobile agent technology to provide information mobility, autonomy, proactivity, and reactive component behavior to face up emergency situations. Moreover, the system is able to operate without communication infrastructures, permanent connections, or full network coverage through MANET technology. Besides, the system enables early resource allocation and integration with existing eHealth solutions, which are groundbreaker features, not present in any other approaches up to date.

In the next paragraphs, there is an introduction of the scenario where the system operates. Then, there is a description of the system and the agents involved. And, finally, there is a detailed description of the overall operation.

6.5.5 Scenario

The proposed scenario is based on a scenario with two different areas, the Emergency Area (EA) and the Emergency Coordination Center (ECC), interacting through the Electronic Triage Tags Mobile Agents (ETTMAs). See Figure 4.

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Figure 4 – Mobile Agent Electronic Triage System

The EA is the zone where there are the victims of a Mass Casualty Incident (MCI). It is the focus of the medical attention, and there may be more than one in an emergency. Triage of the victims is done in this area by trained triage personnel, such as doctors, nurses and paramedicals. After the triage, doctors provide initial medical stabilization to victims and rescue teams (in ambulances, helicopters, and so on) take care of the transportation and evacuation.

Regarding communications, in the EA neither fixed nor permanent communication networks may be available. In some cases, although there might be a network available, such as GSM, it may be saturated, nonfunctional, or even disconnected for security reasons. Therefore, the solution is to use MANETs to communicate all handheld devices and computers supplied to the triage personnel, doctors, rescue teams, and the ECC. Anyway, MANET connectivity in this area is usually intermittent, and therefore permanent connection between devices, including the ECC, cannot be assured. Mobile agents travel across this network with triage information when ad hoc network coverage exists, trying to reach the ECC.

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ECC is the second area in the scenario. All the information regarding the MCI (victims, doctors, specialists, volunteers, rescue teams, medical supplies, and so forth) is managed from there. Access to the nonpermanent ad hoc network is available, and in some cases the access to an infrastructure network is also possible through cable or satellite communications. Usually, the ECC may also be linked to one field hospital.

Emergency personnel move from the EA to the ECC (and to field hospitals) to provide the required services, while rescue teams are in charge of victim transportation, through the devices used by all the emergency personnel and rescue teams connected by MANET communications.

All the emergency information moves from the EA to the ECC by using the devices carried by all the emergency personnel and rescue teams connected by MANET communications, while management information moves in the opposite direction.

6.5.6 System description

From the initial requirements and the scenario described above, it is proposed the use of a hardware platform composed of several components. For the triage personnel and doctors in the EA, we propose the use of handheld devices with RFID reader, IEEE802.11, and GPS support. For the rescue teams, in vehicles, they propose computers with IEEE802.11 network support, GPS, and RFID reader. And for the ECC, computers with RFID reader, and network connectivity through wireless IEEE802.11, wired ethernet, or satellite communications. Furthermore, simple paper triage tags with attached RFID tags for victim unique identification are used. In order to read tags, RFID readers with wired or wireless connection to the handheld device or computer must be available. Finally, the use of discovery and routing protocols on top of IEEE802.11 ad hoc networking is proposed in order to link all unknown handheld devices and computers in the system.

Regarding the hardware infrastructure, MAETTS is based on three main devices: the Triage Device (TD), the Emergency Coordination Center Device

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(ECCD) and the Rescue Team Device (RTD). All of them run mobile agents, so they require a mobile agent platform.

6.5.6.1 Triage Device

The TD is the part of MAETTS used by triage personnel during the triage phase, and by doctors during the victim initial medical stabilization. It is composed of a handheld device which runs an agent platform, and a Manager Agent (MA) acting as the user interface and as a factory of ETTMAs. It also stores ETTMAs, either those created in the same device or the received from other devices.

6.5.6.2 Emergency Coordination Center Device

The ECCD is the part of MAETTS in charge of the emergency management. At least one ECCD is required in a MCI, usually in the ECC. Otherwise, an ECCD in the hospital can be used.

Apart from the computer, the ECCD has an agent platform installed on it, a MA to manage the agents and acting as a user interface, and a Coordination Agent (CA) providing the specific facilities for the coordination of the emergency. Moreover, the ECCD also stores all the ETTMAs arrived from the TDs in the EA, and calculates, creates and assign rescue routes to the RTDs.

6.5.6.3 Rescue Team Device

The RTD is the device used by every rescue team. From the architecture point of view, it is very similar to the TD, and it is composed of a computer running an agent platform, a MA, and all the ETTMAs received from the ECCD

6.5.7 Operation

In the mass casualties scenarios previously described a predefined set of actions are followed, by the different participating actors. Using the MAETTS does not implies to substantially modify these actions, but improve and speed them.

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Below there is a description of the traditional actions and actors involved in an emergency scenario. Moreover, we provide a comparison between their behavior in a traditional scenario and with their innovative system, comprising from the victim identification to the rescue transportation of the victims.

The first event is the incident itself. The result of which is a number of victims, scattered around the EA. At this stage, no medical action is taken, and it is therefore out of the scope of this proposal.

6.5.7.1 Victim identification

In traditional emergencies, the barcode and identifier printed on the paper triage tag is used to uniquely identify victims and to facilitate presencial tracking.

For the victim identification, they propose instead the use of RFID technology through a RFID tag attached to a paper triage tag with the same identifier number printed on it, for fault tolerance purposes.

The identifier is read approaching the handheld device and the RFID reader in the vest to the paper triage tag (including the RFID tag) assigned to the victim. In the triage phase, the read identification is automatically assigned to a new ETTMA. In all the other cases, such as when the victim is collected by the rescue teams, the RFID tag is also read. The display in the computer system in the ambulance may automatically show the information in the associated ETTMA. Afterwards, when the victim reaches the field hospital or the hospital, the RFID is also read by a RFID reader at the entrance, and the ETTMA, that is inside the medical transportation device, moves to the hospital system platform, where the victim information can be eventually integrated in an existing virtual patient record system.

6.5.7.2 Triage

The first medical action taken during emergency situations is the triage. Triage personnel look for victims and approach them. Immediately, they triage these victims, evaluating a few vital signs in a simple, fast, and predetermined way. Once evaluated, an injury level is assigned to the victim, together with the

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associated color in the paper triage tag. At the same time, the victim’s medical values obtained during the evaluation can also be written on this triage tag.

For the management of the information in the initial triage of the victims, we propose the use of a CA running on a hand held TD, able to create ETTMAs to store victim’s information. Triage and medical personnel are provided with reflectance vests that integrate a handheld device which is equipped with a touch screen, a GPS receiver, and a RFID reader.

When triage personnel reach a victim, they create a new ETTMA in their TD, and label the victim with a physical paper triage tag with a RFID tag that is placed in the neck or wrist. The triage personnel measure the victim’s vital signs, evaluate the state, and introduce the triage information in the newly created ETTMA by means of the TD touch screen. Then, ETTMA suggests an injury level to the triage personnel. The color associated with the injury level is also selected in the paper triage tag. If the victim can pronounce his name or some identification documentation is found, this information is also incorporated intot he ETTMA (if the triage personnel have enough time).

6.5.7.3 Initial medical stabilization treatment

After the triage, doctors provide each victim with the required emergency care in order to stabilize them before he can be rescued. All the medication and treatment administered during this phase can be written in the paper triage tag.

In this proposal, this information is entered and stored by the ETTMA, which represents this victim, by means of the user interface in the MA.

6.5.7.4 Victim localization

In order to facilitate rescue teams to find the victims, localization information may be used in traditional solutions. They require additional GPS hardware and communication mechanisms to get and transmit the information.

They also propose the use of GPS technology for the victim localization, but directly integrated in to the MAETTS devices. When the ETTMA is created, it

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automatically retrieves its geographic position through the GPS and stores it together with a time stamp. Later, at periodical intervals, the location information with the corresponding time stamp is added to the ETTMA.

Nonetheless, there are special situations in which no GPS signal is available. In these situations, localization information can be introduced in three different ways. The first option is introducing text location information by hand. This is a very useful feature to locate in accessible ravines for the triage personnel. The second one is done pointing the position where the victim is at a map interface in the handheld device. The third one is done automatically; when an ETTMA is submitted and there is no GPS coverage, the time since the coverage was lost and the last GPS position known is stored inside the agent. Thus, it is possible to estimate a location of the victim using the time of the last known GPS position.

6.5.7.5 Medical information routing

Traditionally, once the victim has been triaged, the triage and medical information is written on the simple paper triage tag and sent together with the victim. In some cases, and only if an infrastructure for voice or data communication is available (e.g. telephone, theTETRA system Dunlopetal.,1999), some medical information can be sent in advance, but in most of these cases information is not automatically sent or tracked, and it requires some human active participation.

In this proposal, the information is routed by the automatic and asynchronous mobility features provided by ETTMAs. The triage information of the victim is stored in an ETTMA, which moves from device to device deciding its route by itself.

The main advantage of using mobile agents for this purpose is that the communication with the final destination may be asynchronous, i.e., no direct connection is required. ETTMAs always jump to the neighbor device most likely to reach the MANET where the ECCDis. Once the ETTMA is in that network, it may jump to the final destination device

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6.5.7.6 Emergency coordination

The coordination and management of the different actors in an emergency is traditionally done from an ECC. In each emergency there is usually at least one ECC, and it is usually in, or near to, the field hospital. This center is in charge of the distribution of rescue teams, the hospital allocation when needed, the medical supplies distribution, and the actors communication.

The ECCD is the device in charge of the emergency coordination. It is the initial destination of the ETTMAs and includes a MA and a CA. The MA provides the general management of the agents and the user interface, while the CA is in charge of the specific coordination of the emergency, including the creation and assignment of routes for the rescue teams, according to the medical status of the victims associated to the ETTMAs present in the ECCD. When an ETTMA reaches the ECCD, it announces its presence and remains there making the victim information available to the CA and MA.

When a rescue team arrives to the ECC, it also announces its presence to the CA in the ECCD. The CA creates a new rescue route, according to the ETTMAs existing at that moment in the system, and sends it to the RTD. At the same time, the ETTMAs of the victims to be transported are also requested to move to the same device. Once the ETTMAs have moved to the designated RTD, the team leaves to the EA to pick up the victims.

6.5.7.7 Transportation

After the initial triage and medical stabilization, victims must be transported out of the Emergency Area. In traditional solutions, medical personnel may request for a rescue team to perform the transportation. This request can be optional, for rescue teams may be proactive and they may look for triaged victims by they own initiative. In any case, these teams arrive to the emergency zone and look for the victims. They reach, rescue, and transport them to a normal or a field hospital.

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The transportation of victims is provided by traditional rescue teams with the help of the route created by the ECCD, using GPS information from the ETTMA, together with the medical information also provided by the ETTMA.

Rescue teams arrive to the EA using the location information in the route. They easily find the victim and, through the ETTMA, they obtain their medical status. When the victim is collected by the rescue team the RFID tag, stucked in the paper triage tag, is read. Since the associated MAETT is already in the RTD, information of the victim triage tag may be instantly displayed and new information may be introduced. Additionally, agents representing the victims, or clones of them, arrive at the ECC, field hospital, or hospital in advance to the victims themselves and may make an early reservation of resources.

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6.6 WIISARD

The WIISARD team focused on developing a system for Metropolitan Medical Response System (MMRS) units. Through a process of user- oriented design and iterative refinement based on participation in four exercises over the grant period, the WIISARD team has produced a fully operationally test bed for integrated system for Medical Response in Disasters (MRiD). This test bed includes a deployable modular mesh network, WIISARD remote objects, Intelligent Triage Tags, iMOX (an 802.11 sensor platform), First-Tier and Mid-Tier medical management systems and a WIISARD Command (a visualization and alerting system). The WIISARD architecture has two components with self-scaling features: Calmesh networks and WIISARD Objects.

6.6.1 Calmesh Nodes

Calmesh nodes provide the network infrastructure for WIISARD. These devices are one-button-on, special- purpose Linux computers that accept multiple wireless networking cards (Figure 3). The computers are enclosed in a water resistant case and have a long battery life that allows continuous operation of network nodes for up to eighteen hours.

Calmesh nodes form a self-scaling network and are wireless routers that configure themselves into expandable networks. Ordinary 802.11 devices connect to any node. Nodes speak with each other via a mesh protocol to form a network. The root node of a network recognizes when there are new devices brought within range of an existing network map and revises routing tables. Routing in the network is based on the best signal strength path to any node. Nodes in the network that have gateways to the Internet via satellite or cellular data publish the existence of their gateway to other network nodes. All nodes in the network share all gateway bandwidth.

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Figure 5 – Calmesh wireless networking node

The addition of a new node with added capabilities, coverage area, and backhaul capability, or both, results in reconfiguration of the network. Mesh nodes also have the ability to form Virtual Private Networks (VPNs). This allows linkages between widely separated areas of Calmesh node coverage through the Internet. Network nodes include a GPS unit to relay their position. Systems in WIISARD without GPS units use trilateration of 802.11-signal strength from the Calmesh nodes for geolocation. Calmesh nodes have been used to create WiFi bubbles over 1.5 km in diameter and sustain transmission speeds of over 2Mb/sec.

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Figure 6 – WIISARD architecture

6.6.2 WIISARD Objects

WIISARD employs a publish/subscribe architecture with self-scaling features that reflect the present state of the art of system design. Software programs on Mid-Tier and First-Tier devices, when activated, subscribe to data objects from the server. Client devices with subscriptions update the model, with the result being disseminated (pushed) to all other subscribe clients. So that a client can tolerate its own loss of network, each client holds a local copy of the data objects it uses (in essence, a write-through cache). Should a client become disconnected, the device can still update its local copies of the data objects. Calmesh nodes connect to each other to form the mesh grid. Individual devices connect to each Calmesh node. The security of data transmissions is maintained by using the standard SSL (Secure Socket Layer) protocol. Devices authenticate themselves through a standard login process.

The architecture self-scaling capabilities include the ability to allow clients to automatically subscribe to data objects on the server, essentially allowing the system to expand as more responders join the network. The approach deals with loss of network connectivity with the server (segmentation of the network) by local caching. However, this creates problems that prompted the proposed research project. Caching of data on one device in a group work environment

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that requires first responders to work collaboratively results in confusion as users are viewing different data on their devices.

6.6.3 Intelligent Triage Tag (ITT)

When medical care is initiated at a mass casualty event, the first activity is the triage of victims, which is the grouping of victims’ by severity of injury. Paper triage tags are often used to mark victims’ triage status and to record information on injuries and treatments administered in the field. In this paper we describe the design and development of an “Intelligent Triage Tag” (ITT), an electronic device to coordinate patient field care. ITTs combine the basic functionality of a paper triage tag with sensors, nonvolatile memory, a microprocessor and 802.11 wireless transmission capabilities.28 ITTs not only allow first responders to enter victims triage status, they also display updates to that triage status with a bright flashing LED. The LED can also signal alerts for transport or immediate medical attention by displaying messages on a LCD screen. ITTs record medical data for later access offsite and help organize care by relaying information on victim location during field treatment. In hazardous environments, where chemical weapons suits prevent responders from using PDA’s, providers could easily enter victims triage status using the external buttons on the ITT.

Figure 7 – Intelligent Triage Tag (ITT)

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6.6.4 Personal Sensor Platform

In a mass casualty situation, medical personnel at the disaster site and other field treatment settings may need to monitor the vital signs of hundreds of seriously injured patients with minimal staffing. The conditions may be primitive and personnel may have to improvise infrastructure. As part of our research to enhance medical response to disasters with Internet-enabled systems, we have developed a prototype wireless blood pulse oximeter system for use in mass casualty events that is designed to operate in WiFi hotspots.28 Pulse ox units were designed using low-cost embedded technologies to operate in integrated or stand alone environments. Units can report data to a command post on the scene or any remote location with Internet access. iMOX units are based on a wireless sensor platform developed for the WIISARD project and used in both ITT’s and the iMOX (Figure 7). This system combines a low power PIC processor with a DPAC module that combines a Ubicomm microprocessor with an 802.11 transceiver. Sensor capability for pulse ox is provided by an OEM pulse oximetry board from Nellcor.

Figure 8 – WIISARD iMOX device

6.6.5 Provider Handheld Device

WIISARD is designed around a model with three types of first responders. First-Tier responders are the frontline providers at the site of a mass casualty incident. They triage the patients, administer treatments, and help prepare patients for transport. Mid-Tier providers are the immediate supervisors of First-Tier providers. They are the team leaders who supervise care functions.

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Command systems support situational awareness and safety monitoring activities within the Command Center.

Figure 9 – WFR screen

The First-Tier system is a wireless handheld device with an electronic medical record (EMR) for use by rescuers responding to mass casualty incidents (MCIs). The components of this device, the WIISARD First Responder (WFR), includes a personal digital assistant (PDA) with 802.11 wireless transmission capabilities, a laser bar code scanner and EMR software that replicates the rapidity and ease of use of the standard paper triage tag for the Simple Triage and Rapid Treatment (START) system29,30 and also provides tools for entering physical examination finds and recording treatments. The WFR includes an HP 5555 handheld device with a Linux operating system. The First-Tier system has a WIISARD objects database client that provides seamless transitions between connected and disconnected operations. The barcode scanner allows providers to integrate victims tagged with barcoded paper tags wrist bracelets with bar codes into the WIISARD system.

6.6.6 Mid-Tier System

Mid-Tier managers are the supervisors of groups of first responders at the triage, treatment, and transport areas and any other ad-hoc areas. In the field,

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they are typically equipped with clipboards and forms and use these data management tools to track victim numbers, status, and destinations. The WIISARD system replaces these devices with tablet computers. Data available to supervisors includes data from victim tags and data entered using the First-Tier device, as well as data entered on arriving ambulances and hospital availability. The graphical user interfaces (GUIs) are designed to provide maximal access to data on patients and resources, while still being tailored to the specific tasks and duties of the scene manager (Figure 10). Triage area managers have access to all logged triage patients and their acuity and decontamination status. Treatment area managers have access to lists of patients in their medical areas, their condition and vital signs. Transport managers can use electronic logs to assign patients to ambulances on scene and designate destination hospitals for disposition. Hospital base stations can view casualties on the field and manage reported receiving capabilities.

6.6.7 Command Center System

In existing Incident Command Systems, situational awareness is achieved manually through paper tracking systems and radio communications. In such systems, information often has high latencies and is incomplete, resulting in inefficient and ineffective resource deployment. The WIISARD system geolocates and displays assets using GPS and 802.11 trilateration and presents summaries of casualty counts and bed availability. It also has graphical displays of data quality and the ability to share diagrams with relevant features (hot zones and other hazards, tactical plans) overlaid on maps. When a victim or first responder enters an exclusion zone, and alert is generated. Additional alerting and decision support capability are under development.

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Figure 10 – Command Center system

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6.7 WISTA

Disaster patient care is best managed through effective dissemination of information within the disaster area. Mass casualty events can occur in remote and unexpected locations and can result in complete absence of traditional communication infrastructure. Insufficient information about the patients and the conditions of the disaster site can result in delay of medical treatment and inappropriate distribution of available response resources. A technological solution that supports real-time monitoring of the disaster sites and patients through multimedia communication, including video, vital signals, medical images and text (e.g. first-hand triage information and patient emergency status), will benefit the patient care and disaster relief operation, especially in large scale disaster situations with large number of victims and large-coverage area. Such a solution can assist emergency personnel in treatment of disaster patients and coordination of medical resources, increasing the chance of taking timely and appropriate actions.

Many existing mobile medical systems for disaster situations use satellites to establish communication between the disaster area and remote base hospitals. These systems treat the disaster area as a single communication entity and do not consider the communication needs within the disaster area. Several emergency telemedicine projects transmit emergency or critical care medical information over cellular networks. However, in a disaster situation, the cellular systems may not be available. A number of emergency patient-tracking systems use barcode/ RFID and PDAs to collect patient status and location, and then disseminate it over the internet. As it has been seen in the previous section, WIISARD project has conducted field tests focusing on continuous collection and transmission of patients’ vital signs. Some government or government sponsored emergency systems such as EDWARDS, TrackStar Systems, EDICS and TAC-SAT PAC, developed proprietary hardware that uses satellites in the 800 MHz and 4.9 GHz licensed band. These systems support the communication needs (mainly administrative information and voice) of the disaster site.

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In this example a low-cost and easy-to-deploy wireless system is introduced (denoted WISTA), that can assist on-site patient care during disasters. The proposed system facilitates real-time transfer of multimedia data from end devices (such as video cameras, sensors, medical images and text) located in the disaster site to the control center. WISTA enables disaster managers to obtain patients’ status information in real-time from the entire disaster site, which can assist the timely diagnosis as well as the treatment of patients. The control center can remotely control the information sent from these devices. For the proposed system, we have developed:

a hierarchical communication architecture: the low-level communication that interconnects the devices employs a Bluetooth wireless network and the upper-level communication network uses an 802.11g based wireless network

a software architecture that is installed on the different components of the system, i.e., the local and remote stations and end devices.

WISTA aims at the effective dissemination of patient information within a disaster area and does not rely on any existing infrastructure. Instead of developing propriety hardware, which leads to high cost and less flexible systems, this system uses standard off-the-shelf hardware. Moreover, this system supports transmission from the entire disaster site to the on-site control center rather than only supporting point-to-point transmission. Instead of disseminating just certain types of patient information such as vital signs, text information, WISTA can simultaneously transmit multimedia patient information including text, video, still medical images and vital signs. Following the proposed architecture for WISTA system, a system prototype over a wireless channel has been implemented and successfully demonstrated simultaneous transmission of video, sensor information, medical images and text patient information from multiple disaster sites to the control center. A simulation study in OPNET is conducted to determine the system scalability and the relationship between the number of local servers that should be deployed in the system and the disaster area geographical span [8].

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6.7.1 System architecture

The proposed WISTA system is deployed in the disaster area to provide last-mile support for on-site patient care. The patient care in a large-scale disaster can be managed in a centric way using the information collected by a control center deployed in the disaster area. A hospital (or a group of hospitals that connect with each other through wired networks) serves as the disaster headquarter receives information from the control center on site. Since the headquarter is usually far away from the disaster site, satellite communication is often used to interconnect between the headquarter and disaster areas.

Figure 11 – WISTA system architecture

As it’s shown in Figure 11, WISTA employs a hierarchical communication architecture, which comprises of two communication levels. The lower-level network interconnects between the local server and the following end devices using a Bluetooth network: PDA (personal digital assistant), GPS (global positioning system), ultrasound devices, video cameras, and vital sign

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monitors/sensors. The local server collects different information from these end devices such as text information input by the EMT (emergency medical technician) through the PDA, the location information from the GPS system, the vital signals from medical sensors attached to the patients, medical images from ultrasound, and video clips from the video cameras. The upper-level network that interconnects between the control center and the local servers uses an 802.11g based wireless network. After each local server collects information from the end devices, it will process (e.g. compress) the information and transmit it to the control center of the disaster area. Through the upper-level network, the control center captures this information and presents it to the onsite disaster managers. In addition, the proposed system also allows the control center to dynamically control the information sent by individual local servers.

6.7.2 System components

Based on the hierarchical system architecture described above, our transmission system comprises of three major components: the control center, the local servers, and the end devices. In this section each component will be described in detail.

6.7.2.1 Control center

The control center is implemented on a laptop located in the mobile emergency center or emergency command center. The control center communicates with all the local servers in the disaster area through 802.11g interfaces. The software architecture of the control center is shown in Figure 12. Upon receiving data from the disaster sites (i.e. local servers), the control center processes the data and presents it to the disaster managers at the command center. The control center includes the following modules:

Multiplexing: Upon receiving information from different disaster sites, this module categorizes the information according to the media types (video, medical image, text, and ECG [i.e. electrocardiogram] signals) and dispatches it to the proper

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processing module. For example, all video information is sent first to the “decompressing” module, while the text information goes straight to the “interpretation and aggregation” module.

Decompressing: This module decompresses video and image information using the JPEG (Joint Photographic Experts Group) algorithm, on an image-by-image basis.

Interpretation and aggregation: This module includes two functions: (1) interpretation: in order to correctly visualize the received information, different types of information should be properly interpreted. For example, the location coordinates from GPS devices should be interpreted as spots on the map. The ECG data points should be mapped to a waveform. (2) aggregation: before “information visualization,” all the processed media must be properly aggregated so that the information from different local servers can be displayed in one user interface.

Information visualization: All the information is presented to users in the GUI (Graphic User Interface). ECG signals are presented as a waveform (the ECG signals are received and plotted point-by-point). The intervals between ECG points on the waveform only depend on the sampling rate configured by the local server or the control server. Video and medical images are displayed in pop-up windows. The GPS coordinates received from the disaster sites are marked on the map of the disaster area.

Parameter control: The GUI contains a number of control panels. The control panels on the control center and the corresponding control panels at the local server are synchronized (i.e. any adjustment on the control panel of the control center will be reflected on the control panel of the corresponding local server). This module allows the disaster managers at the control center to remotely adjust the configurations of the local servers’ information transfer. For example, when a disaster site has more than one

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video camera, the control center can dynamically choose to receive the video from one of the cameras. In addition, the control center can adjust the quality of the medical image sent by each local server.

Information transmitter: Upon receiving the control information from the “parameter control” module, this module transmits the control information to the individual local servers.

Figure 12 – Software architecture at control center

6.7.2.2 Local server

In each disaster site, a local server is set up on a laptop equipped with both 802.11g and Bluetooth interfaces. The software architecture of the local server is shown in Figure 13. Through the low-level device network, the local server collects the patient information from the end devices, then multiplexes,

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transforms and transmits it over the upper level network to the control server. Each local server includes these modules:

Figure 13 – Software architecture at local server

Multiplexing: Through the device network, a local server collects multimedia patient information from the end devices. This patient information is classified according to the media type (video, medical image, text, and ECG signals) and dispatched it to the proper processing modules.

Transcoding: Since the end devices often have limited computation ability, the “raw” patient information needs to be processed before transmission such that (a) unnecessary data transfer is avoided; and (b) each media stream can be transmitted according to the parameters specified by the control center. The transcoding module includes three sub-modules:

Video transcoding: the video transcoding is performed frame-by-fame using the MJPEG (motion JPEG) algorithm (other video

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compression codecs such as MPEG4 and H.263 can also be applied). The MJPEG algorithm can provide compression ratio from 15:1 to 25:1 depending on the parameter setting. The default frame rate is 30 fps and the default resolution for video is 320×240. Both frame rate and quality can be dynamically adjusted by the remote control center.

Image transcoding: The medical images are compressed using the JPEG algorithm. The two parameters related to JPEG compression: resolution and quality can be dynamically adjusted by the control server.

Biosignal transcoding: This sub-module mainly performs parameter selection for ECG signals. An application-layer queue is set up to store sampled points captured from the vital signs monitor. It later sends out the sampled data point by point using the rate specified by the remote control center. The remote control server can determine any sending rate.

Information visualization: The text and transformed media information are visualized in the GUI of the local server. The GUI also contains a control panel, which lists the parameter settings for the transcoding module and the information transmitter module. All the parameters in the control panel are controlled by the remote control center.

Information transmitter: The text and transformed media information is sent to the control center over the upper-level wireless network. This module transmits the four media streams in parallel (each stream is handled by a process). Considering the characteristics of the wireless channel and the requirements imposed by the media types, we have used different transmission methods for different media types. For text, medical image, and ECG waveform, we use TCP to keep the integrity of the data. Based on video’s real-time requirement, TCP is not suitable for video transmission, especially

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in the wireless environment. The burst errors of wireless transmission can frequently trigger TCPs congestion control function, which adds significant delay to the transmission. Hence, we use UDP for video transmission.

6.7.2.3 End device

The end devices collect patient information and deliver it to the nearby local server. Based on the types of information they collect, the end devices can be classified as video devices (e.g. surveillance video cameras), image devices (e.g. portable ultrasound machines), vital sign monitors/sensors (e.g. SpO2 (oxygen saturation) or ECG sensors attached to the patients) and text devices (e.g. PDAs used by EMTs to enter patient information, see Figure 14).

Figure 14 – Text patient information on PDA

6.7.3 Upper-level communication structure

For the upper-level communication that interconnects between the control server and a potentially large number of local servers with high traffic load we propose to use an 802.11g wireless network that uses multiple channels (up to three non-overlapping channels). The entire disaster area is divided into a number of layers (i.e. the co-centered rings in Figure 15). The local servers that

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reside in each layer use the same frequency channel for transmission. For example, in Figure 15 the local servers that reside in the inside ring, middle ring and outside ring transmit to the control center using frequency channels f1, f2, and f3, respectively.

The transmissions that take place in different layers do not interfere with each other since each layer will use a different frequency channel. Therefore, the proposed system is able to support a larger disaster site with higher traffic load than a system that uses a single-channel transmission system. It is assumed that the control center can communicate on multiple channels (the control center either includes one computer that has three network interface cards each set on a different channel, or multiple computers each with one network interface card set at a different channel).

The number of layers as well as the shape of each layer depends on the number of end devices in the disaster area, the traffic demands, and the geographic span of the disaster area. A layer does not have to be a ring shape as the example shown in Figure 15. Since each layer is associated with a channel, the layer definition problem is equivalent to a channel assignment problem, which assigns each layer a frequency channel.

IEEE 802.11g defined a number of data rates (e.g. 54, 48, and 36 Mbps, etc.) which are determined as a function of the distance between the communicating nodes (the distance determined the signal-to-noise ratio). For example, a link can operate at 54 Mbps if the link distance is within 12 meter. A link can operate at a rate up to 18 Mbps if the link distance is 30 meter. Since in the proposed system a link will be set up between the local controller and the control center, local controllers will operate at different data rates depending on their distance to the control center. Note that in addition to the link distance, the SNR is affected by some random factors (e.g. people passing by) which influence the wireless channel and the resulting data rate.

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Figure 15 – Layered structure

6.7.4 Technical issues

To maximize the communication capacity and allow coexistence of the lower and upper level networks different communication technologies are used. For the lower level device network, a Bluetooth based implementation has been chosen. Many consumer products such as PDAs, video cameras and laptops are already equipped with Bluetooth interfaces. In spite of its popularity, Bluetooth has some limitations such as limited bandwidth (up to 1 Mbps). Moreover, this bandwidth can be further reduced due to the fact that it interferes with 802.11g since both these networks operate at the 2.4 GHz frequency band.

On the other hand, WISTA employs a hierarchical multi-tier (lower and upper levels) multi-technology (Bluetooth and 802.11g) communication architecture in contrast to a flat single communication technology architecture where nodes can communicate through a multi-hop network due to the following facts:

Power considerations: The flat multi-hop structure generally consumes more energy from the end nodes than the hierarchical structure due to the routing functionality that needs to be

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implemented at each node. Considering the fact that many battery constrained mobile devices are included in the network, the hierarchical structure of the wireless network is a better choice although there is a need to deploy local servers that aggregate the information transmitted from the end devices. It is assumed that the servers (both at the local servers and at the control center) have a stable power source with no power constraints.

Bandwidth and range considerations: It is well known that the wireless bandwidth is limited and different wireless technology provide different data rates and ranges. In order to cover the necessary range and data rate we chose the 802.11g technology and exploited the fact that 802.11g provides three non-overlapping channels, which increases the available bandwidth at the upper-level communication.

Network interfaces availability: Most of the consumer devices such as PDAs, video cameras as well as medical devices such as ultrasound machines are equipped with Bluetooth interfaces. Therefore, Bluetooth is chosen as the lower-level communication technology. Since Bluetooth is a communication technology with limited bandwidth and range, we did not choose it as the higher-level communication technology.

Finally, WISTA is designed to strengthen the management of patient care in a disaster area and is therefore a good candidate for future ICT (information and communications technology) system for patient management. In current systems, hospital units use mainly voice communication to interact with the disaster site. This system expands the capabilities of current systems by enabling real time transmission of multimedia information (video, voice and text) to the control center. Analysis of the information performed by the medical personnel enables timely and more accurate preparedness in the hospital. Ideally, hospital ICT should be part of the remote disaster headquarters enabling the medical personnel full access to the patients’ records.

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Since the importance of information management in disaster situations has been recognized, a number of disaster response or management systems have been deployed. At this point, it is hard to predict whether these systems will be widely applied in disaster situation due to their cost. This is an easy-to-deploy system which uses off-theshelf hardware and standard unlicensed networks which can deliver multimedia patient information. In fact, some of the proprietary systems and WISTA can be complementary to each other. Since WISTA uses unlicensed networks and consumer products, it can be deployed anywhere and thus capture a large amount of multimedia information from the disaster area. Therefore, WISTA can be deployed as the last mile solution and a satellite based system can deliver the local information collected by the control center to a remote disaster headquarter. Such integration or cooperation requires proprietary systems to support standard 802.11 technologies.

It is foreseen that the information dissemination in the disaster situation will take advantage of all kinds of communication technologies: satellite, licensed broadband, and unlicensed broadband. A disaster management system should be information-orientated rather than system-orientated. Considering the heterogeneous nature of future disaster operations, more effort will be made to solve the interoperability as well as coordination issues. In the future, a disaster system will provide interfaces for multiple standard technologies. Information exchange will be standardized so that multiple systems can work together.

Since different types of information will be transmitted, the information should be categorized, aggregated and presented in a uniform format. Some operation protocols should also be defined so that (1) the architecture of each disaster area can be quickly established and efficiently maintained; (2) when multiple systems co-exist in a disaster area, they can be prioritized based on reliability and availability; and (3) when some systems/networks fail, the alternative systems/networks can be quickly identified and the communication can be restored.

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6.7.5 Conclusions

A cost-effective wireless telemedicine system that can assist patient care in disaster scenarios is offered. The system is based on an easy-to-setup and scalable system architecture. Without assuming any existing infrastructure, the system uses Bluetooth and 802.11g based wireless networks to simultaneously transmit video, still-ultrasound images, vital signals and text from multiple disaster sites to the control center that resides in the disaster area. Moreover, this system offers the disaster managers the ability to remotely control the information sent from the disaster sites. The system enables the on-site control center to collect the patient information in a timely manner and continuously monitor the patient’s situation through enhanced visual information delivery. Such information delivery from multiple disaster sites allows the on-site disaster managers to gain a comprehensive picture of the disaster area. Thus, the use of the system promotes coordination among EMTs, minimizes inefficient and duplicate procedures, which improves the efficiency of disaster patient care and potentially reduces mortality and morbidity.

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6.8 CODEBLUE: WIRELESS SENSORS FOR MEDICAL CARE

As it has been seen in the previous sections, the wireless sensor networks are an emerging technology consisting of small, low-power, and low-cost devices that integrate limited computation, sensing, and radio communication capabilities. This technology has the potential to have enormous impact on many aspects of emergency medical care. Sensor devices can be used to capture continuous, real-time vital signs from a large number of patients, relaying the data to handheld computers carried by emergency medical technicians (EMTs), physicians, and nurses. Wearable sensor nodes can store patient data such as identification, history, and treatments, supplementing the use of back-end storage systems and paper charts. In a mass casualty event (MCE), sensor networks can greatly improve the ability of first responders to triage and treat multiple patients equipped with wearable wireless monitors. This has clear benefits for patient care but raises challenges in terms of reliability and complexity. While there have been many recent advances in biomedical sensors, low-power radio communications, and embedded computation, there does not yet exist a flexible, robust communication infrastructure to integrate these devices into an emergency care setting. CodeBlue is being developed, which is an efficient wireless communication substrate for medical devices that addresses ad hoc network formation, naming and discovery, security and authentication, as well as filtration and aggregation of vital sign data. Code-Blue is designed to operate across a wide range of devices, including low-power “motes,” PDAs, and PCs, and addresses the special robustness and security requirements of medical care settings [9].

In this example a new patient care paradigm to the emergency response arena through automation of the patient monitoring and tracking process is introduced. The miTags is a wireless sensor that can be distributed to casualties at a disaster scene instead of paper triage tags.

MiTags relay sensor data - including vital signs, location, and triage status - over an ad-hoc mesh network to monitoring stations. It supports two-way communication and can also be used to send messages to and from the patient. Multiple sensor add-ons to miTags are developed, including a GPS

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receiver, pulse oximeter, blood pressure cuff, temperature sensor, and ECG sensors.

Members of the distributed response team, such as treatment officers, incident commanders, receiving hospitals, and public health officials, can log onto a web portal to review real-time patient information. This allows them to maintain an accurate and global situational awareness of the casualties and provide better coordination between the pre-hospital caseload and receiving care facilities. Each miTag transmits and receives data with approximate transmission bandwidth of 250 kbps over the 2.4GHz open ISM frequency band, and is compatible with the IEEE 802.15.4 standard. It has a practical indoor range of approximately 20m, and is designed to optimize two important requirements for the emergency response industry: cost and battery-life.

Figure 16 – Real-time patient information is shared between responders at the disaster

scene, hospitals and ambulances

An end-to-end sensor network platform has been developed to support automated patient monitoring. A close collaboration has been kept with the diverse groups of stakeholders within the disaster response, including first responders, public health officials, and trauma centers, in order to design a system that would take into account each of their perspectives and accommodate their requirements. In this example, the miTag is presented as a

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solution for improving patient monitoring. It should be emphasized that the miTag is designed to optimize extensibility, scalability, and cost. It can be integrated with new sensor modalities to address a wide variety of problems within disaster response.

Figure 17 – USB receiver is used to communicate with the miTags. Patient monitoring

software sorts patients by triage priority, displays real-time vital sign trends, and

processes patient data for alerts.

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Figure 18 – The miTag supports a variety of sensor add-ons.

Disaster response scenarios require a major shift toward more scalable, workflow-efficient, and cost-effective products for monitoring patients. Commercial monitors currently on the market require pre-installation of wireless networking infrastructure and can only accommodate a limited number of patients per installed network. These monitors are only capable of vital sign measurement, and have no capability to tracking patient location. This is not viable in a chaotic disaster scenario, as numerous patients are scattered across wide areas, and knowing the whereabouts of a patient is critical for responders to rescue that patient promptly. In addition, existing medical monitors are

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expensive, integrate poorly with workflows, and exhibit a high rate of false alarms that overwhelm care providers.

These issues have long been barriers to the widespread adoption of automated monitoring products. In recent years, research and development of medical sensor networks has grown in both commercial and academic arenas.

Academic research, such as ACTis at the University of Alabama and BodyNets at UCLA, detect data using a body area network of sensors, and route the data through a Wi-Fi enabled PDA to the receiver. These projects all exhibit several flaws in their design, which limit their utility in mass casualty events. These systems often require an additional piece of gateway hardware (e.g. mobile phone, PDA, or custom hardware) to aggregate data from disparate sensors on the body, and route this information to receivers. These gateways increase costs and often rely upon a single wireless communication link to transmit data, which scales poorly and can be frequently unavailable during emergency scenarios. Additionally, these products are standalone and closed solutions, lacking the flexibility to be interoperable with 3rd party software or sensors. These products do not address emergency responders’ need for flexible, scalable, and cost effective technologies. The miTag is a solution to this gap.

6.8.1 Reconfigurable Body Area Networks

In emergency response scenarios, a critical challenge is designing a medical sensor that can deliver suitable functionality (e.g. sensor data transmission rate, type of data transmitted) to meet the evolving patient, provider, and workflow needs. A dynamic medical monitoring paradigm is being introduced, where both the sensor hardware and application software have the ability to tune themselves to suit the usage scenario. The monitoring system can be statically configured prior to deployment and dynamically reconfigured during operation. For example, the miTag can adjust its sensor data transmission rate if the patient condition deteriorates, it can increase the types of sensor data being transmitted if the patient enters or exits the hot zone of the disaster, or the miTag can enter into sleep-mode to conserve battery life.

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Customized monitoring systems can be assembled on-the-fly for different scenarios. This offers numerous significant benefits for the emergency response community by supporting the creation of user-centric and workflow-specific sensor applications, which can reduce the required intervention by users and allow for improvements in usability within a wider variety of responder scenarios. Finally, because the adjustments are made in software rather than hardware, implementation and manufacturing of new sensor applications are greatly simplified, and costs are minimized because the same hardware can be reused in multiple usage scenarios.

6.8.2 Implementation

The miTag is a highly extensible and modular wireless sensor platform. It is composed of a basic wireless communication module, which supports two-way communication with the remote receiving station, and a sensor interface where sensor modules can be added. This interface allows third party sensor vendors to integrate their sensors with the miTag and interoperate with the rest of the networking and data management software.

The miTag supports two types of wireless networks: an on-body short-range network of sensors that collect patient measurements and an off-body long-range network of repeater nodes that relay these measurements to the receiver. Both networks have the capability of dynamically reconfiguring themselves during operation. In practice, patients would be outfitted with an array of miTags, each with different sensing capabilities. As miTags collect data, the data from disparate miTags are first aggregated via the body area network and then forwarded to a long-range mesh network.

As shown in Figure 18, several types of sensors have been integrated with the miTag. The pulse oximetry sensor miTag operates with two possible OEM sensor boards: the Smith Medical Micropower SpO2 board and the Nellcor Nell-1 board. The Smith Medical pulseox is less power hungry than the Nellcor pulseox, consuming 22mW and 65mW respectively. The Nellcor sensor, however, exhibits better motion tolerance and has wider market adoption within clinical care settings. A variety of oximetry probes, including disposable finger

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wraps, pediatric foot wraps, and forehead adhesives, are available from both vendors. The use of either vendor’s sensor should be determined by the usage scenario requirements.

6.8.2.1 Short-Range Body Area Network

Multiple miTags on a patient’s body communicate wirelessly, via a body area network, to aggregate data before transmission to the long range mesh network. When multiple miTags are placed on a patient, the body area network automatically selects one of the miTags to operate as the hub which aggregates data from other sensors on the body. If the designated hub fails to operate (e.g. due to loss of battery power or network connectivity), the miTag array automatically reconfigures and selects a new hub amongst the remaining devices. This redundancy provides the benefit of added reliability and lengthens the operational battery life of the overall body area networked system. Since the aggregation function requires no additional hardware, this helps to minimize cost. This gain in flexibility, however, proposes additional technical challenges into the design of body area networking software – the aggregation functionality must be sufficiently lightweight in order to run onboard mote hardware, which have significantly fewer processor capabilities than the more powerful devices (e.g. PDAs and mobile phones) that are typically used as the hub.

6.8.2.2 miTag Mesh Network

Wireless networking can become particularly challenging during disasters or surge scenarios, where existing infrastructure may be unavailable and the region of patients can be spread beyond the radio range of existing access points. A key technical challenge in this work is the ability to rapidly deploy a reliable and scalable wireless network without relying on existing modes of communication infrastructure (such as Wi-Fi hot spots and cellular phone towers). Our networking software supports automatic rerouting and meshing capabilities to ensure scalability and reliability in mass casualty environments. The wireless network is formed by repeater nodes, which are dispensed by responders on the scene.

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In a typical disaster scenario, responders drop repeaters on the ground as they move through the scene. Repeaters automatically form a wireless mesh network with each other and relay data between themselves to a receiving monitoring station. The network coverage grows dynamically as repeaters are added. Repeaters can be strategically placed in locations to route around sources of interference. Repeaters display a series of colored lights to assist users in dispensing them at the correct locations. A green light indicates the repeater is detecting a strong network coverage, a red light indicates the repeater is out of network range, and a blue light indicates a location where network coverage is low and the repeater should be dispensed there.

Figure 19 – Server hosts information to the web, and is accessible from the web

browsers of both handheld devices and computers.

6.8.2.3 miTag Server-based Software

A central server, designed with service oriented architecture principles, processes sensor data from multiple sensor networks and disseminates it to clients data display software (Figure 19). The server publishes a set of SOAP

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and REST-based web services to allow authenticated 3rd party software applications access to the sensor data. Features of these web services include sensor history retrieval, sensor reconfiguration, user authentication, alarm monitoring, and alert generation.

The server is built exclusively on open source technologies, including JBoss Application Server and MySQL database server. As the server components are freeware, this again minimizes the cost.

The server was developed to be capable of receiving real-time streaming vital signs from a large number of sensor sources, spread over multiple sensor networks, using Java Message Service (JMS) protocol. JMS is a widely-used standard for sending messages via a bus-like architecture. JMS contains a variety of features useful to medical sensor network applications, including built-in security, broadcast messaging, and data management when connectivity to the server is interrupted. A software cache, internal to the server, allows multiple clients to make frequent (1 Hz or less) polls to the server for the latest alerts and sensor data.

Software applications making web service requests over HTTP can receive data at nearly the same rate provided by a push-based, stateful connection, while the application developers benefit from the robust HTTP handling of the JBoss Application Server and the simplicity a stateless connection offers. Performance tests of the server yielded encouraging results on its capability to simultaneously process data from 200 sensors. The server consumed more or less 40% CPU time (spikes up to 50%) on an ordinary laptop with a 3.00 GHz Pentium D processor and 1 GB of RAM. With CPU speeds continuing to increase and multi-core processors becoming increasingly common, JBoss’ inbuilt multithreading allows our software to benefit easily from these trends.

6.8.3 Pilot Deployments

The miTags were piloted inside two departments of the Burn Center at Washington Hospital Center: the burn intensive care unit (ICU), and the burn step-down unit (SDU), in order to demonstrate their ability to operate inside a radio-interference rich clinical environment. One patient in each department was

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monitored for 5 days. The SDU at the Burn Center is a long hallway, approximately 80m in length. In order to provide wireless coverage throughout the hallway bedrooms, 4 repeaters were placed under call lights along the hallway.

A monitoring laptop was placed at the nursing station at the end of the hallway. The ICU was a semicircular room approximately 60m in diameter. When the monitoring laptop was placed at the nursing desk at the middle of the ICU, its USB transceiver directly received wireless coverage to all patient beds in the ICU. Repeaters were not necessary there. Several wireless networks already existed in these departments, including Cisco 802.11b routers operating on the same 2.4 GHz band as the miTags, indoor location tracking tags from Parco operating on ultra-wideband, and telemetry monitoring station from GE Apex Pro operating on the 400MHz band. No interference was reported for these preexisting networks or any medical equipment, including bedside monitors that were actively used on patient participants during the pilot.

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Figure 20 – Example of two teams: Team A using miTags and Team B using traditional

tools.

The miTag system has been developed to automate patient monitoring during emergency events. The system was specifically designed to meet the diverse needs of users in the disaster response arena, minimizing cost and maximizing extensibility and reliability. Cost is minimized on the hardware side through the use of an extensible communication platform that supports a variety of sensors. Reliability is maximized as the long-range mesh network and short-range body area networks are capable of dynamic reconfiguration in the event of node failure. A number of additional capabilities add to the ease-of-use of the system, including user feedback features on the repeater nodes, and the capability to automatically reconfigure the sensor network behavior to suit various usage scenarios. Cost is minimized on the server software side through the exclusive use of open source technologies. Furthermore, the server software is platform independent, requires modest CPU power, and can be rapidly deployed.

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6.9 THE ISCRAM COMMUNITY

The International Community on Information Systems for crisis response and management is one of the best forums in order to check the state of the art within this topic. The annual international conferences they organize is the key part of this community and covers a wide range of topics that can be considered interesting for mass casualty incidents. Let’s see an example with the proceedings or the ISCRAM'09 Conference Proceeding held in 2009 in Gothenburg, Sweden.

6.9.1 TRACK: Human-Computer Interaction

6.9.1.1 Information Overload and Inclusivity

Using Text Analysis for Information Overload in Pan Flu Planning and Response

Sensemaking and Information Management in Humanitarian Disaster Response: Observations from the TRIPLEX Exercise

Identifying and confirming information and system quality requirements for multi-agency disaster management

6.9.1.2 Interactive Map Technologies

Early flood detection and mapping for humanitarian response

Spatiotemporal Mashups: A Survey of Current Tools to Inform Next Generation Crisis Support

An Indoor Positioning System for Improved Action Force Command and Disaster Management

6.9.1.3 HCI Design & Requirements

User Acceptance of Community Emergency Alert Technology: A Case Study

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Mega-Collaboration: The Inspiration and Development of an Interface for Large-Scale Disaster Response

Designing for Firefighters—Building Empathy through Live Action Role-Playing

6.9.1.4 Crisis Communication

CAP-ONES: An Emergency Notification System for all

Computer Supported Collaborative Training in Crisis Communication Management

Towards a Distributed Crisis Response Communication System

6.9.2 Collaboration and Social Networking

6.9.2.1 Decision-Making

Group Decision-Making Method in the field of Coal Mine Safety Management Based on AHP with Clustering

Crisis Decision Making Through a Shared Integrative Negotiation Mental Model

Towards hybrid rational-naturalistic decision support for Command & Control

6.9.2.2 Designing for Collaboration

Designing Collario for Continuous Reviewing and Practicing of Emergency Plans to Ensure Complex System Safety

Information Sharing Using Live Video in Emergency Response Work

Hastily Formed Networks for Disaster Response: Technical Heterogeneity and Virtual Pockets of Local Order

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6.9.2.3 People and Social Media

An Online Social Network For Emergency Management

Repairing Human Infrastructure in War Zones

Twitter Adoption and Use in Mass Convergence and Emergency Events

6.9.2.4 Lightweight Stakeholder Collaboration

Disasters2.0: Application of Web2.0 technologies in emergency situations

Web based macroseismic survey: fast information exchange and elaboration of seismic intensity effects in Italy.

Expectation of Connectedness and Cell Phone Use in Crisis

6.9.3 Standardization and Ontologies

6.9.3.1 Architectures

Towards an interoperable data model for forest fire reports

Exploring Development of Service-Oriented C2 Systems for Emergency Response

Reconsidering information management roles and capabilities in disaster response decision-making units

6.9.3.2 Interoperability

Collaborative process design for Mediation Information System Engineering

Using Architectures for Semantic Interoperability to Create Journal Clubs for Emergency Response

Information Management for Crisis Response in WORKPAD

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6.9.4 Research Methods

6.9.4.1 Analysis, Testing & Evaluation

GDIA: a Cognitive Task Analysis Protocol to Capture the Information Requirements of Emergency First Responders

A Principled Method of Scenario Design for Testing Emergency Response Decision-Making

Evaluating the Impact of Improvisation on the Incident Command System: A Modified Single Case Study using the DDD Simulator

6.9.4.2 Ethnography and Field Reports

Red, white and blue with a little bit of green: an ethnographic study into the Emergency Response Rooms in the City of Amsterdam

Socio-spatial implications of converging physical and digital infrastructures for crisis management: Ethnography of two service technician working environments of a power provider company

Sharing Knowledge: How to Highlight Proven Experience in the Swedish Armed Forces

6.9.5 Intelligent Systems

6.9.5.1 Knowledge, Training and Smart Environments

OpenKnowledge at work: exploring centralized and decentralized information gathering in emergency contexts

Self-Organizing Resource Network for Traffic Accident Response

Crisis response simulation combining discrete-event and agent-based modeling

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6.9.5.2 Simulation and Resource Allocation

Using Computer Simulation for Emergency Response: Lessons Learned from the FireGrid Project

Market Based Adaptive Resource Allocation for Distributed Rescue Teams

DMT-EOC – A combined system for the Decision Support and Training of EOC Members

6.9.6 Open-Track

6.9.6.1 Local Communities and Government Collaboration

Action Research Supported Implementation of a Crisis Competence Centre

6.9.6.2 Information Processing in Environmental Crisis

Approaches to visualisation of uncertainties to decision makers in an operational Decision Support System

Central response to large chemical accidents

Integrating Scenario-Based Reasoning into Multi-Criteria Decision Analysis

6.9.6.3 Dependability and Vulnerability

An Indicator Framework to Assess the Vulnerability of Industrial Sectors against Indirect Disaster Losses

Dependability of IT Systems in Municipal Emergency Management

Capabilities of C2 Systems for Crisis Management in Local Communities

Hallberg, Niklas., Erland Jungert.

Swedish Defence Research Agency, Sweden

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6.9.6.4 Computing Situation Awareness

Computed Ontology-based Situation Awareness of Multi-User Observations

An Emergency Response Model Toward Situational Awareness Improvement

Crowd control by multiple cameras

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7 INFORMATION MANAGEMENT

This Chapter tries to summarize the main organisms in charge of managing the information in mass casualty incidents; REMPAN, RANNET and the EU Health Security Committee.

7.1 RADIATION EMERGENCY MEDICAL PREPAREDNESS AND ASSISTANCE NETWORK (REMPAN)

In 1988 WHO (World Health Organization) acceded to the Convention on Early Notification of a Nuclear Accident and to the Convention on Assistance in the case of a nuclear accident or radiological emergency. WHO established a network of collaborating centers for radiation emergency medical preparedness and assistance, called REMPAN (Radiation Emergency Medical Preparedness and Assistance Network). This is coordinated by WHO/HQ in Geneva in close cooperation with WHO Regional Offices and the International Atomic Energy Agency (IAEA). REMPAN fits well into the global strategy of a "One WHO" and provides a program for the prevention and cure of the health effects of accidental overexposure to radiation.

The main objectives of REMPAN are the following ones:

to enhance medical preparedness for radiation accidents among WHO Member States.

to provide medical advice and assistance in case of nuclear accident or radiological emergency

to assist at follow-up studies.

These objectives are fulfilled by:

strengthening radiation emergency medical preparedness

providing medical advice and assistance to treat and monitor acutely exposed individuals

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improving existing public health advice systems to reduce the long-term effects of overexposure to low and protracted doses to populations living in territories affected by radioactive contamination.

analyzing radiation emergencies and developing recommendations for the treatment of casualties.

analyzing long-term medical consequences of radiation accidents.

Some meetings of Directors of REMPAN collaborating centers are organized by WHO to evaluate the status of the Network and to promote information exchange. The first meeting, which developed the basic principles for the establishment of REMPAN, was held in France-UK in 1987. Subsequent meetings were held in the USA (1988), USSR (1990), Germany (1992), France (1994), Japan (1995) and Brazil in 1997.

Public health actions in cases of radiological emergencies, aim at the protection of the population from acute, chronic or protracted irradiation in relatively low doses raising the possibility for the development of long-term radiation stochastic effects. In addition, this includes measures that can prevent psychological effects of radiation emergency or stress related pathological conditions.

These actions must be carefully planned at the pre-accident period. Effective preparation for public health action is based on principles like probability (what do we expect to happen?), priority (who are most at risk?) and viability (what is it practical to do?). Public health actions in the event of a radiation emergency can be implemented effectively in close cooperation between public health services, radiation protection boards, administrative organs, police and other relevant organizations.

At the international level, a close collaboration before and during a radiation emergency are being established between WHO and IAEA. The harmonization of public health actions at all levels starting from the accident site up to the international level and the active participation in this process of public health

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physicians may contribute significantly to the protection of public health in case of large scale nuclear or radiological accidents.

7.2 RESPONSE ASSISTANCE NETWORK (RANET)

The Response Assistance Network (RANET) is intended to strengthen the worldwide capability to provide assistance and advice and/or to coordinate the provision of assistance including nuclear or radiological incidents.

The aim of RANET is to facilitate:

The provision of requested international assistance

The harmonization of emergency assistance capabilities

The relevant exchange of information and feedback of experience

RANET is designed to provide a compatible and integrated system for the provision of international assistance to minimize the actual or potential radiological consequences of an incident or emergency for health, environment and property.

RANET provides timely assistance in the following areas: advisory, assessment and evaluation, monitoring and recovery. These areas of assistance would be applied in nuclear accidents or radiological emergencies in the context of the Early Notification and Assistance Conventions, and where the radiological consequences exceed a State’s response capabilities.

The RANET consist of a network of Competent Authorities (CAs) that is capable and willing to provide, upon request, specialized assistance by appropriately trained, equipped and qualified personnel with the ability to respond in a timely and effective manner to:

Nuclear or radiological emergencies

Other nuclear or radiological incidents

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Whether an incident or emergency originates on a State’s territory or other area under its jurisdiction or control, a State may request assistance from the IAEA. Upon receiving an official assistance request, the IAEA through its IEC (Incident and Emergency Center) becomes the focal point for the facilitation and coordination of international assistance. The IEC assesses the request and provides initial advice to the requesting State. The IEC may deploy an IAEA Field Response Team (FRT) to perform an initial evaluation of the situation and to recommend whether activation of RANET capabilities is necessary. RANET response will be then tailored to the specific situation.

If the activation of NAC (National Assistance Capabilities) resources is recommended, the IEC will alert the appropriate NWPs (National Warning Points) and request coordination with appropriate CAs. The CAs will inform the IEC regarding the availability of their resources for assistance and, if required, the resources will be placed on standby. This concept is outlined in the next figure.

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Figure 21 – Outline of the RANET concept An Assistance Action Plan (AAP) for the requested assistance will be developed by the IEC in coordination with the requesting State, CAs providing assistance and other international organizations. This plan will specify the responses needed and whether they will be deployed and/or provided from an external base. The AAP should include all technical, financial, diplomatic, organizational and logistical aspects of the assistance to be provided.

Upon acceptance of the AAP by the requesting State, the IEC will notify the assisting States’ CAs and request activation of NAC resources. The Assistance

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Action Plan should contain provisions for inclusion of other CA’s NAC resources, if needed. Changes to the Assistance Action Plan must be coordinated with all parties before the changes are implemented.

7.2.1 NAC activation

NAC activation could involve one or more of following ones: an Assistance Mission, a Field Assistance Team (FAT) as part of the Joint Assistance Team (JAT) and/or an External Based Support. The type of assistance will be specified in the Assistance Action Plan. The different types of capabilities that can be activated are these:

7.2.1.1 Assistance Mission

This consists of a group of qualified experts to address nuclear or radiological incidents providing advice, assessment, training, medical, monitoring or other specialized assistance.

A team leader, who is identified and agreed before deployment, leads the Assistance Mission. The team leader is responsible for all on-scene assistance activities and ensures coordination with the requesting State, IEC and any External Based Support. The concept of an Assistance Mission is outlined in the following figure.

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Figure 22 - The concept of an Assistance Mission 7.2.1.2 Joint Assistance Team (JAT)

A Joint Assistance Team is normally requested to address more complex assistance. The JAT consists of IAEA Field Response Team and all deployed FATs.

A Joint Assistance Team Command, composed of all FAT leaders and an IAEA FRT leader, manages all on-scene JAT assistance and ensures coordination with the requesting State, IEC and External Based Support. A Chairperson, is identified and agreed upon before deployment, heads the JAT Command. The concept of JAT is outlined in the following scheme.

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Figure 23 – The concept of the Joint Assistance Team 7.2.1.3 External Based Support

External Based Support is any support to an Assistance Mission, a JAT, IEC or to a requesting State. Such support can be expert advice on assessment, monitoring, analytical, and medical or other specialized emergency response function. This support is not deployed to the event scene but is provided from another location.

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7.2.2 Field operational safety

The Assistance Mission leader or JAT Command should implement the activities set by the Assistance Action Plan. They are responsible to ensure that all activities are performed in a safe manner by following procedures, which at a minimum should meet appropriate IAEA safety standards. In an emergency response, priority will be placed on the safety of personnel and members of the public. Unsafe or possible unsafe conditions, operations and/or activities should not be conducted until JAT Command or the Assistance Mission leader has provided an acceptable, safe solution.

7.2.3 Assistance termination

The requesting State or the assisting party may at any time request termination of assistance received or provided under the Assistance Convention. Once such a request has been made, the parties involved should consult with each other to make arrangements for the proper conclusion of the assistance.

Termination of assistance could be through any of the following:

All Assistance Action Plan tasks are certified as completed by the parties.

The requesting State may declare at any time the end of the requested IAEA assistance.

The IEC may declare at any time the end of assistance due to failure to resolve unsafe or unsecured conditions or practices, or the failure of the requesting State to comply with the Assistance Action Plan or JAT Command/NAC has completed all Assistance Action Plan items.

JAT Command/NAC considers individual Assistance Action Plan tasks completed. JAT Command can release certain assets as Assistance Action Plan tasks are completed. Upon termination of assistance NAC resources will be demobilized. Partial

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demobilization of resources can occur as the individual Assistance Action Plan tasks are completed.

7.2.4 Financial arrangements

Some financial support for RANET activities may be provided through the IAEA’s regular budget or from other IAEA resources. The IAEA may cover the expenses for the initial mobilization and deployment of the Assistance Mission or Joint Assistance Team. If the IAEA cannot cover these initial expenses, the CAs may cover the expenses, which may be reimbursed at a later stage.

It is expected that the State that is a member of RANET will provide financial support to maintain its national preparedness and response capabilities that may be available for any international assistance. States are responsible for maintaining basic insurance for, or otherwise assume financial liability, for responders and equipment that they deploy. The IAEA assumes no liability for personnel or equipment.

7.3 EU HEALTH SECURITY COMMITTEE

The terrorist attacks in the USA in September 2001 prompted governments and international bodies to review and reinforce policies, contingency plans and resources to prevent and mitigate the effects of such attacks. The need for joint action in the EU to complement national measures led to the establishment, in October 2001, of the Health Security Committee, made up of high-level representatives of the Health Ministers, to serve as the coordination platform for public health preparedness and response to deliberate releases of biological, chemical and radio-nuclear agents.

The SARS (Severe Acute Respiratory Syndrome) epidemic in 2003 opened up a new dimension in the public health area: a previously unknown disease with features similar to influenza and common cold was spreading rapidly causing high mortality and morbidity, fast travel and global trade facilitating transmission in the absence of relevant vaccines and drugs. The epidemic resulted in a major re-think of public health defenses against communicable diseases and demands for research to find effective counter-measures. Above all, it stressed

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the need for world-wide cooperation to nip such diseases in the bud by detecting outbreaks early and acting at their source. Action by the countries affected with support and guidance from the World Health Organization helped prevent catastrophic developments; coordination in the EU based on the Early Warning and Response System (EWRS) contributed to Member States’ knowledge of the situation and readiness to stem any potential spread of the disease.

7.3.1 Purpose and scope

Public health emergencies are dominated primarily by events related to pathogens transmitted from person to person or through unsafe food or products; or through animals and plants or by harm to individuals by the dispersion or action of biological, chemical or physical agents in the environment. Common to all such emergencies are assets and resources to be used and consequence management aspects to go through in developing emergency or contingency plans. This communication identifies the key building blocks of generic preparedness planning. It is based on experience gained through the exchange of information and sharing between the Commission and Member States of plans concerning smallpox and pandemic influenza and extensive work with the help of the Health Security Committee and the Community Network for the epidemiological surveillance and control of communicable diseases in the European Community.

This led to the elaboration of a detailed technical guidance document which contains individual attention points, objectives, checklists and division of public health roles and functions for Member States, for relevant Community Agencies

and for Commission services for each of the key components of the planning process. The overall goal is to assist Member States in developing their plans and factoring in the EU dimension, with its body of laws in various sectors with a bearing on public health emergency plans. The Communication together with the technical guidance document provides the backbone for developing core elements in national plans, addressing generically different types of health threats, whether anticipated (such as pandemic influenza) or unexpected (e.g. a SARS–like epidemic) and aims at improving the interoperability of such plans.

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The framework for cooperation in generic preparedness planning in the EU covers three main activities:

sharing national plans and making comparisons, evaluations, in particular through joint tests and guidance on peer reviews of plans, and improvements on the basis of specific checklists set out in the technical guidance on generic preparedness planning

identifying the contribution and role of existing Community legislation and ensuring that national plans take them fully into account, as well as examining the need for further Community measures

examining and improving implementing arrangements, which could help improve the timely flow of information and the interoperability and congruence of plans and responses

7.3.2 Essential components of generic preparedness planning

The key components that need to be fully addressed in order to arrive at public health emergency plans are:

Information management

Communications

Scientific advice

Liaison and command and control structures

Preparedness of the health sector

Preparedness in all other sectors and inter-sectorally

The experience gained from cooperation on planning at EU level has shown that the ability to respond to a public health emergency depends heavily on the

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extent to which these issues have been considered in advance and whether plans have been put in place that address each and every component.

7.3.2.1 Information management

Information management concerns the gathering, handling, use and dissemination of information related to an emergency, to detect and identify the hazards and risks, monitor the status and evolution of emergency, identify the assets and resources available and their distribution and use and the status of systems serving information needs for the various actors involved.

Information is all manners of description and representation as well as the generation of knowledge and the understanding of implications of facts and figures. It involves surveillance and medical intelligence, data from sensors and monitors and meters of all sorts, clinical and epidemiological data, health data and statistics, and data on products, goods, infrastructure and services relevant to the emergency. Organizing adequate health and/or medical surveillance by Member States before an event and improving afterwards is necessary to identify potential public health threats, their scale and extend and their international relevance at a very early stage and follow their evolution and changing circumstances. Pre-event surveillance and monitoring applies to communicable, toxic, chemical, radio nuclear and physical threats, whether deliberate or not and changes in the environment that may precipitate natural phenomena with public health consequences. Standards for surveillance in different areas, including case definitions and trigger levels need to be comprehensive and applied rigorously.

The Community has played a key role in setting requirements and organizing the coordination of surveillance and monitoring related to a wide range of emergencies through several rapid alert systems, dedicated surveillance networks, radiation protection monitoring systems and information systems for chemical substances.

Medical intelligence and the scanning of media reports provide information for risk analysis purposes and allow suspicious or unusual situations and events to

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be spotted at an early stage and advance warnings to be issued. Member States and the Commission have developed powerful tools for this purpose.

Clinical and laboratory diagnosis is part of the organization of information management, both to identify unknown agents and to confirm known agents. Member States are responsible for diagnosis and the Community, through reference laboratories, together with the ECDC (European Center for Disease prevention and Control), provides an EU-wide cooperative platform on laboratory and quality procedures, collating clinical data and secondary confirmation.

Laboratory capacity must be available at Member State level and, for issues beyond the national capacity or when no national capacity is available, cooperation between laboratories within the Community must be organized to ensure comprehensive coverage throughout the EU.

Collecting and sending for analysis of environmental samples to laboratories require the application of protective measures. International transfer of materials in this respect is subject to rules negotiated under the appropriate UN-bodies and further work is required in which the Member States and the Commission are key players, to ensure that transfers for public health purposes are not obstructed or unduly delayed.

7.3.2.2 Communications

The distribution of accurate and timely information at all levels is critical in order to minimize unwanted and unforeseen social disruption and economic consequences and to maximize the effective outcome of the response. The information management described in the previous section cannot be achieved without accurate and timely distribution of the information.

Communications can come in many forms such as text, voice, and video and, their infrastructure must be in place and be as robust as possible, so as to preserve communication channels even in emergencies when some forms may be incapacitated and sufficient redundancy must be built in to cater for the loss of particular systems (e.g. telephony) or premises or a collapse due to

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excessive traffic (e.g. computer system or Internet crashes). In the case of a major public health emergency, existing wired communications infrastructure might have been damaged or destroyed, preventing the use of wired networks for communications. Alternatives must be provided, including wireless transmission.

Authorities at national level as well as the Commission have the communication systems and standard operating procedures in order to understand and agree the scientific, economical, political and social implications of messages.

Public authorities should communicate effectively with the public and the media before and in anticipation of events that may lead to public health emergencies, from an early stage in any major incident, establishing themselves as the leading, if not the only, source of authoritative information and continuously during the unfolding of the event and its consequences. Member States, the Commission and relevant Community agencies are working to coordinate their crisis communications to ensure the messages they give are accurate and comprehensive.

At the level of each Member State as well as the Commission, this requires the existence of systems and procedures for communication between authorities and with professionals and the public in clear and unambiguous terms. Coordination is paramount to obtain in the EU consistency and accuracy in the messages to the public, preserving confidence in the ability of authorities to face up to an emergency and avoiding a public health crisis. This implies clear flow of data input and feedback, uninterrupted flow of information and data transfer, and responsibilities of each relevant actor to collect, analyze and report the surveillance and monitoring response data from the first notification to the appropriate structures. Connecting the competent authorities and decision makers requires 24h/7d operational contact points in the Member States and in the Commission and these have already put in place for many sectors of EU activity.

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7.3.2.3 Preparedness in all other sectors and inter-sectorally

The processes required to deal with public health emergencies beyond the health sector work in two ways: they serve to prepare other sectors to assist the public health authorities in medical interventions, such as triage, isolation, quarantine, treatment and medicine administration and vaccinations, and they also serve to introduce and apply measures dealt with mostly by other sectors, such as

logistics (e.g. establishment of stocks – resources and minimal requirements for protective gear and medical devises and other counter-measures)

culling decontamination issues

power and drinking water supplies

transport measures, in particular at points of entry and exit of the territory of Member States

telecommunications

civil protection and civil defense operations on shelter, rescue, and on making available vital supplies such as food, water equipment and materials and transfers between countries of such resources and assets

co-operation between medical and law enforcement intervention on banning public gatherings and closing down premises, forensic epidemiology and on legal and ethical implication of countermeasures (e.g. quarantine; confidentiality of passengers lists, transport of dangerous goods, customs, controls and enforcement, requisitioning of property…) etc.

In particular, Community customs risk management systems should be used to send information directly to targeting centers and border posts. The use of international Customs co-operation will also assist in securing the supply chain

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and so facilitate the rapid movement of vital supplies to target areas. Management of threats to security is primarily a law enforcement function that focuses on the measures taken to anticipate, prevent, and/or resolve a terrorism threat or incident. Law enforcement authorities or agencies of Member States are in the lead for threat management. The Commission is setting up a network connecting the relevant authorities of Member States to provide EU-level coordination in this area.

Consequence management by Member States includes measures to detect and diagnose releases and outbreaks and protect public health: search, rescue, and medical treatment of casualties; evacuation of people at continuing risk; protection of first responders; and prevention of the spread of disease through contact-tracing, isolation and treatment of cases, quarantine of those exposed and restriction of movement for specific areas and closing down of premises (social venues, schools, theatres, other mass gatherings).

The latter two will require the intervention of authorities other than health services and therefore coordination between the services and authorities involved. Consequence management also focuses on restoring essential government and local services and providing emergency relief to government, businesses and individuals affected by the consequences of the emergency response. If wider community assistance is required in the event of a major health emergency, the Community Civil Protection Mechanism could prove a valuable tool for ensuring rapid deployment of the required assistance. To assist Member States efforts, the Commission has set up a programme on critical infrastructure protection in the fight against terrorism The Commission is set to publish a Green Paper on the key issues of the European Programme for Critical Infrastructure Protection (EPCIP).

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8 RESEARCH

This Chapter shows some of the research projects that can be considered as state of the art within this project, even if they are not exactly focused on CBRN mass casualty incidents. Some project details and participants are given as well as a brief description.

8.1 SECOND GENERATION LOCATOR FOR URBAN SEARCH AND RESCUE OPERATIONS (SGL FOR USAR)

The Second Generation Locator for Urban Search and Rescue Operations (SGL for USaR) is mission oriented towards solving critical problems following large scale structural collapses in urban locations. The devotion, courage and expertise of rescuers need to be matched by procedures and technology that will enable safe and effective responses. This Integrated Project will combine chemical and physical sensors integration with the development of an open ICT platform for addressing mobility and time-critical requirements of USaR Operations.

The project will also focus on medical issues and on the relevant ethical dilemmas. SGL for USaR has marshaled a pan-European interdisciplinary project team to produce a well-balanced consortium of 21 partners including rescue teams, researchers and SMEs along with the support of 15 LOIs. The project is formed by eight sub-projects (work packages) running in parallel. These WPs address the development of simulation environments; the development and validation of portable devices for location operations; the development and validation of smart sensors environment for monitoring the situation under the ruins; the management of medical information, including privacy and bioethics;

Project Details

Start Date: 2008-10-01

End Date: 2012-09-30

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Duration: 48 months

Project Reference: 217967

Contract Type: Collaborative project (generic)

Project Cost: 6.22 million euro

Project Funding: 4.86 million euro

Programme Acronym: FP7-SECURITY

Programme Type:7th FWP (Seventh Framework Programme)

Web Site: www.sgl-eu.org

Project Partners:

Environics oy

Ecomed bvba

Faenzi s.r.l.

Direccio general de prevencio i extincio d'incendis i salvaments

Critical links sa

Bay zoltan alkalmazott kutatasi alapitvany

Service départemental d'incendie et de secours du vaucluse

Markes international limited

National and kapodistrian university of athens

Savox communications ltd

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G.a.s. Gesellschaft fur analytischesensorsysteme m.b.h.

Temai ingenieros s.l.

Anko anonymos etaireia antiprosopeion emporiou kai viomichanias

Entente interdepartementale en vue de la protection de la foret et de l environnement contre l incendie*e pfei

Dupli use 999823912 : osterrichische akademie der wissenschaften

Technische universitaet dortmund

Loughborough university

Universidad politecnica de madrid

Gesellschaft zur forderung der analytischen wissenschaften e.v.

Valtion Teknillinen Tutkimuskeskus (VTT)

8.2 SEAMLESS COMMUNICATION FOR CRISIS MANAGEMENT (SECRICOM)

SECRICOM is proposed as a collaborative research project aiming at development of a reference security platform for EU crisis management operations with two essential ambitions:

Solve or mitigate problems of contemporary crisis communication infrastructures (Tetra, GSM, Citizen Band, IP) such as poor interoperability of specialized communication means, vulnerability against tapping and misuse, lack of possibilities to recover from failures, inability to use alternative data carrier and high deployment and operational costs.

Add new smart functions to existing services which will make the communication more effective and helpful for users. Smart

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functions will be provided by distributed IT systems based on an agents infrastructure. Achieving these two project ambitions will allow creating a pervasive and trusted communication infrastructure fulfilling requirements of crisis management users and ready for immediate application.

The SECRICOM solutions are based on four technological pillars:

Secure encrypted mobile communication on existing infrastructures (GSM, UMTS networks) secure push to talk systems

Improved interoperability among various existing communicating systems, creating recoverable networks and seamless connectivity

Introduction of distributed systems and the agent paradigm forming a smart negotiating system for parameterization and independent handling of requests suitable for rapid reaction use

Security based on trusted hardware enhancing the confidentiality of data and the privacy of users

The SECRICOM will assure interface from systems currently deployed for crisis management to systems of new generation which will be defined in next decade such as SDR. Important impact is to enable seamless and secure interoperability of existing hundreds thousands radios already deployed to ensure the protection of invested resources and adaptivity to future development and emerging technologies.

Project Details:


End Date: 2012-04-30

Duration: 44 months


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Programme Acronym: FP7-SECURITY

Programme Type:7th FWP (Seventh Framework Programme)

Web Site: www.secricom.eu

Project partners:

Bumar sp. z.o.o.

Technische universitaet graz

Nextel sa

Itti sp.zo.o.

Smartrends, s.r.o.

Bapco limited

Universite du luxembourg

Commissariat a l'energie atomique (cea)

Ardaco, a.s.

Hitachi europe sas

Infineon technologies ag

Ustav informatiky, slovenska akademia vied

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8.3 THE INTEGRATED MOBILE SECURITY KIT (IMSK)

The Integrated Mobile Security Kit (IMSK) projectS. The IMSK accepts input from a wide range of sensor modules, either legacy systems or new devices brought in for a specific occasion.

Sensor data will be integrated through a (secure) communication module and a data management module and output to a command & control centre. IMSK will have an advanced man-machine interface using intuitive symbols and a simulation platform for training. End-users will define the overall system requirements, ensuring compatibility with pre-existing security systems and procedures. IMSK will be compatible with new sensors for threat detection and validation, including cameras (visual & infra-red); radar; acoustic and vibration; x-ray and gamma radiation and CBRNE. Tracking of goods, vehicles and individuals will enhance situational awareness, and personal integrity will be maintained by the use of, for example, non-intrusive terahertz sensors.

To ensure the use of appropriate technologies, police and counter-terrorist operatives from several EU nations have been involved in defining the project in relevant areas. Close cooperation with end-users will ensure compatibility with national requirements and appropriate interfaces with existing procedures. The effectiveness of IMSK will be verified through field trials. Through IMSK security of the citizen will be enhanced even in asymmetric situations.

Project Details


End Date: 2013-02-28

Duration: 48 months




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Web Site: www.imsk.eu

Project participants

Bruker daltonik gmbh

Thales security systems sas

Diehl bgt defence gmbhcokg

Dompagnie industrielle des lasers cilas sa

Selex communications spa

Airshipvision international sa

Deutscher fussball-bund ev

Trivision aps

Thales research & technology (uk) limited

Regione lombardia.

Swedish national police board

Selex sensors and airborne systems ltd

Qascom srl

Eppra s.a.s.

As regio

Universita degli studi di catania

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Ministere de l'interieur

Fraunhofer-gesellschaft zur foerderung der angewandten forschung e.v

Telespazio spa

Thyia tehnologije d.o.o

Deutsches zentrum fuer luft - und raumfahrt ev

Totalforsvarets forskningsinstitut

Valtion teknillinen tutkimuskeskus

Commissariat energie atomique cea

Commission of the european communities - directorate general joint research centre

The university of reading

8.4 EUROPEAN SOFTWARE DEFINED RADIO FOR WIRELESS IN JOINT SECURITY OPERATIONS (EULER)

The EULER project proposal gathers major players in Europe in the field of wireless systems communication integration and software defined radio (SDR), is supported by a strong group of end-users, and aims to define and actually demonstrate how the benefits of SDR can be leveraged in order to drastically enhance interoperability and fast deployment in case of crisis needed to be jointly resolved. The proposed activities span the following topics: proposal for a new high-data-rate waveform for homeland security, strengthening and maturing ongoing efforts in Europe in the field of SDR standardisation, implementation of Software defined radio platforms, associated assessment of the proposal for high-data-rate waveform for security, and realisation of an integrated demonstrator targeted towards end-users. Significant interaction with E.U stakeholders in the field of security forces management will contribute in

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shaping a European vision for interoperability in joint operations for restoring safety after crisis.

Project details

Project Acronym: EULER



Duration: 36 months



End Date: 2012-02-29

Project Status: Execution


Web Site: www.euler-project.eu

Participants

Universita di Pisa

Telespazio SPA

Selex Communications SPA

Elsag Datamat S.P.A.

Budapesti Muszaki es Gazdasagtudomanyi Egyetem

Astrium Limited

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EADS Secure Networks

Elektrobit Wireless Communications OY

Prismtech Limited

Oulun Yliopisto

Indra Sistemas S.A.

SAAB Aktiebolag

Ecole Superieure d’ Electricite

Nederlandse Organisatie Voor Toegepast Natuurwetenschappelijk Onderzoek

Commission of the European Communities – Directorate General Joint Reseach Centre

Imteruniversitair Micro-Electronica Centrum

ROHDE & SCHWARZ GMBH&CO Kommanditgesellschaft

8.5 NETWORK OF TESTING FACILITIES FOR CBRNE DETECTION EQUIPMENT (CREATIF)

The CREATIF network is dedicated to provide a communication platform for technology users and decision makers, providers and testers to discuss the future development of testing and to support user decisions and product / service development. Stakeholders are invited to exchange their views and knowledge: testing facilities can publish information about their expertise and testing capabilities / facilities in a database on testing facilities within EU-27, an

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advisory group of selected end-users and industrial experts will be established to integrate their point of view into project deliverables and topical workshops. In these workshops specific themes in the field of certification and testing of CBRNE detection equipment will be discussed.

CREATIF will ensure a careful examination of existing testing protocols and relevant standards to suggest harmonization of testing in the field of CBRNE detection both on a geographic scale within EU-27 and on a technical level.

Possibilities to amend testing protocols by covering human factors and operational / scenario based testing will be suggested. Additional deliverables of the network will be a roadmap for a European certification system for CBRNE detection products & services and a concept on the continuation of the CREATIF network as an autonomous body after the end of the funded project.

Project details:

Duration: 30 months

Progamme: FP7-Security, Coordination Action

Proposal No 217922

Starting date: February 2009

End date: July 2011

EU-funding: 831.300 Euro

Web Site: http://www.creatif-network.eu/home.html

Partners:

Austrian Research Centers

DGA- Centre d’Etudes du Bouchet

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DGA- Etablissement Technique de Bourges

Cotecna Inspection S.A. COT CH

Federal Institute for Materials Research and Testing

The Swedish Defence Research Agency FOI SE

Netherlands Organization for Applied Scientific Research ARC

Web Site: http://www.creatif-network.eu/home.html

8.6 IDENTIFYING THE NEEDS OF MEDICAL FIRST RESPONDER IN DISASTERS (NMFRDISASTER)

Project description: Identifying the Needs of Medical First Responder in Disasters (NMFRDisaster) is a project which coordinates medical first responders with research institutes with the purpose of identifying needs for further researches in the following areas:

Training methodology and technology used to train medical first responders for disasters.

Understanding the human impact of disaster on first responders.

Ethical and legal issues influencing the medical response to disasters.

Personal Protective equipment used in Chemical and Biological incidents.

Use of blood and blood products in disasters.

This will be achieved through a preliminary research on existing information followed by a workshop where the needs of the first responders will be identified, matched with existing knowledge and products.

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Project details:

Project acronym: NMFRDISASTER

Project reference: 218057

Project start date: 2008-05-01

Duration: 12 months

Project cost: 815.079 €

Contract type: Coordination (or networking) actions

Final date: 2009-04-30

Project status: Closed

Project financing: 815.079€

Project participants:

Charles Univerzity in Prague (Czech Republic)

Center for science, society and citizenship (Italy)

Fundación Rioja Salud (Spain)

Sinergie S.R.L (Italy)

IFRC Reference Centre for Psychosocial Support C/O Danish Red Cross (Denmark)

Ambulancezorg Nederland (Netherlands)

Samur Protección Civil Ayuntamiento de Madrid (Spain)

Al-Quds University (West Bank and Gaza Strip)

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8.7 COMMON OPERATIONAL PICTURE EXPLOITATION (COPE)

Project description: The Common Operational Picture Exploitation (COPE) project will integrate COTS solutions and novel technologies to achieve a step change in information flow both from and to the first responder in order to increase situational awareness across agencies and at all levels of the command chain. A user-driven approach will be taken to develop new technologies for supporting user information requirements at the scene of the event.

First responders belong to a heterogeneous group in terms of crisis environments as well as roles, command structure, organizational and national differences. Therefore, this project will apply a wide range of human factors methods to better understand the processes of individual agencies to ensure that new systems both match requirements and can be integrated with legacy processes and technologies. COPE will use the skills and competencies of a strong team of research scientists both from industry and academia, of technology providers and systems integrators supported by end users.

Project details:

Project acronym: Cope


Project start date: 2008-02-01

Duration: 36 months

Project cost: 3.89 million €

Contract type: Collaborative project (generic)

Final date: 2011-01-31

Project status: Execution

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Project financing: 2.54 million €

Web page: http://cope.vtt.fi/project.htm


Skysoft Portugal – Software e tecnologias de informaçao S. A. (Portugal)

Centre for European Security Strategies (Germany)

UTI Systems S. A. (Romania)

BAE Systems (Operations) Limited (United Kingdom)

The Provost Fellows and Scholars of the College of the Holy and Undivided Trinity of Queen Elisabeth Near Dublin (Ireland)

BAE Systems C-ITS (Sweden)

Ministry of Interior and Administration reform (Romania)

Pelastusopisto, Emergency Services College (Finland)

8.8 DEVELOPING A CRISIS COMMUNICATION SCORECARD (CRISCOMSCORE)

Project description: The purpose of this project is to develop an audit instrument and relevant guides for crisis communication strategies, with which public authorities are better prepared to communicate in crisis situations.

The project has four key objectives:

First objective is to identify critical factors for communication strategies in media relations before, during and after crisis situations.

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Second objective is to identify critical factors for communication strategies in relations with civilians and miscellaneous public groups (survivors, casualties, deceased victims, family to workers, first responders and affected communities) before, during and after crisis situations.

Third objective is to construct a Balanced Scorecard for public authorities to measure and improve their readiness to communicate in crisis situations.

Fourth objective is to simulate implementation by facilitating the use of the Balanced Scorecard and the Strategy Guides for spokes-people and crisis communication with other public groups.

This is a project to improve crisis communication, by identifying critical factors in media relations and relations with civilians (survivors, casualties, deceased victims, family to workers, first responders and affected communities) before, during and after crisis situations. These crises may be the result of acts of nature, or acts of man (both intended, such as terrorism, or unintended, such as major accidents and infrastructure failure).

By identifying critical factors the challenges of crisis communication are addressed. The findings will be reported in Strategy Guides and used as a basis for the Balanced Scorecard. The results will be available for public authorities.

Is needed an integrated approach, stimulating cooperation between the various organizations involved in crisis management and government levels. The consortium consists of four universities in various countries and an end user organization that has extensive experience in the field and a good network with related public and other organizations involved in crisis management.

Project details:

Project acronym: CriscomScore


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Project start date: 01/02/2008

Duration: 39 months

Project cost: 1.013.207 €

Project status: Execution

Project financing: 799.174 €


University of Jyväskylä (Finland)

Ben Gurion University of the Negev (Israel)

University of Tartu (Estonia)

Norwegian University of Science and Technology (Norway)

Emergency Services College Finland (Finland)

8.9 REAL-TIME ON-LINE DECISION SUPPORT (RODOS)

Project description: The objectives of the RODOS project are to develop a real-time on-line decision support system that could provide consistent and comprehensive support for off-site emergency management at local, regional and national levels at all times following a nuclear or radiological accident. The use of the system for training and exercises was a further important consideration in its developments. The overriding consideration was promote, through the development and use of the system, a more coherent, consistent and harmonised response to any future accident that may affect Europe.

The RODOS project was launched in 1989 to respond to these needs. It increased in size through the European Commission’s 3rd, 4th and 5th Framework Programmes. Significant additional funds have been provided by many national R&D programmes, research institutions and industrial

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collaborators, in particular, by the German Federal Ministry for the Environment, Nature Conservation and Nuclear Safety (BMU). Up to 40 institutes from some 20 countries in the EU, CEE, and FSU were actively involved in the project.

As a result of these collaborative actions, the comprehensive Real-time On-line DecisiOn Support system (RODOS) has been developed which can be applied generally within and across Europe. It can be used in national or regional nuclear emergency centers, providing coherent support at all stages of an accident (before, during and after a release), including the long term management and restoration of contaminated areas. Special attention has been given to radiological emergencies caused by dirty bombs, terrorist attacks, traffic accidents, etc.

The dispersion and deposition of material released to the atmosphere (up to 47 days) is predicted using a nested chain of flow and dispersion models, which cover two distinct areas:

the near range within an area of 160 km X 160 km.

the far range up to thousands of kilometres.

Appropriate interfaces exist with local and national radiological monitoring data, meteorological measurements and forecasts. Estimates of the current plume position are updates every 10 min, prognostic calculations are performed every 30 min. A hydrological model chain covers the dispersion of radioactive material into and through most aquatic environments (rivers, reservoirs, lakes, estuaries, coastal waters, seas, etc).

Data assimilation tools update diagnoses and prognoses as monitoring data (e. g. gamma dose rates, ground deposition or food contamination) arrive. Customisation tools exist for adapting the underlying data bases to local, regional and national conditions in Europe.

The system is able to support decisions about the introduction of a wide range of potentially useful countermeasures (e. g., sheltering and evacuation of people, distribution of iodine tablets, food restrictions, agricultural

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countermeasures, re-location, decontamination, restoration, etc.). Costs of implementation, manpower resources needed and quantities of waste material produced can be estimated as well as the effectiveness in terms of reducing contamination levels in the environment and radiation doses to members of the population. The software used enables the user to compare and evaluate the benefits and drawbacks of different countermeasure strategies (e. g. risks, costs, feasibility, public acceptance, perceptions, social, psychological and political implications and preferences or values of decision makers).

RODOS is a UNIX based system and has a client-server architecture that allows it to be distributed across a network of computers. Three categories of users can access the system:

via an X-Windows user interface (full functionality)

on PCs with standard browser via a simplified Web based user interface

as passive users with access to results generated by Category A or B users.

Furthermore, software tools exist for directly exchanging raw and processed data between decision support systems of neighbouring countries. A LINUX version of RODOS is available by mid 2005.

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Figure 24 – RODOS system

Figure 25 – RODOS centre

European coverage: The PV 6.0 version of the system has been installed in national emergency centers in several European countries (Germany, Finland, Spain, Portugal, Austria, the Netherlands, Poland, Hungary, Slovakia, Ukraine, Slovenia, and the Czech Republic).

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Web page: http://www.rodos.fzk.de/rodos.html

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9 REFERENCES

[1] A. P. Sharoda, M. Reddy, J. Abraham, C. DeFlitch and F.A.C.E.P, "The Usefulness of Information and Communication Technologies in Crisis Response," AMIA Annual Symposium Proceedings, vol. 2008, pp. 561-565, 2008.

[2] J. P. Killeen, T. C. Chan, C. Buono, W. G. Griswold and L. A. Lenert. (2006, A wireless first responder handheld device for rapid triage, patient assessment and documentation during mass casualty incidents. AMIA Annual Symposium Proceedings 2006pp. 429-433.

[3] D. Mendonça, T. Jefferson and J. Harrald, "Collaborative adhocracies and mix-and-match technologies in emergency management," Communications of the ACM, vol. 50, pp. 44-49, 2007.

[4] B. S. Manoj and A. H. Baker, "Communication challenges in emergency response," vol. 50, pp. 51-53, 2007.

[5] R. Martí, S. Robles, A. Martín-Campillo and J. Cucurull, "Providing early resource allocation during emergencies: The mobile triage tag," Journal of Network and Computer Applications, vol. 32, pp. 1167-1182, 11. 2009.

[6] C. Ashok-Kumar, G. Flaig, C. Kunze, W. Stork and K. D. Mueller-Glaser. (2008, "Efficient resource estimation during mass casualty emergency response based on a location aware disaster aid network " in Anonymous

[7] J. C. Buono, T. C. Chan, W. G. Griswold, R. Huang, F. Liu, J. Killeen and D. Palmer, "WIISARD: Wireless internet information system for medical response to disasters," in 2008,

[8] Y. Chu and A. Ganz. (2007, WISTA: A wireless telemedicine system for disaster patient care. Mobile Networks and Applications 12(2-3), pp. 201-214.

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[9] Tia Gao, C. Pesto, L. Selavo, Yin Chen, Jeong Gil Ko, Jong Hyun Lim, A. Terzis, A. Watt, J. Jeng, Bor-rong Chen, K. Lorincz and M. Welsh, "Wireless Medical Sensor Networks in Emergency Response: Implementation and Pilot Results," IEEE Conference on Technologies for Homeland Security, pp. 187-192, 2008.

[10] D. C. Cone, D. S. MacMillan, V. Parwani and Van Gelder. C., "Pilot Test of a Proposed Chemical/Biological/Radiation/ Nuclear-Capable Mass Casualty Triage System," Prehospital Emergency Care, vol. 12, pp. 236-240, 2008.

[11] D. C. Cone, J. Serra, K. Burns, D. S. MacMillan, L. Kurland and C. Van Gelder, "Pilot Test of the SALT Mass Casualty Triage System," Prehospital Emergency Care, vol. 13, pp. 536-540, 2009.

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