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Features May 2004: Volume 1, Number 2
   

Wireless Wizardry
The personal digital assistant is connected to a pulse-oximeter clip attached to a disaster victim’s finger. It sends the data through a wireless Wi-Fi modem to the command center.
By Neal Matthews

 
     

When the first bomb went off, Megan Miller was knocked flat. She came to, at the doors of the ground floor elevator, surrounded by about 10 other badly injured victims. Her stomach felt wet, and when she looked down she saw a 10-inch gash from jagged shrapnel. She was confused and disoriented, but when she heard the wails of the fire truck sirens drawing closer she knew that help was on the way.

The first crew of firemen was setting up a command post in the parking lot when BAM! a second bomb exploded at the building’s loading dock. This one contained an ounce of highly radioactive cesium-137, making it a “dirty bomb.” Now the original command post was suddenly contaminated. This meant that some of the first responders were also casualties, and the most severely injured found themselves inside a hot zone of radiation.

How could rescuers stay safe, while finding out who needed immediate attention and evacuation to a hospital? How could they transport Megan Miller and the other critically injured out of the chaos before they succumbed?

These are the main questions this disaster drill, Operation Moonlight, was trying to answer. But there was another, larger question being tested by researchers, students, and staff from UCSD’s California Institute for Telecommunications and Information Technology (Cal-(IT)2), where Miller, ’05, and several of the drill’s other “victims” work. In a world where terrorism can suddenly create 500 or 1,000 casualties, and existing emergency medical response relies on aging technologies, can advanced wireless networks be adapted to help save more lives?

Leslie Lenert, MD, certainly believes so. Lenert, 44, is the principal investigator on the UCSD School of Medicine’s joint project with the VA San Diego Medical Research Foundation and Cal-(IT)2 called WIISARD (Wireless Internet Information System for Medical Response in Disasters). A three-year, $4.1 million project funded by a Homeland Security contract through the National Institutes of Health, WIISARD constitutes a major effort to transfer UCSD’s engineering expertise into the public health sphere.
Lenert was appointed as an associate director at Cal-(IT)2 last June to help oversee Homeland Security projects that capitalize on UCSD’s expertise in wireless network engineering. “Essentially, what I can do is hear the problems that one group of people has, and then hear the solutions that another group has, and imagine how they can be knit together,” he explains.

With that in mind, Lenert was present at the disaster drill in the vacant Farmers Insurance building in Carlsbad, last May. The drill was organized by the San Diego Metropolitan Strike Team (MMST), whose medical director, Theodore Chan, is an associate professor in the emergency department of the UCSD Medical School. “In our drills, problems have arisen that WIISARD can address,” says Chan. The strike team, made up of about 100 first responders, including SWAT teams, paramedics, firefighters and hazardous materials crews, “needs something that tracks people to within a few feet,” Chan continues. “The test showed that the system works, but we have a lot of refining to do.”

The drill was the first big test of WIISARD’s “emergency room in a box,” which first responders would use in a disaster such as a gas attack at the convention center or a truck bomb at a Chargers game. Two other drills, one slated for April and another for late 2006, will refine the system. During the first drill, Lenert, Chan and other researchers were in a mock “command center”—actually a UCSD shuttle bus outfitted for wireless communication—looking at two display screens. One screen showed the location of a dozen or so volunteer victims, and the other showed their heart rates and the levels of oxygen being absorbed into their blood.

The boxed emergency room is envisioned as a cache of equipment carried on a fire truck. This includes wireless transmission devices called “bread crumbs,” which are positioned throughout a disaster scene. To test this concept, the first paramedics to arrive at the site in Carlsbad dropped suitcase-sized transponders throughout the building to establish a wireless “mesh” network. This system created an “always best connected” wireless link to the command center, switching the communications pathway among the ethernet, internet or cellular connections whenever the signal was momentarily broken. “We understand that what happened on 9/11 was there were no communications. This was the biggest single failure,” Lenert says. “So you have to bring your own network.”

At the disaster site, a radiation perimeter was established outside the vacant building and paramedics had to don full anti-radiation suits and masks before they could venture in to treat Megan Miller and the others. When they found Miller they checked her injuries, tried to stop her bleeding with direct pressure on the wound, then entered her vital signs into a Personal Digital Assistant (PDA), which they hung around her neck. Other victims had pulse oximeters clipped to their fingers and attached to the PDAs. These sent a constant reading of heart rate and oxygen uptake to the mock command center in the shuttle bus. The PDAs also had a device, sending information on the patient’s location. When WIISARD becomes fully functional next year, emergency medical specialists in the command center will be able to monitor each patient’s vital signs and dispatch the nearest paramedic when these become critical.

In the next drill, scheduled for April, the PDAs will be replaced with bulky wristbands, called “tags,” which will include a bar code as well as both a locator feature and a pulse oximeter. The emergency room in a box will carry dozens of these battery-powered tags, each about the size of a cigarette pack, and medics will strap them onto the wrists of patients.

The wristband tags are being developed with the help of students in the Jacobs School of Engineering as part of their Electronic and Computer Engineering (ECE)191 and 291 classes, in which they work on a real project with local companies through Cal-(IT)2. Some of the students found the work so valuable that they stayed on to help with WIISARD after completing the class. Ramesh Rao, the UCSD division director at Cal-(IT)2 who oversees Homeland Security projects, was delighted by this level of dedication. “Students want to be able to talk about this project when they graduate,” Rao observes. “It demonstrates their ability to work on open-ended projects, to work against a deadline, and make design choices and trade-offs.”

The students are helping integrate the pulse oximetry sensors into the wristband, as well as working on the battery configuration, wireless code development and the parts required for location tracking. Rick Pan, ’04, oversaw research on batteries, power consumption and related part ordering, and came away with a deeper appreciation of group endeavors. “Working in a team to do research is challenging, but it’s effective,” says Pan. “We all have our unique strengths. Everyone contributes his knowledge and, at the same time, we learn from each other. No matter how good an engineer I am, I know I have weaknesses. Working with different people is the best way to improve my productivity and the overall productivity of the group.”

Lenert believes that the interdisciplinary nature of the WIISARD project will have a lasting influence at UCSD. “I’d like nothing more than to make this kind of problem my main focus over the next 10 years,” says Lenert, who relinquished about half his work as chief of the Laboratory for the Study of Patients’ Preferences at the VA in order to oversee WIISARD. “It’s a redirection of what I’ve done. It means I can’t do certain things I would have otherwise, like help doctors and patients talk about difficult decisions. But in view of the urgencies that we faced, that just wasn’t as important.”

Lenert became acutely sensitive to the current medical urgencies shortly after 9/11. A friend at Science Applications International Corporation (SAIC) took him to a conference about the national response to terrorism that included officials from the “black ops” side of the National Security Administration. “What I heard was that another attack on the United States is expected,” he says. “I felt I needed to be involved in this because when our country faces a dilemma or a problem like terrorism, we cannot go about our business as usual and expect to survive. We have to adapt what we’re doing and find a way to move forward.”

After the drill in May, the WIISARD team learned that in order to move forward they had to adapt to the fluid decision-making that occurs at a disaster scene. Before the drill, they thought there would only be one collection point where all the victims would be taken before being loaded into ambulances for transport to a hospital. But Miller, who was designated as badly wounded, found herself wheeled on a gurney (through radiation detectors and a watery scrub-down) to one of two transfer stations. “The commanders on the scene set up a station for people with minor injuries, and one for more seriously ill people,” says Lenert. “It just made sense to them at the time. So we learned that we can’t impose a structure on the first responders. We found that our work is about being sufficiently adaptive to them.”

The other main lesson is the importance of a live video feed from inside the disaster. One of the Hazmat team members was supplied with a video camera on his helmet, allowing the first responders in the command center to see what hazards emergency crews would have to face. “So there were two main lessons,” says Lenert. “The engineering lesson, being able to track patients to multiple transfer points, and the system requirement for having video.”

At the next disaster drill in April, in addition to enhanced video capability, Lenert expects to have a couple of dozen wristband tags, most of these are being developed by engineers and students at Cal-(IT)2, but a few from a company called Awarepoint, whose chief engineer, Derek Smith, is a ’98 Jacobs School alumnus in electrical engineering.

In a recent meeting between Lenert and the principals of Awarepoint, Lenert explained that various design options for the wristband tags were still on the WIISARD table. “I don’t want to be stuck in one channel at this point,” Lenert told Smith and his two colleagues. “There’s no way, short of building this thing and trying it out, to decide whether this is going to work.”

So Lenert wants to try a few of Awarepoint’s wristband tracking devices, which do not have a pulse oximeter, to see how they perform next to the ones being developed by Cal-(IT)2. Part of his motivation is the encouragement of a company that might be interested in manufacturing parts of the WIISARD system, once it has been proven to work.
Whether there will be a market for a wireless emergency room in a box depends on the tragic prospect of more man-made disasters. But Lenert is confident that frontline technology can be integrated into emergency medicine. Referring to the October 2002 takeover of a Moscow theater by Chechen separatists, Lenert says: “When rescuers went in with knockout gas, there were many deaths because of the lack of coordination of the medical team.” While Russian security forces freed 650 hostages when they stormed the theater, 116 died. Most of these died as they waited for antidote injections to counteract the gas. “The emergency care wasn’t managed so that commanders knew which patients needed immediate help,” Lenert explains. “With WIISARD, we can probably save hundreds of lives if there’s a serious event, and if we can effectively marshal the resources that are available now.”

Lenert often reflects on the lessons of the Moscow theater attack, and the September 2004 massacre at the school in Beslan in Southern Russia, where 331 hostages were killed, most of them children. This is one way he keeps the technicians, students, engineers and scientists who are involved in WIISARD focused on their true goal. “We’re not running a company to design this stuff and sell it,” he says. “What we’re trying to do is figure out what components would be useful, and how they should work, and what people should build in the future.” He pauses, breaks into a smile, then adds, “This has certainly been the most interesting, challenging and positive experience I’ve been through.”

Neal Matthews is a San Diego-based writer specializing in
science and technology.

RELATED LINKS

California Institute for Telecommunications and Information Technology - Cal (IT)2 VIEW

WIISARD News Release
VIEW

"When our country faces a problem like terrorism, we cannot go about our business as usual and expect to survive."