Community communications infrastructure

Enhancing community readiness through intelligent applications of communications technologies

to create a community system

the need to create community readiness in order to partner with civil government and participate in providing a secure, safe event

Community = .org .edu .com

Develop a communications rich testbed to develop and refine applications that are useful and valuable to the community

Focus on community intelligence for support of public safety and law enforcement

There is a need to design develop and test an all-source fusion and predictive intelligence capability for civil/community support of public safety

A system to synergize technologies along with their subject matter expertise in medicine, intelligence, environmental monitoring, communications, and other critical capabilities.

Evolve the applications to sustain a high state of readiness while providing an ambient system that enhances the day to day quality of life

Physical infrastructure

Professional relationships

Personal interactions

Develop a modular template that can be implemented at the component level

Such as system endeavors

To promote the evolution of an environment that enhances general

Health and wellness

To deploy an operational sensor net for effective and useful

Environmental monitoring

To create valuable and relevant

Educational experiences

To institute community enriching, environment preserving, personally fulfilling

Recreational activities

We need to generalize the focus in such a manner that we can also respond to other challenges

facilitate a cooperative arrangement of organizations

unified intent

a distributed/ integrated sensor network

information fusion center

knowledge fusion tool

there were several aspects of shadowbowl that need to be differentiated

at the core level was the

communications infrastructure

redundant multi modal networks

terrestrial – electronic and photonic

electromagnetic – RF and optic

sensors

chemical

biological

radiological

acoustical

optical

electro magnetic

seismic

thermal

meteorological

hydrological

the sensors were both fixed and mobile (man/vehicle portable)

Comms, lift(transport) and power are always the most common and most costly failures

Being “CLiPed”

Designed and developed for the worst case scenario but implemented in ways that support every day needs

The need to integrate a group of entities that do not routinely work together in day-to-day operations.

Mother nature is the largest, most frequent, most catastrophic threat we face

Earth quakes , floods, storms, drought , heat , cold

organizations offered their technologies along with their subject matter expertise in medicine, intelligence, environmental monitoring, communications, and other critical capabilities.

We really need to evaluate the realistic need for secure communication and collaboration in a disaster

Avoid arbitrary requirements that don’t help !!

Develop the capacity for a virtual arrangement of agencies

fully functioning Operations Center used for displaying field sensor readings—fire, acoustic, chemical, biological, physiological sensors—video surveillance, population densities, medical reachback encounters, and a prototype Virtual EOC

a forward operations center provided a communications hub, tying the multiple RF, wireless data, laser-optic and satellite circuits into a significantly robust and redundant infrastructure node.

sensor circuits as well as the voice, video, mobile, and medical data networks entered the forward operations center and were multiplexed into the network

designed as a second tier command center that personnel from official agencies would fall-in on if the need had emerged.

Words of wisdom

Think globally

Act locally in light of the global need

Design a system eventually expand to the international community and will establish mutually beneficial relationships with other organizations

benchmark established policy, procedures and standards

it is imperative to validate the capabilities reported as being available for disaster operational medicine… or people will die!!!!!

We must exploit the Opportunity for informal benchmarking at large public events

benchmark and evaluate disaster and operations

we must first design and develop a method to provide an initial assessment of a set of new technologies and benchmark their contribution to the overall disaster and operations

examined all aspects of product and services capabilities

The operational test and evaluation was designed to validate contributions from new high technology sensors and communications equipment that had been recently developed to assist disaster medicine operations.

Data were collected during the Shadow Bowl exercise, which provided some significant insight into the new technology being examined.

A number of new, high technology sensors were demonstrated at Shadow Bowl.

sensing equipment strategically placed

triage sites fitted with communications resources set up to link back to reach-back facilities depending on the types of injuries

serviced from wireless and satellite communications.

Unfortunately, due to technical difficulties the wireless communications links were not operating

Connectivity was the critical path, considering most of the technology used required some form of continuous network communication. The quality of video transmission was directly dependent on available bandwidth.

Although feedback from Denver was that the communication and image quality was sufficient, the nurses and medical staff at Shadow Bowl felt that the consultations with the doctors in Denver took longer than those at Driscoll or USA, and weren’t as “real-time”.

, it was felt that for some of the exercise patients broadband circuits are very important to complete an adequate treatment

Words of caution!!!

Future utility compromised knowingly instigates nothing good

Futile Uselessness Compromised Knowingly Is Never Good

Suboptimally Tended Universally Promotes Ignorant Decisions

Future Utility Compromised Knowingly Is Never Good

Suboptimal Technology Universally Promotes Ignorant Decisions

Here are memes from the doc u sent,…..

This is just a first hack……

DRAFT

Shadow Bowl

identified key shortfalls of homeland security elements and the management of resources supporting them.

a model was applied during an operational exercise around Super Bowl XXXVII.

products provided by private

This event-driven exercise was called “Shadow Bowl

a follow up activity to the Strong Angel exercise for managing displaced populations.

The purpose of Shadow Bowl was to demonstrate a community readiness model and medical response to a mass casualty event.

The goals of the project were to

provide enhanced public safety using an advanced communication network and sensor grid,

develop response abilities to a mass casualty surge through medical reachback,

build a collaboration model between civilian, military, public, and private partners.

This exercise provided a framework for exploring and developing new mass casualty response methods using biomedical devices and informatic technologies, and communication systems that enhance the ability to collaborate and effectively respond to emerging needs during natural or man made disasters. .

Context of operations was

Communications Infrastructure for Public Safety at Large Public Events

recognized resource constraints that presented potentially critical weaknesses in any security plan

The operational space included

a dense urban downtown district,

a deep valley river estuary,

an extensive commercial waterfront,

an international airport and busy airspace.

massive crowds transiting venues.

Traditional command center operations rely on extracting information from field units in order to develop an awareness of a situation at the incident site.

In this arrangement, information primarily flows vertically—from the field to the command center and back.

information flow between non-allied, inter agency information systems is a critical issue.

given the nature of the distributed command center operation and the threat of potential terrorist attacks, an information fusion, threat integration and cross-cultural collaboration concept is needed in order to facilitate common situation awareness among participating agencies.

It is important to establish an informal partnership with a coalition of organizations from academia, industry, citizen groups, and the federal government.

a series of exercises

the deployment of a suite of communications equipment

Operation Shadow Bowl facilitated a cooperative arrangement of organizations from across the country and from multiple disciplines, all falling-in on a common axis and unified intent for supporting San Diego during Super Bowl XXXVII.

Redundant parallel networks connecting the multiple organizations

a backup system in the event of a problem in the SDPD system.

LightPointe 155 Mb laser connections. Free space optics

HPREN 802.11 RF 11 Mb wireless connection.
This was the fastest most reliable of all the network links

Redundant T1 lines 1.5 Mb to the SDSU net.

slow but reliable.

This network path was quickly saturated by bandwidth intensive video conferencing services.

INMAR satellite

KU band satellite services

TeraBurst OC48 sonet connection to SDSC

Department of Justice, Office for Domestic Preparedness, sponsored the deployment of reliable connectivity to the San Diego Police Department and the San Diego County Sheriff’s DOC.

Surveillance, Situational Awareness, Sensor Grid

Sensors: Since the potential for a radiological “accident” or chemical attack was high for this event, a number of new, high technology sensors were deployed and demonstrated at Shadow Bowl.

These included sensing equipment strategically placed around the Super Bowl complex to monitor the environment for toxic agents, fire, chemicals and other potentially hazardous materials.

sensors were tested and validated prior to the event.

. Chemical spills,

radioactive

biological waste

small fires

On site sensors included

radiation detection,

aerosol chemical detection,

water quality,

seismic activity,

wind speed and direction,

relative humidity

temperature.

Participants standing watch in the operations center were able to track real-time sensor feeds covering specified vulnerabilities that were identified

. This tracking was tied to an Indications and Warning (I&W) concept in which potential scenarios were analyzed and key areas of interest were mapped out

surveillance or sensor employment.

This standing “threat information fusion center” had direct lines of communication with public safety and law enforcement personnel

4.0 Surge Capacity, protection, and medical Reachback (integrate carl taylor stuff)

Medical organizations supporting the Super Bowl XXXVII effort on January 26 were a group of companies that do not routinely work together in day-to-day operations.

Had a catastrophic event occur on January 26, 2003 the medical facilities in Southern California would have been strained under the load of required medical care.

One goal of the Shadow Bowl exercise event was to prepare local San Diego emergency medicine providers with a short burst of “what-ifs” in case the unthinkable occurs.

The exercise was not meant to grade, certify or be critical of participant performance, but to provide a learning experience which may help save many lives should a catastrophic event have occurred on January 26, 2003.

The operational setting was used to develop a test and evaluation exercise using a well planned scenario with learning objectives provided the companies and reach-back hospitals involved with a tactical and strategic learning experience.

It also provided a test bed for both local and distant supporting hospitals to coordinate their actions and lessons that could not be learned without going through the exercise experience.

The Bioterrorism Hospital Preparedness Program Cooperative Guidance Agreement authored by the Health Resources and Services Administration/U.S. Department of Health and Human Services lays the ground work for defining surge capacity:

“in the wake of the terrorist attacks of September 11, 2001, and the subsequent anthrax epidemic, attention was focused on the ability of hospitals and emergency medical services to respond to bio-terrorist events.

We need to generalize the focus in such a manner that we can also respond to other challenges

Outpatient care providers and EMS personnel also face the challenge of becoming trained and prepared to respond to biological/chemical mass casualties,

whether they present in large numbers acutely or more insidiously over time.

The EMS entities around the country are generally well prepared to respond to routine emergencies and minor epidemics,

they need plans and infrastructure to respond to new challenges posed by biological/chemical/radiological event.

A sudden influx of huge numbers of sick or contaminated patients form such an event will completely overwhelm the medical system.

the prospect of an overwhelmed medical response system has created an awareness of the need to define and quantify surge capacity

plainly stated how many sudden, unexpected patients can a health system, or a region handle at one time?

For reasons of convenience rather than experience the current working number presumes that a system or a region should be prepared to handle a surge of patients.

The actual number is somewhat arbitrary,

surge capacity is defined as how many beds does a system have that are unoccupied on any given day.

this argument is flawed.

Shadow Bowl Exercise Analysis

Data collected during the medical exercise are shown below.

The most significant exercise observation involved patient tracking and management after they were triaged.

the earthquake scenario severed much of the area’s infrastructure, rescue resources were severely strained and did not respond as might be expected in “normal medical emergencies.”

large number of patients that might be expected in an earthquake event for each type of injury at varying levels of severity requiring care.

The 5,000 “what if” patient count of approximately 100,000 people (5%) in the Super Bowl Complex and immediate surrounding area was considered modest as to what might be expected in an event like this.

Number of Patients

Type of Injury	Moderate Injury	Severe Injury	Critical Injury
Burns	250	176	74
Adult Trauma	750	528	222
Pediatric Trauma	250	176	74
Chemical Exposure	125	88	37
Radioactive Biological Waste	125	88	37
Shock	875	616	259
Electrocution	125	88	37
Totals	2500	1750	750

The large number of patients would have put an extraordinary strain on local hospitals, evacuation infrastructure and patient management systems.

Treatment for burn patients was the most critical.

The 74 critically injured burn patients would have absorbed all of the beds dedicated for burn patients on the west coast.

Some of those critically injured patients would have been required to be transported to hospitals as far away as San Antonio Texas for treatment.

It was assumed that all severely injured and critically injured patients would require some hospitalization.

Moderately injured patients would have required some treatment in a hospital or clinic, but likely not a lengthy hospital stay.

Systems need to be developed to triage patients with seven different types of injury at two locations

using different communications means (video and voice/data).

When the communications links to reach-back facilities failed during the exercise for the voice/data triage site, all treatment exercises were transferred to the forward operations site at the river where video communications were occurring.

injuries that were seen in the field were (Chemical exposure, electrocution, shock and Biological agent exposure)

for most injuries there is no statistically significant data set.

All personnel giving treatment at the garage site were medical professionals (two registered nurses and one physician).

All those providing advice at the reach-back facilities were physicians.

The number of patients seen and the average estimated time to treat each patient are shown in the table below for each injury type. Time to treat is an estimate by the health care professionals on the scene.

Injury type, Number of Patients and Estimated Time to Treat

Treatment of the injuries varied depending on the severity given for each patient scenario.

On scene healthcare professionals were encouraged to provide realistic vital signs and symptoms to the reach-back partners in order to make the exercise realistic.

Because of the large number of patients involve, there was a significant issue regarding follow-up care for patients initially seen.

The primary reasons given for patient deaths were lack of medical equipment, lack of medical supplies and inability to get a patient evacuated immediately.

a high number of deaths, it was the opinion of the health care professional on the scene that these numbers were very realistic.

a large number of patients who would have been treated for shock and biological exposure injuries

. Neither of these injuries were treated because the field triage unit communications to reach-back partners was inoperative.

Accordingly, the death rate illustrated in the chart below can be expected to be higher than normal overall because most of the deaths reported are from trauma and burn patients which might be expected to result in death.

Eighty-eight percent of the injuries evaluated in the reach-back scenario were burn or trauma patients.

Healthcare professionals provided their evaluations after treating each patient.

Because the communications links in the field failed, there were approximately 40 “patients that were not seen” during the exercise by the reach-back partners.

These patients would have been “seen” using voice/data communications links.

roughly 40 patients were inadequately treated because of communications problems.

40 notional patients were recorded in the evaluation results table to draw attention to the potential wireless communications bandwidth problem. *Communications failure of the field unit. Potential to encounter wireless bandwidth overload in an actual emergency is estimated very high. The chart below illustrates evaluation results pictorially:

Collaborative efforts, civilian—cross cultural collaboration

Operation Shadow Bowl facilitated a cooperative arrangement of organizations from across the country and from multiple disciplines,

a common axis and unified intent for supporting San Diego during Super Bowl XXXVII.

These organizations offered their technologies along with their subject matter expertise in medicine, intelligence, environmental monitoring, communications, and other critical capabilities.

The result of this support was a demonstration of community readiness to partner with government and participate in providing a secure, safe event on 26 January.

There is a need for a standing, all-source fusion and predictive intelligence capability.

Establishing this capability requires two essential components:

1) a unified intelligence organization for civil support

2) a rich flow of current information from field units from regional and national information coordination centers.

Analysis of information requires shared, real time situation awareness on behalf of multi-disciplined subject matter experts, scattered across local, state and federal agencies.

experts must be able to provide time-sensitive input to key responder decision makers who are monitoring developing events.

Shadow Bowl, in partnership with ESP (Extranet Secure Portals) Group , established the Counter terrorism Information Network (CTIN) portal.

CTIN was a distinct Community of Interest (COI) within the ESP Group’s existing CyberCop portal, and was used for secure communication and collaboration.

Representatives from the local, state and federal level were invited to the portal to participate in ongoing chats and to view surveillance videos, emergency directories and other information that was vital during the event.

The portal was used as an underlying communication system that would be available in case a security event was to take place.

The secure Portal technology, originally developed under the Defense Advanced Research Projects Agency (DARPA), emphasizes security through its network architecture and its underlying rights-based applications.

The Portal allows users to

share libraries of documents

case studies,

send secure e-mail,

participate in ongoing threaded discussions,

create private chat rooms,

monitor ongoing tasks,

create and distribute surveys

share online briefings.

Users only see data for which they have specifically been granted access.

The combination of E-Team and CTIN created

an information-sharing grid for

law enforcement,

medical,

health,

fire,

EOC staff.

a virtual “unified command” made up of subject matter experts in emergency operations.

Allied with this virtual arrangement of agencies, was Shadow Bowls’ “Tunnel” facility located at San Diego State University.

The Tunnel was a fully functioning Operations Center used for displaying field sensor readings—fire, acoustic, chemical, biological, physiological sensors—video surveillance, population densities, medical reachback encounters, and a prototype Virtual EOC.

This forward operations center provided a communications hub, tying the multiple RF, wireless data, laser-optic and satellite circuits into a significantly robust and redundant infrastructure node.

Shadow Bowl sensor circuits as well as the voice, video, mobile, and medical data networks entered the forward operations center and were multiplexed into the SDSU network domain.

The operations center was able to track real-time sensor feeds covering specified vulnerabilities that were identified by San Diego security planners.

This standing “threat information fusion center” had direct lines of communication with law enforcement personnel in case a developing situation had been identified.

Moreover, the Tunnel was designated a second tier command center that personnel from official agencies would fall-in on if the need had emerged.

5.0 IDMI

The International Disaster Medicine Institute (IDMI) is working with the National Disaster Life Support Consortium to support state and federal agencies in fulfilling their responsibilities for homeland security and natural disasters.

IDMI is an independent 501(C)3 not for profit organization whose mission is to support developing and advancing disaster medicine as an international resource

. The IDMI mission:

· Provides improved medical responses for terrorist attacks and natural disasters

· Support community preparedness to mitigate the medical consequences of a mass disaster event

· Enable communities to plan for, train and respond to terrorist attacks including a mass casualty disaster

· Support industry strategic planning

· Support development of disaster response products and services to fulfill the needs of first responders

· Support forums of industry providers and first responders to address needs and package products and services to fulfill those needs

working to provide more effective and efficient responses to reduce avoidable injuries and casualties.

The scope of IDMI work will eventually expand to the international community and will establish mutually beneficial relationships with other organizations.

The community of readiness experts utilized the Shadow Bowl event as a backdrop from which to evaluate medical first responder needs and the effectiveness of existing disaster preparedness for large public events where terrorism and natural disasters are a concern. RTI took the lead in developing an exercise scenario to provide meaningful assessments of the Shadow Bowl participants.

One purpose of the Shadow Bowl exercise was to benchmark established policy,

procedures and standards and provide interface back to the IDMI consortium regarding the capabilities reported as being available for disaster operational medicine.

The results of the Shadow Bowl benchmark will also assist in IDMI in comparing nationally known vulnerabilities against the vulnerabilities identified by local and state respondents.

the International Disaster Medicine Institute’s goal is to expand disaster medicine industry member’s scope of knowledge regarding first responder needs and shortfalls.

participation in Shadow Bowl activities provided the Opportunity for informal benchmarking at a large public event

· Assessment of medical responders capabilities and corresponding needs where the disaster medicine support industry might assist.

· The Discovery elements where IDMI might advise its members to assist medical first responders and their reach-back constituents.

· The opportunity to provide Feedback to disaster medicine support industry regarding areas of critical concern or extreme needs.

· The venue to Compile initial elements of medical first responders and their reach-back constituents following the Shadow Bowl event.

· The ability to Provide data for knowledge based investment decisions targeted to improve homeland security capabilities

· The ability to Identify and report the return on investment opportunities for homeland security capabilities to disaster and operations medicine support industry members

· A realistic setting to Identify initial elements to develop a nationwide view on key vulnerabilities and the capabilities available for preventing and/or responding to threats and/or natural disasters.

Shadow Bowl solution

- Provided an interface with industry leaders for developing a technical operations and medicine roadmap

- Provided key elements for the IDMI business plan and work plan development for industry and first responder forums during 2003 and 2004.

- Provided a vehicle to articulate first responder needs to the supporting disaster operations medicine industry

benchmark and evaluate disaster and operations medicine tools

There are no set standards for evaluating first responders or commercial products or services against established standards.

The shadowbowl event was designed to provide an initial assessment of a series of new technologies and benchmark their contribution to the overall disaster operations

and medicine requirements. To accomplish this, a disaster scenario that examined all aspects of product and services capabilities was developed.

In the shadowbowl exercise an assessment of capabilities that included:

1. Personnel

2. Equipment

3. Infrastructure

4. Consumables

5. Plans

6. Events and exercises

The scope of the Shadow Bowl Exercise was deliberately limited in scope,

the scenario was developed to evaluate elements of new technology in a demanding disaster operational environment.

Exercise Goals:

Determine local medical assistance saturation point
Determine effectiveness of medical reach-back resources available
Identify and assess appropriate technologies to provide medical reach-back capabilities infrastructure
Measure time to initiate medical reach-back deployment to operations
Determine effectiveness of two levels of medical reach-back tools

Voice (phone communication)
High rate data rate video

Using the exercise scenario assess reach-back tools for five injury types

1. Burns

2. Electrocution

3. Adult Trauma

4. Pediatric Trauma

5. Exposure to radioactive biological waste elements

6. Exposure to toxic chemical elements

7. Shock

Some measures which were examined include:

Time to respond to medical call for help
Patients released on site
Patients transported to hospital facilities
Number on site deaths
Number Injuries by type
General effectiveness of mobile triage units
Constraints due to infrastructure (roads, bandwidth, bridges…)
Constraints due to equipment
Constraints due to trained personnel
Constraints due to consumables

Although a detailed time line included event-by-event issues, the following general exercise scenario was presented to the participants at approximately 1325 on 25 January 2003:

Situation: On Sunday, January 26, 2003 approximately one hour prior to the scheduled Super Bowl kick-off an earthquake measuring approximately 7.5 on the Richter scale struck the San Diego Area. The epicenter was located near the juncture of the Mission Valley Fault and the Florida Canyon Fault, less than a mile west of the Qualcomm stadium complex.

Initial indications are that there are several thousand people injured or killed in the Super Bowl complex including some security and medical personnel. Although severely damaged, the stadium is still in tact. Most injuries inside the stadium are a result of falling debris, collapsing interior walls and burns from small fires near food courts. Damage outside the stadium is significant, especially in the south and west parking areas. A number of light poles fell causing numerous injuries and several deaths. Injuries include electrocution from falling light poles, hospitality tents and auxiliary generation systems located in the parking area. Additionally, there are a large number of individuals with burns from several vehicle fires and numerous grills from tailgate parties. There were several dozen injury automobile accidents in the stadium complex as a result of the earthquake. Approximately 10% of the emergency vehicles are damaged and non-functional; 10% can function at only partial capacity, and are not mobile.

Damage outside the stadium complex is substantial, but confined to an area within approximately three miles of the epicenter. There is limited damage elsewhere in the San Diego metropolitan area. In general, the area that experienced most damage is bounded by Interstate 8 to the north approximately four miles and State Route 163 east for four miles past Interstate 15. All four of these major arteries have been closed due to damage to the roadways and/or bridges. Most secondary roads are open, but jammed with traffic. There are reports of several hundred injuries outside the stadium complex in the defined area. There are also several possible deaths. There is no electrical service to the defined area and landline communications have been severed. There is a significant amount of black smoke in the air where one of two oil storage facilities near the stadium have caught fire. Additionally, two tanker trucks carrying hazardous material, one near the Interstate 8 & I-15 interchange and the other parked in a service area near some automobile dealerships, have been damaged and are spilling their contents. There are vapors from both accident sites spreading throughout the area. One spill is radioactive medical waste from a local hospital and the other is a corrosive chemical. Damage was done to both the local reservoirs and water will be rationed as the water transport system is inspected and repaired. Additionally, most of the major water lines crossing the lower Mission Valley have ruptured. Weather conditions are clear, 75 degrees, dew point is 49 degrees. The wind is light and variable at less than two MPH.

6.0 Conclusion

Data were collected during the Shadow Bowl exercise, which provided some significant insight into the new technology being examined. Few of the reach-back users at hospitals involved in the exercise received any training on the tools, which were introduced to them for the first time in the exercise scenario. Although the exercise application was very similar to that of telemedicine, there were a number of new technology tools introduced. For purposes of the exercise, this White Paper discusses three types of technology tools, which played key parts.

Voice/Data Communications: Initially, the exercise was planned to utilize two triage sites fitted with communications resources set up to link back to reach-back facilities depending on the types of injuries.

Adult and pediatric trauma and burn injuries would be served by the video communications links and chemical, biological exposure, shock

Sensors: A number of new, high technology sensors were demonstrated at Shadow Bowl. They included sensing equipment strategically placed around the Super Bowl complex to monitor the environment for toxic agents, fire, chemicals and other potentially hazardous materials.

Although not directly involved in cueing for the medical scenario, sensors were tested and validated prior to the exercise event.

The exercise was developed to utilize some of these sensors in a simulated state. Chemical spills, radioactive biological waste and small fires were all built into the exercise scenario and simulated at the appropriate times.

Super Bowl attendees exposed to these elements made up the “actors” presented in the medical exercise scenario.

electrocution injuries would be serviced from wireless and satellite communications.

Unfortunately, due to technical difficulties the wireless communications links were not operating at the time of the exercise.

When it became known that the voice/data wireless and satellite communications were not operating at the designated triage site, chemical, electrocution and biological exposure patients were moved to the triage site handled by the video link. All exercise data collected was done from the triage site using video communications links.

Video Communications: There were numerous repetitive sessions with USA, Denver, and Driscoll Children’s hospital where remote triage was performed on about 25-30 patients via a Wave3 system called Session was used. The exercise required approximately 90 minutes to execute.

Connectivity was the critical path, considering most of the technology used required some form of continuous network communication.

The quality of video transmission was directly dependent on available bandwidth. Specifically, video quality experienced over broadband connectivity establish a link at 512Kbps with both Driscoll and USA, but were limited in our transmission to Denver to 128Kbps. The results of those variable resulted in a recommendation that remote participants establish at least 256/384Kbps.

Additionally, because higher quality images (at a faster frame rate) were transmitted to Driscoll and USA, it was felt that for some of the exercise patients broadband circuits are very important to complete an adequate treatment. Interestingly, although some of the participants experienced periodic network outages prior to the scenario, most of the calls to the reach-back sites connected satisfactorily. Also, once the link was established, it didn't drop until either endpoint “hung up”. During exercise, we had one “operator” function as the technician/switchboard, who called the participating hospitals depending on the medical need. Generally, burns went to Denver, pediatrics went to Driscoll, and trauma went to USA. In practice we found that participating hospitals were eager to help in any way they could, and gladly remained “on call” to treat the next patient, regardless of the specific condition. Additionally, we had originally set up the configuration with a tabletop microphone, but quickly found out that the surrounding chaos and noise prevented effective communications between the remote doctor and local nurse. We switched to headsets and found that to be quite effective. Patient follow-up proved to be a weak part of the exercise, perhaps more by the operational reality than poor scenario design. Frequently, we would be in a call to a clinic and they would (appropriately) ask how an earlier patient was responding to treatment already provided. Exercise nurse/actors were unable to keep the remote locations informed as events developed. This type of situation can be expected in a real world situation given the number of patients and severe injury level involved in this scenario. It was clear that the reach-back hospitals were keeping track of the patients, whereas on site nurses were simply running patients through different treatment scenarios, and not keeping extensive records of the mounting victims. Initially video communications had been designated to be involved with only trauma and burn victims. When it became known that the voice/data communications were not operating at another triage site, chemical, electrocution and biological exposure patients were included on the video link.

7.0 Conclusions

The Shadow Bowl earthquake scenario put a significant strain on medical care system. Key lessons learned include:

· Breakdown of the transportation infrastructure prevented an efficient evacuation of patients needing more care than could be provided at the disaster site.

· Breakdown of wireless communications prevented treatment of half the expected reach-back patient load. In the event of a real emergency, wireless bandwidth can expect to be jammed creating a real problem for reach-back communications. Dedicated frequencies for use in emergency operations are needed.

· Patient management at the disaster site is a significant problem.

· Overload of mortuary facilities is potentially significant near the disaster site.

· Evacuation will be required outside of the local area in case of a mass injury disaster such as this one. Most evacuation will require air transport assets. Some facilities as far away as Texas would have been needed for burn patients in the Shadow Bowl scenario.

· Shortages of water and essential medical supplies at local hospitals would require evacuation of patients out of the local area.

· Local area residents flocking to healthcare facilities could be expected to quickly overload hospital and clinic facilities. This situation would likely exacerbate evacuation of critically injured out of the local area for required treatment.

· Closing of roads and bridges significantly alter medical assistance plans, delaying patient evacuation and increasing death rates.

· Data results indicated exercise results for video triage were excellent. The systems used in the Shadow Bowl Exercise utilized telecommunication landlines for video telemedicine. In a natural disaster such as an earthquake, use of telecommunication landlines should not be expected to be available and alternatives must be considered.

· Treatment of victims at the Shadow Bowl Exercise was given by healthcare professionals (registered nurses, physicians and an EMT). In the event of an actual disaster of this type, the level of caregiver’s training can be expected to be lower than experience during the exercise. While the value of a reach-back system can be expected to be more valuable under such circumstances, the time to treat can be expected to climb significantly.

· A methodical threat analysis and vulnerability evaluation should be accomplished prior to each major event where a medical reach-back system may be employed. The reach-back system capabilities should be evaluated against standards. A set of standards should be established prior to accomplishing an operational test and evaluation.

The results of the Shadow Bowl Exercise accentuated the value of new telemedicine tools in treating large number of patients when infrastructure overload occurs. There are a number of issues that need to be examined more closely to utilize the high technology systems just becoming available. Integration of these new products as tools to distribute healthcare more efficiently and effectively should include an operational test and evaluation of the proposed systems into the larger medical care system is recommended. This system of systems operational test and evaluation process should be developed in accordance with accepted procedures and standards to accomplished testing and evaluation before new systems are put into action. It would behoove the medical community to establish a well-founded operational test and evaluation system to establish standards and eventually certify each sub-system within the system of systems. There is significant opportunity for RTI and the other Shadow Bowl participants to collaborate in the fielding of a system of high technology communications, medical monitoring and patient management systems that can be deployed anywhere any time. A modular, expandable system could meet the needs of medical first responders world wide as new tools are developed and fielded. RTI’s experience can help provide the engineering expertise needed to develop a methodical, robust systems integration approach.