Introduction
Although many lessons were learned from the 1995 Tokyo subway sarin gas attack, the introduction and upgrading of nuclear, biological, and chemical (NBC) response equipment began at a national level in Japan only in 2002, after the World Trade Center and anthrax attacks in the United States in 2001.Reference Tokuda, Kikuchi, Takahashi and Stein1, Reference Okumura, Ninomiya and Ohta2 Drills under the Japanese law concerning the “Measures for Protection of the People in Armed Attack Situations etc.” (Civil Protection Law) provided opportunities for medical teams to provide on-site medical intervention and practice pre-decontamination medical care while wearing personal protective equipment (PPE). In chaotic situations of mass decontamination, the ability to command, control, and communicate is particularly important for various on-site decision-making processes that must be executed in an expeditious and flexible manner.Reference Okumura, Suzuki and Fukuda3 These decisions depend, in part, on the number and condition of casualties, the type of contamination agent involved, and the capabilities of the decontamination process.
To strengthen the medical control, command, and communication structure, Information Technology (IT) tools can be used effectively as a communications support framework. Information technology has progressed in the field of remote medicine, and some technologies, such as the transmission of the patient's vital signs to a hospital, are used in prehospital care. Real-time images and on-site data also are important for first responders in the acute phase of a mass-casualty incident (MCI) and disaster.
The purpose of this report is to present an evaluation of the efficiency of new IT tools for medical command use during a mass-decontamination exercise.
Report
IT Tools
Remote Video Camera System—Mass decontamination includes zoning to separate an affected area into a hot zone (contaminated area); warm zone (decontamination area); and a cold zone (uncontaminated area). In Japan, inflatable tents are placed between the warm and cold zones.Reference Okumura, Ninomiya and Ohta2 This makes it difficult for the on-site Medical Commander to monitor and assess the entire contaminated and decontamination sites, especially the interface between the hot and warm zones, which is a vital area for medical command (Figure 1, online). Rapid assessment of the numbers and severity of the patients in the hot and warm zones facilitates the appropriate use of medical resources such as antidotes, and helps determine the number of medical personnel with Level-C PPE required in the warm zone.
To provide information using the remote video camera system, one member of the medical team wears Level-C PPE with a high-vision video camera system (HXR-MC1 Digital HD Video Camera Recorder, Sony Corp., Tokyo, Japan) with a waterproof camera head mounted to the shoulder (Figures 2a–c, online). The body of the video camera system is placed inside the PPE. The image recorded by the camera is similar to that being viewed by the wearer, and is transmitted using a real-time video transmitter (RVT-SD100 Location Porter, Sony Corp., Tokyo, Japan) and a 3G mobile network (NTT Docomo Corp., Tokyo, Japan) to the on-site Medical Headquarters, where the remote video camera feed is received and displayed on high-definition display panels (Figure 2d, online).
The video camera system operator in the warm zone also can communicate with the on-site Medical Commander using a bone-conductive microphone-based radio system. This bone-conductive microphone system transmits a clear voice, even through a mask and in a noisy environment.
IT Tools for Medical Command during Mass Decontamination—An interactive system can be located at each of the following points: (1) the on-site Medical Headquarters; (2) in the area where casualties triaged as “immediate” are treated (known as the “red” zone in Japan); (3) in the on-site coordination office; and (4) in the remote Medical Headquarters of the local government office. The system facilitates a two-way audio-video system, with a real-time image of a white board positioned at the exit of the red zone which contains information regarding patient age, gender, triage category, suspected diagnosis, method of transportation, and receiving hospital (Figure 3a, online).The white board image, which is virtualized by tracking the 2-dimentional x-y motion of the pen, is transmitted wirelessly, allowing medical personnel to view it on a laptop computer in each remote area (Figure 3b, online).
Communication is facilitated by the city communications infrastructure and wireless (Wi-Fi) technology; if an event is localized, the wireless network would likely be largely functional. Although real-time information on patients at the scene is necessary for rapid and accurate evacuation of patients, it is very difficult for staff at the remote medical headquarters of a local government office to obtain such information, even though evacuation by air is coordinated by such offices.
IT Tools in the NBC Medical Command and Decontamination Vehicle—A special vehicle dedicated for Medical Command and Decontamination functions as the on-site Medical Headquarters (Figure 4, online). This vehicle has several tools for Medical Command communication, such as a facsimile machine, printer, scanner, laptop computer, television, and satellite phone, through which information can be exchanged. In addition, the vehicle, prepared by the Nippon Medical School (Tokyo), has its own self-sufficient decontamination system, and a generator capable of supplying electrical power to the remote video camera and IT communication network system.
On-Site Verification
On February 2, 2010, a drill of Civil Protection Law measures was conducted by Tokushima prefecture and the Cabinet Secretariat of the Japanese government, in collaboration with other agencies and organizations, to ascertain the effectiveness of the new IT tools for Medical Command during mass decontamination. The drill was based on the following scenario: a terrorist attack in a sports stadium triggered an explosion followed by the spread of an unknown liquid into the auditorium. The terrorists escaped the scene. Several spectators in close proximity to the explosion were injured severely, and subsequently lost consciousness, while other spectators became ill. The number of virtual victims was 200; of these, eight were severely affected, categorized as “red” (immediate care); 20 were moderately affected, categorized as “yellow” (delayed care); and 37 were mildly affected, categorized as “green” (mild), according to the triage protocol used. The first responders were from the Fire Department and the Japan Self-Defense Forces (JSDF); eight of the responders wore Level-A PPE suits, and 21 wore Level-C PPE suits. While these first responders determined the priority of decontamination at the scene, the Medical Command and Decontamination vehicle arrived to function as the on-site Medical Headquarters, providing the new IT tools for Medical Command (ie, interactive network system and web camera system). The Medical Commander at the scene — an experienced emergency physician — deployed one member of the medical team wearing a Level-C PPE with the remote video camera system to the warm zone, to provide the Medical Commander with accurate information regarding medical needs. Twenty other members of the medical team, along with fire department personnel with Level-C PPE, were deployed to the warm zone, and categorized victims at a primary triage post. They also treated victims who had severe airway problems, or obvious symptoms relating to nerve agents, before subjecting them to wet or dry decontamination. A team member with a remote video camera system transmitted an image from the warm zone to the Medical Commander.
The interactive network system worked at all points. At the remote Medical Headquarters of the local government office, the Medical Commander could view the on-site situation and determine the numbers and severity of casualties listed on the white boards. This information on casualties proved useful for the coordination of transportation by air, as several agencies and organizations were involved. The dedicated Medical Command and Decontamination vehicle was used as the on-site Medical Headquarters, and facilitated coordination with other agencies.
At a debriefing session after the exercise, a Medical Commander at the scene reported that the image from the remote video camera system helped with decision making regarding the distribution of medical resources and transportation of casualties to definitive hospitals. Triage information just prior to transportation was important for effective transportation.
Discussion
Following the sarin gas attack, a hot zone (contaminated area), a warm zone (decontamination area), and a cold zone (uncontaminated area) were demarcated at the scene, as on-scene decontamination of victims was deemed necessary.Reference Okumura, Ninomiya and Ohta2
In a mass decontamination NBC response, medical teams are vital at the scene of an event to perform airway management by endotracheal intubation and to administer medications. Japanese law prohibits Emergency Medical Technicians from performing life-saving interventions, such as endotracheal intubation and administration of medications, to victims of a chemical attack at the scene. However, medical teams at the scene do not have sufficient experience to methodically manage patients following NBC attacks.
The advantage of having a remote video camera system in the hot and warm zones is that it allows early recognition of the number and severity of victims. This is important for decision making regarding the need for deployment of medical resources and the transfer of victims to definitive hospitals. Terrorist bombing attacks typically occur in closed spaces where the power of the explosion is amplified.4 As underground areas often are a target point, a cold zone is naturally created; use of a remote video camera system is especially effective in such a situation. Although the video camera system uses an eye-view image, not a bird's-eye view image, the Medical Commander at the scene can determine the situation in the hot and warm zones using bilateral communications via the bone-conductive microphone system. Issues with the image quality of the remote video camera system are related to the position of the camera head affixed to the shoulder. Direction of the camera head requires adjustment beforehand, as it cannot be adjusted during a task. In addition, it is not efficient for one person to function only as a videographer; for that purpose alone, a robot might be more efficient.
The advantage of these IT tools for communication is the integration of information, which facilitates efficient use of medical resources and patient transfer to definitive hospitals. Nevertheless, the system has some shortcomings that require technical improvements: (1) wireless communication is delayed by a few seconds, which results in a lag between the video and audio transmissions; (2) the white board images contain analog information, whereas digital information is transmitted, which requires that the descriptions on the white boards be done in a format that is easy to read and visually interpret; (3) the camera direction must be preset, but should be able to be changed to enable independent remote control, and be able to withstand harsh conditions (wind, rain, sunlight); and (4) commercial networks in the countryside or in critical urban situations sometimes are inefficient, whereas a satellite network system works in both areas. These two network systems must be independent of each other, and the IT system should be able to work on either system.
The advantage of the NBC Medical Command and Decontamination vehicle is that it enables a virtual overview of medical teams at the scene. In mass-casualty incidents, sending and receiving information are crucial for effective medical activities at the scene, and the vehicle has several easily accessible IT tools in a single unit able to function as a Medical Headquarters at the scene. On the other hand, the deployment of the communications system of this vehicle requires approximately 15 minutes, which is acceptable for local events due to natural hazards, such as earthquakes in which the affected area is small, but is problematic for mass-casualty incidents such as blast events and street rampages. Deployment time must be decreased; repeated training in its use can help in this regard.
Conclusion
New medical IT tools evaluated in a civil protection decontamination drill to support a Medical Command proved effective for determining the distribution of medical resources and the decisions to transfer victims to hospitals. Such IT tools will be useful for mass decontamination in NBC events.
Acknowledgement
The authors thank Mr. Takayoshi Kato, Deputy Counselor of the Cabinet Secretariat for Crisis Management, Government of Japan, for his invaluable assistance and critical review of the article.
