U' S' Army Medical Department Special Medical Augmentation Response Team SMART

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U. S. Army Medical Department - Special
Medical Augmentation Response Team (SMART)

• Colonel Ron Poropatich, MD
• Director, Clinical Applications Division
• Telemedicine Advanced Technology Research
  Center
• U. S. Army Medical Research Materiel Command
• Fort Detrick, MD
• Director, Telemedicine Directorate
• Walter Reed Army Medical Center
• Washington, DC

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Telemedicine

• Definition telemedicine is the use of electronic
  information communications technologies to
  provide support health care when distance
  separates the participants.
• Institute of Medicine - 1996

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Worldwide Telemedicine Rapid Deployments since
1993. . .
Bosnia, Macedonia Croatia, Kosovo
Sweden
Kuwait
Germany
Egypt
Ivory Coast
Haiti
Cuba
Somalia
Korea
Panama
Kwajalein
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Worldwide Telemedicine Deployments since 1993
Ivory Coast
Germany
Bosnia Macedonia Croatia
Panama
Cuba
Haiti
Kuwait
Korea
Egypt
Kwajalein
Somalia
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Original - 1993
Satellite VTC
- 30 cubic feet - 332 lbs. - 148K
Current - 2000
Satellite VTC
- 6 cubic feet - 175 lbs. - 58K
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Telemedicine Consult Activity1993-1995
Radiology

• Global Mission
• Most common consult regardless of site was
  dermatology
• Orthopedics - most common surgical consult
• Total of 19 different subspecialties
• N 240 consults

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Medicine
Dental
40
3
Surgery
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Telemedicine Journal 1996 2(3)201-10
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Telemedicine Specialty Response Team
Accomplishments

• Real World Deployments
• Somalia Feb 93
• Croatia May 93
• Macedonia Mar 94
• Haiti Aug 95
• Kenya Sep 98
• El Salvador Nov 98
• Argentina Jul 99

• Publications
• Telemedicine Journal 1995
• Telemedicine Journal 1996
• Military Medicine 1998

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Background -Specialty Response Teams

• US Army Surgeon General directed this effort in
  1997
• Coordinated action with the DoD other U.S.
  agencies
• Teams composed of U.S. Army personnel DoD
  civilians
• Equipment training provided by the US Army
  Medical Research Materiel Command, Fort
  Detrick, MD

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SMART Mission

• Provide a short duration, medical augmentation to
  regional domestic, Federal and Defense agencies
  responding to disaster, civil-military
  cooperative action, humanitarian emergency
  incidents.
  
  
• Foreign nations supported thru U.S. State
  Department coordination.

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SMART Team Categories

• Chemical/Biological
• Trauma/Critical Care
• Stress Management
• Telemedicine (MC3T)
• Preventive Medicine
• Burn
• Veterinary
• Health Systems Assessment Assistance

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Location of Special Medical Augmentation Response
Teams in the U.S.

• Walter Reed AMC, Washington, DC
• Dwight David Eisenhower AMC, Augusta, GA
• Brooke AMC, San Antonio, TX
• Madigan AMC, Tacoma, WA
• Tripler AMC, Honolulu, HI
• Landstuhl AMC, Landstuhl, Germany

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Special Medical Augmentation Response
Team Medical Command, Control, Communications
Telemedicine (MC3T) - Overview

• Readily Deployable
• 72 hour on site capability
• 58,000 for the complete set
• 175 lbs for the complete set

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Telemedicine (MC3T) SMART Mission

• Provide medical command, control communications
  to any of the deployed SMART teams
• Provide world-class telemedicine augmentation
  (technical advice/support) to local medical
  authorities in disasters/mass casualty incidents

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Telemedicine SMART Capabilities
o Initial on-scene incident assessment
capabilities to task organize and call
forward additional tailored teams, supplies
and equipment. o Basic manportable
communication equipment sufficient to
communicate intra and inter-team and to home
base. o Technical expertise and manportable
telemedicine equipment sufficient to install,
operate and maintain a rudimentary, emergency
telemedicine capability from a remote field
site.
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Telemedicine SMART Capabilities (continued)
o Assistance to civil authorities in
communicating emergency patient and provider
needs providing local authorities with
medical situational awareness.
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Telemedicine SMART Personnel Composition

• 1 Medical Officer (Team Leader)
• 1 Operations/Technical Officer
• 1 Medical Logistics/Administrator

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Telemedicine SMART Equipment

• Laptop computers (3)
• Field Computer (rugged)
• Zydacron V.35 Interface card
• Audio/Video capture board
• MS OS, Windows NT (3)
• Digital cameras
• 3 Lead EKG/Pulse oximeter/BP with data interface

• Gas powered generator
• Uninterruptable Power Supply (UPS)
• Power strip
• Printer
• Satellite Service, 64 Kbps INMARSAT
• Cellular phones (2)
• Hand held radios (10)

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Estimated Telemedicine SMART Costs

• Deployment Equipment 58,000/team
• Training 8,000/team
• Communications 10,000/yr
• Yearly Sustainment Costs
• Maintenance 3,500/team
• Hardware (3 yr life cycle) 15,000/team
• Retraining 2,000/team

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Medical Command, Control, Communications,
TelemedicineConcept of Operations

• Issue Warning Order
• Deploy within 12 hours of notification
• Equipment checked as baggage for commercial
  airline (if military air not possible)

Tokyo subway CW attack, 1995
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Current Capabilities

• Digital camera - Sony DKC-ID1
• Color scanner/printer - Canon BJC-80
• Lunch pail-Type computer w/ VTC
• 2 Laptop computers - Dell
• LAN

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Capabilities (contd)

• INMARSAT B-terminal (MacKay)
• 2 Cell phones (Nokia 2160i)
• Analog/digital/IS-136
• Digital message mode
• 1 kW Gasoline generator (Honda)

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Capabilities (contd)

• 10 hand-held radios
• Motorola XTS 3000 Model III (UHF version)
• Encryption
• Analog/Digital Capable
• 255 channels
• Range 5 miles
• Optional repeater can extend to gt30 miles

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Very Small Aperture Terminal (VSAT) Satellite
Augmentation

• 72 hour - 1 week deployment from TATRC
• 64 - 768 kbps data rate
• 2-4 phones
• TCP/IP
• ISDN for VTC

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Responsibilities

• Regional Medical Center
• Staffing
• Readiness status
• Feedback
• TATRC
• Training
• Maintenance
• 24hr Help Desk Support
• Modernization (assuming MEDCOM reimbursement)

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Responsibilities (contd.)

• Communications costs
• Regional Medical Centers
• INMARSAT bills (4/min voice, 9/min data)
• Cell phone bills
• TATRC (assuming MEDCOM funding)
• VSAT air time

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SMART MC3-T - Benefits

• Rapidly deploy and re-deploy
• Increase situational awareness-anytime, anywhere
• Provide real-time command and control
• Maintaining Standard of Care for all military
• Miniaturization will increase deployability
• Use will decrease need for on-the-ground medical
  presence (?)

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Development Issues

• Personnel turn-over
• Equipment maintenance
• Difficulty with use of the current VTC system
• User feedback for future changes
• Portable civilian satellite limited to 56/64kpbs
  transmission speed

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Schedule

• SMART MC3-T equipment deployed to 6 Regional
  Medical Centers
• Milestones (24-36 months out)
• Upgrade INMARSAT B units
• Update/convert VTC units
• TMED Master Storage System configuration and
  procurement
• Telemedicine Training course refinement

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Modernization for the SMART MC3-T

• Newer INMARSAT technologies
• Speech/Voice Recognition
• H.323 videoconferencing
• Wearable computers
• Ultrasound

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OB/Gyn clinic in a suitcase
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Special Operations Medical Diagnostic
System (Clinical Assessment Recording Environment)

• Embedded Functions
• Interactive Medical Reference Library
• Electronic Medical Record
• Specialty Medical Knowledge Bases

• Provides Interactive
• Diagnoses and Treatment Decision Aids
• Medical Sustainment Training

• Interface Features
• PIC Read/Write
• Focused Tele-consultation
• Internet Access
• Speech Recognition/Language Translation
• Chem/Bio Threat Detection Module

• Supports
• Medical Mission Planning
• Medical Reconnaissance

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ConclusionQuestions??
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Further information

• Telemedicine Advanced Technology Research
  Center, Fort Detrick, MD
• http//www.tatrc.org
• Walter Reed Army Medical Center, Washington, DC
• http//www.wramc.amedd.army.mil

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Global Grid Telemedicine System (GGTS) - Concept

• Use EXISTING AVAILABLE military
  telecommunication infrastructure located at
  Site R
• Add an Expert Management System
• Final Product A military telemedicine
  communications backbone with an intelligent,
  transparent, consultation routing system

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What is Site R ?

• Originally established (June 1953) as an
  Alternate Joint Communications Center
• Extensive capability to provide world wide
  command control communications
• Located in Ravenrock Mountain, PA (100 Km from
  Washington, DC)
• Fort Detrick, MD inherited installation support
  mission (October 1997)
• Feasibility study completed (May 1998)

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Global Grid Telemedicine System - Vision

• Access to DoD (as well as commercial)
  communications infrastructure at bandwidth
  appropriate to the telemedicine application.
• An intelligent (artificial intelligence based)
  object oriented global teleconsultation yellow
  pages sytem designed to route incoming consults
  to the appropriate on duty consultant.
• Connectivity from anywhere to anyone

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Global Grid Telemedicine System - Next steps

• Concept for developing GGTS is feasible
• U.S. Army Medical Department developing
• complete functional analysis
• business process review
• list of validated functional requirements
• operational concept

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Lessons Learned

• All SMART team members should have passports
  security clearance on orders.
• Test system all components before deployment
  include all necessary peripherals.
• Activate cell phones
• Load anti-virus software on all systems.
• Load all drivers on to system.
• Insure you have all required backup cables
  connectors
• Insure you deploy with right size team package
  (60 CMF) (70CMF) (91 CMF)

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Lessons Learned

• Pre-coordinate INMARSAT stowage on aircraft.
• All point to point VTC calls should be POINT TO
  POINT. (Minimizes potential points of failure
  when using video bridge)
• Have a copy of published local VTC numbers.
• Coordinate ground transportation for movement.
• Insure MREs and water are provided and packed.
• Insure members have travel credit card a line
  of credit for local purchases
• Add a 50 - 100 extension cord with more than
  one surge protector