Disaster medicine through Google Glass

Short report 1

Disaster medicine through Google Glass Luca Carenzo, Federico Lorenzo Barra, Pier Luigi Ingrassia, Davide Colombo, Alessandro Costa and Francesco Della Corte Nontechnical skills can make a difference in the management of disasters and mass casualty incidents and any tool helping providers in action might improve their ability to respond to such events. Google Glass, released by Google as a new personal communication device, could play a role in this field. We recently tested Google Glass during a full-scale exercise to perform visually guided augmented-reality Simple Triage and Rapid Treatment triage using a custom-made application and to identify casualties and collect georeferenced notes, photos, and videos to be incorporated into the debriefing. Despite some limitations (battery life and privacy concerns), Glass is a promising technology both for telemedicine applications and augmented-reality disaster response support to increase operators’ performance, helping them to make better choices on the field; to optimize timings; and finally

Disasters and mass casualty incidents are traditionally defined as overwhelming events where resources are scarce and time is a constraint [1]. Nontechnical skills, defined as ‘decisionmaking and team interaction processes used during the team’s management of a situation’, can make a difference [2]. Introducing a tool that helps providers in these aspects could possibly improve their ability to respond to such events. Among new revolutionary devices developed in recent years, one has not unleashed its full potential, but is still very appealing to the medical field. Google Inc. (Mountain View, California, USA) has recently released a novel augmentedreality tool, Google Glass (Glass). They are designed as an interactive personal communication device that is in fact an (almost) hands-free computer mounted on a glass frame. Glass is operated by voice commands with limited controls needing interaction with an integrated touchpad. Sound is provided through bone vibration, allowing only the person wearing them to hear it in noisy environments, a headset can be plugged in [3]. Glass runs on an android-based operating system, which is open for any custom-made application development. They are equipped with a screen, camera, Bluetooth, and Wi-Fi connections that are used by the system to generate augmented information of the observed world. Augmented reality is the process of supplementing real world information with computer-processed sensory data obtained, for instance, by the glass camera, the Internet, GPS, or other sensors. We recently tested Glass-mediated augmented-reality response to a sudden crisis during a full-scale simulation held in Novara, Italy, on 4 June 2014, as part of the current edition of the European Master in Disaster Medicine 0969-9546 © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins

represents an excellent option to take professional education to a higher level. European Journal of Emergency Medicine 00:000–000 © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins. European Journal of Emergency Medicine 2014, 00:000–000 Keywords: augmented reality, disaster medicine, Google, Google Glass, mass casualty incident, telemedicine, triage Research Center in Emergency and Disaster Medicine and Computer Science applied to Medical Practice (CRIMEDIM), Università del Piemonte Orientale, Novara, Italy Correspondence to Francesco Della Corte, MD, Research Center in Emergency and Disaster Medicine and Computer Science applied to Medical Practice (CRIMEDIM), Università del Piemonte Orientale, Novara, Italy Tel/fax: +39 0321-660620; e-mail: [email protected] Received 21 July 2014 Accepted 29 October 2014

(EMDM) [4]. The simulation involved 100 mock casualties and almost 300 healthcare providers and rescue personnel. A complex humanitarian emergency was simulated with a migration wave overwhelming a NATO ROLE-2E field hospital deployed by the Italian Army. The entire incident response chain was activated, including on-thefield and in-hospital medical activities. The incident commander and the triage officer were equipped with Glass. Battery life was extended by means of an external battery pack and no operators had any limitation because of battery life. Each pair of Glass was running a custommade application, specifically designed by our research team to be used in a mass casualty incidents setting, based on the Simple Triage and Rapid Treatment algorithm [5]. Applications were designed using the Glass Developer Kit (GDK) freely available on the net (https://developers.google. com/glass/develop/gdk/). The application was easy to use and a 10 min training on the field was enough to enable operators to perform augmented triage. The overall goal of this application was to provide an augmented-reality, hands-free environment that could help healthcare providers during the rescue operations. Each provider was equipped with a roll of quick response (QR) code triage tags, simply made by printing unique QR codes on colored labels. The application was designed to act as a closed loop to triage casualties one after another and could be entirely controlled by vocal commands, hence leaving the handsfree for other tasks. After the initialization of the application, Glass asked for a QR code reading. Once a tag was scanned, a progressive casualty ID appeared on screen and Glass proceeded by asking the operator appropriate questions, on the basis of the preselected triage algorithm, DOI: 10.1097/MEJ.0000000000000229

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up to the assignment of a triage code. This was then automatically uploaded to a database, paired with the assigned casualty ID, a timestamp, and GPS coordinates. Before ending the loop, it was also possible to take an optional picture or video of the casualty or the surroundings, which again was automatically georeferenced and associated to the unique casualty ID. With this, the simulated dispatch center could follow in real time the triage operation process and provide an additional tool to dynamically evaluate the appropriate response to the event. The information flow from the scene to the dispatch center is summarized in Fig. 1.

the exercise to produce the after-action report for the simulation debriefing. Fig. 2

A selected number of observers from the simulation management team were also equipped with Glass including one of the first ambulances leaving the spot, as shown in Fig. 2. Observers equipped with Glass were provided with a custom-made application designed to augment direct observation. All observers could record key actions through video and pictures and associate them with notes taken by dictation. Data were automatically timestamped and updated on a central server, where they were aggregated along with other data collected during

Google Glass being used aboard one of the first ambulances leaving from the scene of the event during the mass casualty incident full-scale simulation.

Fig. 1

Protected remote database

Healthcare provider with Google Glass

Visual guided triage algorithm

Casualties and environmental pics Casualties and environmental video Casualties QR code (triage tags and temporary ID) Casualties and operator’s GPS position

Casualties

Dispatch center

Casualties

Smart allocation of vehicles, personnel and resources Schematic flow of information from the Google Glass to the dispatch center and appropriate feedback. QR, quick response.


Google Glass Carenzo et al. 3

There are some reports of the use of Glass in emergency medicine [6] but this is, to our knowledge, the first report of its use during a disaster medicine (DM) event, even if in a simulation setting. Although doctors are among the early enthusiasts and adopters of this technology [7], it is not entirely clear yet what the applications and potential of such technology could be and whether this will have a real impact on performance or outcome. The greatest potential from our experience derives from the possibility to develop custom-made applications and consequently generate augmented-reality solutions for emergency and disaster management. We structured our tests on the basis of two different fields of applications: telemedicine and augmented reality. DM telemedicine uses could be the remote visual monitoring of the scene to the dispatch center and to the hospitals involved. Photo and video documentation could be available for immediate response support and later forensics analysis. Images and reports broadcasted to hospitals could be viewed by different specialists for live distance consulting that could be automatically transmitted to the operators on the scene. In hospital, applications could include dynamic monitoring of surge capacity and bed occupancy from anywhere, remote multiparametric monitoring, lab and radiographic reports without looking/walking away from patients or during procedures, and streaming of procedures and surgeries to other staff members and medical students. Altogether, the educational potential would also be invaluable. For augmented reality for DM, these usually require custom-made applications to process the data being collected on the field. One example is the augmented triage application that we designed, specifically made to automatically keep track of casualties’ triage code (and position) and at the same time to attempt reducing overtriage and undertriage. By forcing the operator to follow a predetermined algorithm prompted by Glass, this could reduce the time spent triaging each single casualty and increase the accuracy of the triage itself. In addition, Glass could be used to keep track and monitor the treatments applied and the drugs administered. In hectic moments, such as on a disaster scene, one of the greatest challenges is often to provide a proper documentation of casualties and related procedures. Glass could create hands-free and paper-free clinical records that are automatically synchronized with the dispatch or the hospitals. Drugs and equipment could interface with Glass with QR codes, which most of them already have printed on. Other augmented-reality examples for rescuers could include a live view of the scene map superimposing all triaged casualties represented as small colored dots on the basis of the geolocalization data uploaded to the remote database; another example could be building safety assessment and building triage. One advantage of custommade solutions is the possibility of developing applications that can also work asynchronously, in case of absent or lost

connection. The triage algorithm can run irrespective of network access and the data can be stored locally and uploaded as soon as the network is restored. Moreover, new research is developing solutions to provide Internet access to emergency areas by using MESH networks that allow users to link up without a centralized Internet service (http://www.technologyreview.com/news/516571/build-your-owninternet-with-mobile-mesh-networking/). Casualty identification is another huge step. Face recognition is already available for Glass, and is an extra step from simply taking pictures of casualties for later identification. However, this is not officially supported by Google at the moment, and it has been heavily criticized because of the ease of possible misuse for reasons other than just medical or forensic purposes. Finally, one more promising application is in the field of DM training. It is well-known that objective debriefing plays a key role in medical simulation and any tool that could increase objective evaluation could enhance the results obtained by a simple and direct observation [3,8]. Some limitations to the use of this technology should be taken into consideration: privacy concerns and legal regulations are among the most common issues that could prevent the greater use of this technology. Having a tool that can take photo or videos or can collect large amounts of clinical data and streaming them directly somewhere else is different from passing papers directly to the hands of a physician or a nurse in the hospital. It must be ensured that only the relevant personnel can access this information. The use of Glass itself does not alter the privacy in a disaster setting; the main point is to be careful about how the data are streamed through. If there is no third-party server between Glass and the healthcare secure server, privacy issues should be a relatively minor concern. In countries such as the USA, the Health Insurance Portability and Accountability Act prevents patient data from being uploaded to third-party servers such as Google’s. However, for custom-made application running on the Glass, it is possible to use one's own institutional databases. In any case, considering the exponential power of such technologies, which are moving way faster than regulations, it is most likely that things could change in the upcoming future. Health 2.0 is the new era we are now living in, where new portable technology and advanced communication devices increase the quantity and quality of the information available, to the extent of acting as an enabler for care collaboration. Glass could be the future of Health 2.0, allowing interactive medical management and augmented reality whose purpose in the medical field is to increase the operator sensitivity and to optimize timings and procedures, such as in the process of improving triage accuracy.

Acknowledgements We would like to thank Prof. K. Koenig, CDMS, University of California at Irvine for her help and support


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in making the study possible. Google Glasses were bought using Department Research Funds.

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Conflicts of interest

There are no conflicts of interest.

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