In this thesis an electronic triage tag with wireless interconnectivity is developed, implemented and tested. The tag submits triage information to the incident command center over a wireless mesh network which is built up by the tags themselves. Furthermore the tag is wirelessly interfaceable with vital value sensors to allow live monitoring of patients. The developed device works autonomously, without any user intervention and is attached to colored bracelets which are already used for triage. There is no need to change the triager’s work flow. The electronic triage tag is a time-efficient extension for existing triage tools to aid rescue forces in accelerated treatment and evacuation of victims.
Mass Casualty Incidents (MCI) overwhelm medical resources and require the treatment of a large amount of patients within a very short time. Triage is a process used in MCIs to assign scarce medical resources to victims so that as many as possible can survive. Currently, the triage process is carried out with the help of a Paper Based Patient Tag with a unique ID, signaling the victim’s treatment priority by its color (red, green, yellow or black). Paper-based triage strives for a fast and accurate treatment of victims, but it has problems with regard to the speed and accuracy of transmitting triage information. Live monitoring of victims’ vital values is not possible because of the paper-based process and the lack of medical personnel. An electronic approach promises a faster situation overview and, thus, faster treatment of victims. However, the introduction of new systems must be done in a sensible way, so that the triager’s process and workflow is not modified.
Contents
Abstract
Acknowledgements
1. Introduction
1.1. Motivation
1.2. Scope
1.3. Outline
2. Background
2.1. Triage
2.1.1. The START Triage Method
2.1.2. Other Mass Casualty Triage Systems
2.1.3. TriageTags
2.2. Issues With Current Triage Tags
2.3. RelatedWork
2.3.1. SOGROMANV500
2.3.2. AID-N
2.3.3. WIISARD
2.3.4. eTriage
2.3.5. More Related Projects
2.4. Analysis
3. Requirements for an Electronic Triage Tag
4. The eTriage Concept
5. Hardware Development
5.1. Selection of Communication Standard
5.2. TheeTriageTag
5.2.1. SelectionofSoft-andHardwarePlatform
5.2.2. Selection of Hardware Components
5.2.3. Communication Interfaces
5.2.4. PCBDesign
5.2.5. Assembling the PCB
5.2.6. Case
5.2.7. Assembling the eTriage Tag
5.3. TheeTriageGateway
6. Software Development
6.1. Developing with Lightweight Mesh
6.1.1. Typical Application Structure
6.1.2. BasicNetworkConfiguration
6.1.3. Data Transmission
6.1.4. Data Reception
6.1.5. SoftwareTimer
6.2. TheeTriageTagFirmware
6.2.1. Application Task Handler
6.2.2. AD ConversionofTemperature SensorVoltage . . . . . .
6.2.3. GPSInterface
6.2.4. MicroSDSPIProtocol
6.2.5. Address Initialization and Administration
6.2.6. Communication Protocol
6.2.7. Software Timer
6.2.8. LED Indicator
7. Testing
7.1. HardwareFunctionalityTest
7.1.1. AssembledHardwareComponents
7.1.2. OperatingTime
7.1.3. Range Test
7.2. Software Test
7.2.1. Module Test
7.2.2. SystemTest
8. Conclusion and Future Work
8.1. Conclusion
8.2. FutureWork
A. Schematics and Layout
B. Software
B.1. AppMessage_t Structure
B.2.FuseBitSettings
B.3. Introduction to Lightweight Mesh
B.4. Data Transmission Options and Status Codes
B.5. Data Reception Options and Status Codes
List of Figures
2.1. TheSTARTAlgorithm
2.2. TheCareFlightTriageAlgorithm
2.3. The Sieve Triage Algorithm
2.4. TheMETTag
2.5. TheSMARTTag
2.6. TriageLights
2.7. ReflectiveSlap-OnTriageTag
2.8. ClothespinTriage
2.9. AneTriageTag
4.1. TheeTriageComponents
4.2. The eTriage Concept
5.1. AtmelWirelessSolutionsDiagram
5.2. OverviewortheHardwareDesign
5.3. Block Diagram of ATmega256RFR2
5.4. MCUSchematics
5.5. Block of Diagram deRFmega256-23M00
5.6. GPS Receiver Schematics
5.7. Temperature Sensor Schematics
5.8. MAX1555 Charging Controller Schematic
5.9. LP2985 Voltage Regulator Schematic
5.10. eTriagePCBDesignTop
5.11. eTriagePCBDesignBottom
5.12.3DDesignofanoldPCBVersion
5.13. Assembled eTriage PCB Top
5.14. Assembled eTriage PCB Bottom
5.15. Assembled eTriage Tag (Yellow) and Colored Bracelets
6.1. OverviewofSoftwareComponents
6.2. State machine of the eTriage tag
6.3. SDCardBlockDiagram
6.4. SDCardPinout
6.5. Destination Address Management for eTriage Tags
7.1. LP2985 Voltage Regulator: Input vs. Output Voltage
7.2. Wireless Charging Test Setup
7.3. MAX1555 Charging Controller: Charging Voltage and Current .
7.4. DischargeCycle
A. 1 . PCB Design of the eTriage Tag
A.2.SchematicsoftheeTriageTag
A.3. Bill of Material: eTriage tag
A. 4.eTriageTagCaseDesign
B. 1.LWMNetworkTopology
B.2.LWMArchitecture
B.3.LWMFrameFormat
List of Tables
5.1. Estimated Power Consumption at 3.3 V
5.2. SPIPinout
6.1. Software Timer Options
6.2. Basic SD Commands
6.3. ResponseTypeR1
6.4. Implemented Software Timer
B.1. ATmega256RFR2 Fuse Bit Settings
B.2.NetworkDataRequestParameters
B.3.NetworkDataRequestOptions
B.4. Network Data Request Status Codes
B.5. Network Data Indication Structure Field
B.6. Network Data Indication Options
Listings
6.1. Typical Application Structure
6.2. Data Transmission
6.3. Data Reception
6.4. Software Timer
6.5. TypicalNMEAStrings
6.6. NMEA Message Structure
B.1. Example Test Messages Saved on SD Card
B.2. AppMessage_t Structure
B.3.SensornamesandCategories
Abstract
Mass Casualty Incidents (MCI) overwhelm medical resources and require the treatment of a large amount of patients within a very short time. Triage is a process used in MCIs to assign scarce medical resources to victims so that as many as possible can survive. Currently, the triage process is carried out with the help of a Paper Based Patient Tag with a unique ID, signaling the victim's treatment priority by its color (red, green, yellow or black). Paper-based triage strives for a fast and accurate treatment of victims, but it has problems with regard to the speed and accuracy of transmitting triage information. Live monitoring of victims' vital values is not possible because of the paper-based process and the lack of medical personnel. An electronic approach promises a faster situation overview and, thus, faster treatment of victims. However, the introduction of new systems must be done in a sensible way, so that the triager's process and workflow is not modified. In this thesis an electronic triage tag with wireless interconnectivity is developed, implemented and tested. The tag submits triage information to the incident command center over a wireless mesh network which is built up by the tags themselves. Furthermore the tag is wirelessly interfaceable with vital value sensors to allow live monitoring of patients. The developed device works autonomously, without any user intervention and is attached to colored bracelets which are already used for triage. There is no need to change the triager's work flow. The electronic triage tag is a time-efficient extension for existing triage tools to aid rescue forces in accelerated treatment and evacuation of victims.
Acknowledgements
I would like to acknowledge and thank Erion Elmasllari for the guidance and support that was essential for the completion of this thesis. His incredibly useful comments, remarks and engagement accompanied me through the entire process.
I would like to express my gratitude to my principal supervisor
Prof. Dr.-Ing. Marco Winzker for making helpful suggestions how to organize my thesis.
My employment at the Fraunhofer Institute for Applied Information Technology provided me a creative space to develop and to reflect on my ideas.
I thank my fellow labmates at the FIT for the stimulating discussions, and for all the fun we have had in the last months.
Last but not the least, I would like to thank my family: my parents and my brother and sisters for supporting me spiritually and keeping me harmonious throughout writing this thesis.
Thank You!
1. Introduction
1.1. Motivation
A Mass Casualty Incident (MCI) is any incident in which regularly available medical emergency resources are overwhelmed in terms of rescue personnel, transport vehicles and hospital capacity[59]. A large amount of patients spread out across a sizeable area needs to be treated within a very short time. Disasters like the 9/11 attack in September 2001 where 2.996 people were killed, the 2005 London bombings where 52 people were killed and over 700 severely injured, or natural disasters like the Haiti earthquake in 2010 which led to over 200.000 deaths are just a few examples. Incidents of lesser extent can also overwhelm rescue services of a particular region. Examples are the Oktoberfest attack in 1980 with 211 injured and 13 death, the train accident in Santiago de Compostela in 2013 where 97 people died or the incident at the Loveparade in Duisburg in 2010 causing 21 deaths and 541 injured. In general such situations are rather complex, putting high demands on rescue forces at the scene. In order to ensure a good coordination and speedy response, clearly structured processes and techniques have been developed over time. Triage is one of these techniques. It aims to assign scarce medical resources to victims so that as many as possible can survive. As there are many victims and not enough medics available in MCIs, an individual treatment can not be ensured in most cases. Instead, the order and priority of victim's treatment and transport to a hospital is determined based on the severity of their injuries. The process of categorizing victims according to their need for medical attention, hence their chance for survival, is called triage.
At first contact during the triage, the condition of each victim is quickly assessed and he or she is assigned to one of four categories representing the urgency of treatment and transport. Currently, a Paper Based Patient Tag (PBPT) with a unique ID is attached to each victim signaling the assigned category by its color (red, green, yellow or black)[1]. After triage is finished for all victims, they are transported to a local medication center, where he or she will be further medically treated and registered by name before he or she will be transported to a hospital. Additional information like a short diagnosis, treatment history (given medication etc.) and vital values maybe written on the tag while another team gives first medication. Parallel to the treatment a list with all triaged victims is maintained and updated frequently to aid the incident command center in getting a good and fast overview of the extent of the MCI. Although this approach guarantees a fast and accurate treatment of victims, problems still occur.
- Information about victims is sent to the command center only after all victims have been triaged. This can last up to 30 - 40 minutes, hindering a fast response.
- The list of all victims may not be up to date because the time between discovering and reporting a victim can be very long due to communication problems (destroyed infrastructure, overloaded radio traffic)
- Victims may be assigned to the wrong category because their condition rapidly changes
- The information on the tag may become unreadable because of contaminations with dirt or blood
- If a tag is replaced (e.g. in case of retriage), all information written on the tag needs to be copied by hand which is a time-consuming, error prone process
- Live monitoring of vital values is not possible because of the lack of medical personnel
- An overview of triage information (number of victims, assigned categories, location etc.) is needed at several places at the same time, e.g. at the gathering site, the incident command center, the remote command post or at nearby hospitals. Currently the data has to be read from the tags and transmitted using handheld radios which is an error prone process and could lead to misunderstandings. If, for instance, hospitals would have access to this data in advance, they could prepare before the patient arrives.
It needs to be mentioned that this is just an excerpt of the problems, which has been elaborated from interviews with triagers and experts in that field[1]. There are many more organizational problems during MCIs, but these are outside the scope of this work.
At present, technologies like smartwatches and other wearables with wireless data transmission capabilities are integrated in our everyday life to simplify it and aid us in solving common problems. At the same time in large scale emergencies where every second counts to save a life, paper based triage tags are used to store, transmit and update information. The thought of accelerating or simplifying this process by using technology similar to that we use every day, is not new.
Several attempts trying to address above mentioned issues have already been made[57][3][8][14][30][32]. However, none of them provides a user centered solution which is as intuitive and as easy to use as a paper based tag.
If an electronic device that does not change the triagers workflow and at the same time aids for an efficient patient care in MCIs can be developed, treatment and evacuation of victims can be accelerated, thus giving rescuers the time to save more victims, faster.
1.2. Scope
The aim of the presented work is the development and prototype implementation of an electronic triage tag with wireless interconnectivity to aid rescue forces getting a fast overview of the current situation in case of an MCI. The eTriage tag[30][14][32] developed by Erion Elmasllari at the Fraunhofer Institute for Applied Information Technology (FIT) serves as a base model. However, the technology used in that project should be substituted by smaller, cheaper and energy-efficient hardware to get a lightweight device with a fair operating time which transmits triage information wirelessly to a central instance. The eTriage tag presented in this work aims also to be wirelessly interfaceable with vital sign sensors like the one developed by Marc Jager in [50] or the ones presented at cooking hacks[38].
1.3. Outline
The thesis is organized as follows:
- Chapter 2, Background: The first section of chapter 2 presents various triage systems and tags that are currently being used. The next section highlights the issues encountered by these systems. Related projects aiming to solve these problems are introduced in section 2.3. In particular, the eTriage system developed at the FIT is explained. The final section provides an analysis of the previously mentioned projects and describes their problems.
- Chapter 3, Requirements: Chapter 3 presents the requirements for an electronic triage tag, derived from the analysis section of chapter 2.
- Chapter 4, The eTriage Concept: Chapter 4 introduces the eTriage concept, its components and the network structure. 5.2. Furthermore the software architecture is explained and an introduction to the used software stack is provided.
- Chapter 5, Hardware Development: The hardware design and implementation of the eTriage tag is described in this chapter. It starts with the selection of an appropriate transmission standard, followed by the selection of suitable hardware components. The assembly of these components to get a fully functioning eTriage tag is described at the end of this chapter.
- Chapter 6, Software Development: This chapter deals with the development of a firmware for the eTriage tag. First of all an introduction to the development of custom applications with Atmel's Lightweight Mesh software stack is given. After that the design and implementation of the eTriage tag firmware is described.
- Chapter 7, Testing: In chapter 7 both the hardware and software modules separately and the assembled device is tested. An integration test and a test of the system which includes the eTriage tags and the eTriage gateway is conducted. The outcomes of these tests and their meanings are presented and analyzed.
- Chapter 8, Conclusion and Future Work: Chapter 8 provides a summary of this work and draws its conclusions. Future work and possible improvements, both technical and general are presented.
- Appendix: The appendix provides the reader with information not absolutely necessary to understand this work but important to reproduce it or parts there of.
2. Background
This chapter introduces basic knowledge and theoretical background important to understand this work. The current approach to a large-scale emergency is introduced to get a rough idea of what challenges and problems paramedics are facing in such scenarios. The next section presents existing systems and products in the field in order to get a good overview of state-of-the-art devices, network communication technologies, existing services, applications and standards. In particularly the eTriage system, a crisis management system developed at the Fraunhofer Institute for Applied Information Technology (FIT) is highlighted.
2.1. Triage
Triage is the process of determining the priority of a victim's treatment conducted in those emergencies where medical resources are insufficient. Its aim is to save the life of as many people as possible regardless of the quality of life afterwards. This could imply that treatment of a victim which will survive for the next two hours can be postponed even though it means that he will loose one hand because of delayed treatment. It could also imply the deliberately withholding treatment of people whose chances of survival are minimal no matter how much care they receive.
Triage methods classify victims into different categories according to their need for medical attention. A special triage tag is allocated to each victim representing one of the following classifications:
1. Black: Expectant
- Victims are unlikely to survive regardless of given help. Pain relief will be provided.
2. Red: Immediate
- Life-threatening wounds, immediate help required.
3. Yellow: Delayed
- Serious and potentially life-threatening injuries but stable conditions for the moment. Transport to hospital can be delayed.
4. Green: Minor
- Lightly wounded and able to walk (’’Walking Wounded”). Likely to survive for up to a day.
2.1.1. The START Triage Method
Simple Triage And Rapid Transport [61] (START) is a triage method developed in 1983 by staff members of the Hoag Hospital and Newport Beach Fire Department located in California. This triage method was intrinsically taught to California emergency workers for use in earthquakes. Because of its simplicity and field-proven use in other mass casualty incidents such as train wrecks or bus accidents it is now widely established in the United States of America.
One advantage of the START method is that it can be performed by lightly trained lay and emergency personnel and is not intended to replace or instruct medical personnel. In this method the triager does not give any treatment except of positioning the neck so that the victim has no impediment to breathing. To ensure an objective triage and simplify the classification of injured people an algorithm for emergency personnel has been developed. The algorithm illustrated in figure 2.1 is also a good way to learn the system quickly.
2.1.2. Other Mass Casualty Triage Systems
The START triage method described in section 2.1.1 is one of the mass casualty triage methods widely adopted in North America. However, there are many more notable triage methods and algorithms currently used in different countries. The assigned categories are similar to the ones mentioned in section 2.1.1, although they vary between countries and are not dependent on the triage method being used. A rough overview of the worldwide most frequently applied systems is provided in the following section.
Abbildung in dieser Leseprobe nicht enthalten
Figure 2.1.: The START Algorithm [39]
Care Flight
The CareFlight Triage algorithm has been developed by Norcera and Garner in 2001 providing responders with a primary MCI1 triage tool to standardize disaster response in Australia. This algorithm distinguishes between walking and non-walking patients followed by assessing the ability to obey commands, the presence of respirations and the palpability of the radial pulse (cf. figure 2.2). Different than in the START method it does not observe the respiratory rate and assesses the level of consciousness first[6][2].
Abbildung in dieser Leseprobe nicht enthalten
Figure 2.2.: The Care Flight Triage Algorithm[6]
Triage Sieve
The Triage Sieve methodology has been published by Hodgetts and Mackway- Jones in 1995 as a component of the Major Incident Medical Management and Support (MIMMS) [56] course for healthcare providers. It has been widely advocated in the United Kingdom and has been adopted in parts of Australia. Similar to the START algorithm Triage Sieve assigns priority based on the assessment of ability to walk, airway patency, breathing and pulse rate (cf. figure 2.3). Differently than in START Triage Sieve defines abnormal breathing as < 10 breaths or > 30 breaths/min. A pulse rate > 120 bpm is categorized as ”immediate” which is a parameter found to be correlating with the presence of a shock[56][6].
Abbildung in dieser Leseprobe nicht enthalten
Figure 2.3.: The Sieve Triage Algorithm[6]
STM
Sacco et al. published in 2008 the Sacco Triage Method (STM) for prioritizing patients during a MCI. Differently from above mentioned triage methodologies STM has less of an algorithm but more of a mathematical model that not only orders the treatment of patients based on their probability of survival but also includes the potential for deterioration and available resources. The STM is currently the only system that relies on empirically derived assessment criteria with the possibility of changing the prioritization of patients in a real-time manner based on available resources. It is a very complex triage method requiring software support, personnel for data entry, communication to incident command and resource availability information which may limit the usability in real-world applications. There are no published reports using the STM [11][6].
2.1.3. Triage Tags
As described above, triage includes dividing victims of Mass Casualty Incidents (MCI) into several categories according to their need for medical treatment. To document and make the category visible, as well as to show the priority of medical treatment, the victims need to be tagged in some way. The tagging of victims is usually done with so called triage tags. These tags vary strongly between countries because no international standards have been established yet. This section presents a variety of the commonly used triage tags and their advantages and disadvantages.
MET Tag
The Medical Emergency Triage (MET) tag (figure 2.4) is used by many different US institutions including the US Government, U.S. Army, U.S. Air Force etc. This tag not only includes the color coding but also provides space for additional information like a victim's personal data (e.g. name, sex, address, age etc.), time and date, location of injuries, medication history and two smaller triangular tags for attaching to severed body parts.
SMART Tag
The SMART triage tag is similar to the MET tag but in a folded design. It is used by some US states (e.g. Massachusetts) and, among others, by the British Military. TSG associates reports [54] that the SMART Incident Management System was successfully used by EMS crews during the Boston Marathon bombing. Similar to the MET tags, the SMART tag provides a lot of space for additional information including personal data, time and date, type of injury, treatment history and different from the MET tag it provides also space for a second triage. Because colour categorisation is achieved by folding the tag appropriately, it makes re-triage in both ways (worsening and improving condition) possible.
Abbildung in dieser Leseprobe nicht enthalten
Figure 2.4.: The MET Tag MT137 [63]
Abbildung in dieser Leseprobe nicht enthalten
Figure 2.5.: The SMART Tag [54]
Triage Lights
E/T Light[62] has developed electronic Triage Lights. These lights are waterproof, dustproof and long lasting LED lights which can be programmed to light up in any of the four triage colors. As the inventors state they are better than chemical light sticks because they are cheap, they can be turned off and they can indicate a series of conditions via blinking.
Abbildung in dieser Leseprobe nicht enthalten
Figure 2.6.: Triage Lights [62]
These lights may not only be used for triage but also for sports and outdoors or to be recognizable in the dark.
Slap-On Tag
Rhen et al. present and evaluate in their research article a triage method developed by the Norwegian Air Ambulance Foundation[55]. They conclude that this method, based on the triage Sieve method, ”[...]is feasible, timeefficient and accurate in allocating priority during simulated bus accidents and may serve as a candidate for a future national standard for major incident triage”[9].
Abbildung in dieser Leseprobe nicht enthalten
Figure 2.7.: Reflective Slap-On Triage Tag: Immediate (red); Delayed (yellow); Minor (green); Deceased (White/Black)[9]
They replaced the commonly used paper tags with reflective, slap-on bracelets in corresponding colors (cf. figure 2.7). All other relevant triage information is written on parts of the victims' body, usually the face. The slap-on tags are widely established in scandinavian countries, because traditional paper tags are likely to perish in the sub-arctic climate and they are problematic to identify in sub-optimal lightning[1][9].
Other Sorts of Tagging
Because the most important part of triage is the color-coded tagging of victims, any suitably colored object can be used to indicate the triage category. In the example in figure 2.8 Capt. Anthony Jarecke from the U.S. Military uses clothespins as triage tags during an exercise.
Abbildung in dieser Leseprobe nicht enthalten
Figure 2.8.: Capt. Anthony Jarecke During a Triage Exercise [17]
2.2. Issues With Current Triage Tags
Paper-based triage and registration systems are still state-of-the-art because they are robust and their usage is intuitive. However, information about affected individuals stays among the persons themselves, complicating disaster management considerably. Reporting recently tagged victims to the incident command center is done orally using handheld radios, which could lead to misunderstandings e.g. in terms of language or dialect. Data recorded on the tag can only be duplicated by manually copying it, which is a laborius and time-consuming process. The color coding of the MET triage tag is done by tearing off parts of it, making re-triage possible only for worsening conditions, resulting in over-triage2 if the victim's condition improves. The SMART tag is folded and encapsulated in a plastic housing which makes it impossible to see all the information written on the tag. To access it, the tag needs to be removed from the housing and unfolded, wasting a huge amount of time. Additionally tracing back a single person who may or may not have passed different stations of the rescue chain is practically impossible. It can occur that victims walk around wounded and confused in some kind of shock. Finding these missing victims in an area which may be totally destructed and dangerous is very difficult, if not impossible. In general, it is challenging to get an immediate and accurate situation overview (i.e. number of victims, categories and their location), leading to sub-optimality in deploying forces. Triage and registration might be performed at different areas by different teams which automatically leads to different lists. These lists have to be sorted and updated manually which is a time consuming and error-prone process. Important to mention is also, that the majority of civil rescue forces consists of volunteers which usually have only little experience with large scale emergency situations. They are well skilled but do not operate as strictly in hierarchy as for instance armed forces do [28].
2.3. Related Work
This section gives a brief introduction to several projects which have dealt with the difficulty of an efficient patient care and transport in mass casualty incidents. Most of these projects try to address the problems with state-of- the-art triage processes.
2.3.1. SOGRO MANV 500
The project SOGRO[57] focuses mainly on the efficient marking and localization of patients in mass casualty incidents. For that purpose specific hand held mini computers, personal digital assistants (PDAs), were developed. Triagers use one of these and a special, colored plastic bracelet to store the triage category, the gender and the estimated age of the victim with a time stamp and location information on a RFID chip inside the bracelet. The color of the bracelet represents the triage category and the data set on the chip can be read out and extended by personnel at the incident site or in the hospital. With the PDA the triager is also able to take a picture of the victim which is sent, together with the data and the current location, to a server. Automatic location monitoring in real-time or an interface for connecting vital sign sensors is not supported in SOGRO.
2.3.2. AID-N
A similar approach to the present work is followed also by AID-N (”AID-N:The Advanced Health and Disaster Aid Network: A Light-Weight Wireless Medical System for Triage”)[3]. This work implements the CodeBlue[7] software system on the MicaZ[41] and TmoteSky[27] motes from Crossbow Technology and MoteIV respectively. Running the CodeBlue ad-hoc mesh network stack, based on TinyOs[37], the sensors provide features like triage, status display, vital sign monitoring, location tracking, information display, and alarm signaling[64][10]. This information is intended to be submitted wirelessly via the ad-hoc mesh network, however, this project seems not to be under development anymore; the website has not been updated since 2007.
2.3.3. WIISARD
Another triage system aiming to replace the traditional paper tags was developed by Lenert et al[8]. The WIISARD system consists of several components working together, including an electronic wireless patient tag, tracking and data relay units, first responder devices and integrated software systems. First responders entering the scene would move throughout the site, carrying a satchel full of patient tags, a responder tag (TDRU) and a data entry device in form of a PDA. The patient tags would be attached to the victim which is then ”logged into the system” via the PDA. Relevant information like triage status, condition, identification, treatment or indications needs to be entered manually via the PDA. Patient's location information is gathered through an active Radio Frequency Device (RFID) system using observed radio signal strength. Gathered data (AP signal strength, battery life, acceleration, temperature and orientation) is passed to nearby TDRUs which route it to the mobile command post.
The WIISARD tag itself, with dimensions of 120mm x 65mm x 22mm, is relatively large and consumes up to 2W of energy. As triagers need to carry as many tags as possible at the scene, a much smaller tag is appropriate. Entering data manually via the PDA can be a time consuming strenuous process, especially considering that most triagers are wearing gloves. Information like battery life or acceleration sent by the tag might not be of direct interest for paramedics treating victims.
2.3.4. eTriage
As part of the BRIDGE EU project[1] the Fraunhofer Institute for Applied Information Technology FIT developed a electronic triage system, which aims to support rescue teams during the triage process in order to accelerate the evacuation and medical treatment of victims in large scale emergencies. The key idea is to improve the communication link between the field personnel, the transport site, the incident command center and inform surrounding hospitals about incoming patients while not interfering with the current triage process. This should ensure better coordination of rescue services and faster evacuation of victims with no need for training or process changes. The main component is similar to the SOGRO project[57] a color-coded, snap-on plastic wristband extended with a mobile electronic device, called eTriage tag shown in figure 2.9. This special tag sends timestamped location and vital value information over an ad-hoc network to the incident command center. The data gets updated frequently and if no existing networks are available the eTriage tag builds up it's own independent, fully functioning ZigBee network.
Abbildung in dieser Leseprobe nicht enthalten
Figure 2.9.: An eTriage Tag[14]
The eTriage system consists of several components working together. The tag itself features an embedded GPS module, a temperature sensor, a RFID chip and a network component (ZigBee) for communication with the data network. For unstable and severely injured victims, special sensors can be attached to their bodies that transmit vital values to the emergency response control center using the ZigBee tag's network[14][30][32].
2.3.5. More Related Projects
As there are many more projects addressing the challenges and problems during an MCI, introducing all of them would go far beyond the scope of this work. A few of the notable ones are mentioned here for completeness' sake.
CodeBlue: This project introduces the CodeBlue infrastructure comprising a suite of protocols letting many types of devices (e.g. wireless sensors, handheld computers etc.) coordinate their activities. A wireless vital sign sensor based on the Mica2[5] mote which monitors heart rate and blood oxygen level and Another wireless sensor which captures a trace of the heart's electrical signals through a set of leads attached to a patient's chest are part of that project [7].
Marcel Noe [58] describes in his dissertation the development and implementation of a wireless sensor network for monitoring patients in MCIs. His approach is to enhance a sensor measuring vital signs[50] with a functionality to transmit data wirelessly to a central control station. He develops a prototype board based on an Atmel AVR chip which runs a ZigBee implementation and intends to be interfaced wirelessly with the first aid sensor.
The ALARM[12] project aims to technologically assist rescue teams in case of a MCI. At the moment little information is available. The project aims to build an integrated service platform to simplificate and accelerate communication and information flow between rescue teams at the scene, command incident centers and nearby hospitals. After assessing the information available it, can be assumed that this project aims more to create consistent processes and scheduling as to develop a concrete technical solution.
2.4. Analysis
After reviewing related projects addressing the challenges and problems oc- curing during the organization of rescue forces in MCIs, an analysis of these projects and their approaches is presented here. The requirements for an electronic triage tag are derived from this analysis and presented in chapter 3.
Although all previous projects have a good approach in facing the mentioned problems, none of them addresses all of the problems at once. Where they do try to address all problems, the interaction with the resulting device is non intuitive and slows down or changes the triagers workflow. The WIISARD project, for instance, submits unneeded information like battery life time or orientation to the command center and stresses the network bandwidth. Furthermore the triager needs to carry three different device types. The triage tag itself is relatively large and the interaction with it is achieved through typing information manually in a handheld PDA. Considering that triagers wear gloves, data input on WIISARD can be relatively time consuming.
The AID-N project has a good approach but a display is not needed and shortens unnecesarily the battery life and increases the weight of the tag. Furthermore it can distract people from their actual tasks. The one-button interaction is a good idea but in the end a device operating automatically without any user interaction might be less time consuming and does not disturb the triagers' workflow.
None of these devices feature an easy to access storage for logging the treatment history or other relevant information. The devices which accommodate a storage chip cannot share saved information in case the battery is low or device is not working properly. The logged data might be lost in that case.
The eTriage tag developed at the Fraunhofer Institute for Applied Information Technology is the device which comes closest to the requirements. It only needs an easy to access logging system and the actual size and weight of the device should be reduced. The ZigBee[13] mesh networking technology is a good approach which enhances the network coverage with every new device joining the network.
Based on the above considerations, the work presented in this thesis builds on the features of the eTriage tag developed at the Fraunhofer Institute for Applied Information Technology (FIT). The outcome is a completely new device with several more features. The requirements, design, implementation and testing of the triage tag developed in this thesis is presented in the following chapters.
3. Requirements for an Electronic
Triage Tag
Detailed requirements for an eTriage system were developed, among others, by Fraunhofer FIT in collaboration with the BRIDGE consortium partners[1]. These requirements were elaborated from former projects in that field and interviews with current experts in crisis management and triagers. The eTriage system concept of the BRIDGE project consists of several hardware and software components, of which this work concentrates only on the electronic triage tag. Requirements regarding other components are not considered here.
No Intervention One of the major requirements for the electronic triage tag is, that the tag should work autonomously, without any user intervention. The current triage work flow of the medical personnel should not be modified by the tag. There should not be any disadvantage compared to the traditional system when using the eTriage system as a supplement. It should start working automatically when it is applied to a victim and work as long as possible.
Traceability The electronic triage tag should enable to tracing the victims. In disasters it could happen that victims walk around away from where the rescuer last saw them. For the medical personnel and the incident command center this information is important in order to find those victims. Furthermore creating a map showing all victims and their current location should be possible. This map helps the incident command to coordinate available ressources for a fast and well-orchestrated operation.
Wireless Interconnectivity The eTriage tag needs to able to communicate wirelessly with other devices. Presence of wires would hinder rescuers and interfere with the triage process.
Reliability The system should react as insensitive as possible to disturbances. A self-organizing, self-healing ad-hoc network should be implemented. The sensor nodes should form a network with the highest chance of remaining connected when nodes move in and out of reach. Furthermore the electronic triage tag should be dust and spray proof. For that reason a suitable case for the electronic triage tag should be built.
Expandability The system should be expandable both in hardware (external sensors) and software (new firmware). This includes updating the firmware with new commands at any given time.
Storing of Data The technical solution should be able to store sensor data, commands, location data and other information time stamped on an internal memory. This memory should be accessible physically over a common interface, e.g. USB or SD-Card. This ensures that the data is available without the use of special devices or other BRIDGE components.
Provide Ambient Temperature The electronic triage tag should be able to measure and transmit the ambient temperature. This is important, so that the incident command center knows whether there is fire or another dangerous heat source in the direct surrounding of the victim.
Cost Efficiency In the best case scenario, the technology developed in this work should be ready for series production. For this purpose a cost efficient selection of hard- and software is preferred.
Small Size and Light Weight The electronic triage tag should be as small and as light weight as possible in order to not overload the medical personnel. Triagers need to carry many of these devices at the same time, usually in packs of 36.
4. The eTriage Concept
This chapter introduces the eTriage concept. It is important to know how the eTriage tag is embedded in a communication system, in order to understand how the tag communicates with other parts of the system. The overall system consists of a combination of hard- and software components with clear interconnecting interfaces. This ensures that each part of the system can be developed, implemented and tested independently from others. Even though some parts might not be implemented yet, they can be replaced by simulators to test the functionality of already existing parts. This makes the development of the electronic triage tag simpler and facilitates the detection of potential problems in an early stage to take adequate measures.
Abbildung in dieser Leseprobe nicht enthalten
Figure 4.1.: The eTriage Components
Figure 4.1 illustrates the eTriage system which is build up of several com- ponents.
The Electronic Triage Tag The electronic triage tag consists of a colored, reflective, snap-on plastic bracelet similar to the ones currently being used for triage in several countries. These bracelets are augmented with microelectronic components and various sensors. The eTriage tag provides a radio which transmits information like temperature and location to the incident command center. These tags can also serve as a router in order to make the wireless network denser and to bridge a greater distance. The principal focus of this work is on the development and implementation of the electronic triage tag.
The Triage Relay The triage relay is a small device that is intended to clip on a rescuer's trouser belt and needs no user interaction. Its purpose is to gather information from the disaster field and forward it to the incident command center. This is important in case there are connectivity islands where the bracelets are connected to each other but none of them has a connection to a gateway (cf. figure 4.2). As the rescuer with a triage relay moves around the disaster field data, from these connectivity islands can be gathered and forwarded to a gateway as soon as one is in reach. The development of the triage relay is not part of this work and will be not described in detail.
Clip-On Sensors The clip-on sensors are reserved for victims classified as ”Immediate”. These sensors monitor vital values, like pulse or breathing rate, and forward them to the eTriage tag, which in turn sends the data to the incident command center. The clip-on sensors can be of different types; for instance a sensor like the one developed by Marc Jager [50] or one of the sensors introduced by cooking hacks [38] extended with a wireless interface can be used. The clip-on sensors are outside the scope of this work and therefore not further elaborated here.
The Triage Tablet The triage tablet is mainly used for visualizing the information gathered by the tags. It provides the command center with a map of all registered victims and their current category status. Additionally, for victims classified as ”Immediate”, vital values are displayed here.
[...]
1 Mass Casualty Incident
2 Over-triage: Categorizing a victim in a more critical category than he or she is in
- Arbeit zitieren
- Julian Quandt (Autor:in), 2015, An Electronic Triage Tag with Wireless Interconnectivity. Design and Implementation, München, GRIN Verlag, https://www.grin.com/document/1305586
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