A Sahana Pre-Disaster Preparedness Case Study

Lost Person Finder (LPF) - Customization and Integration of the Sahana Missing Person Registry (MPR), and First Use in Drill

Main author: Glenn Pearson, February, 2010.

This describes work in progress, not yet fully operational in October, 2009, and subject to change.

I. Description of Role in Disaster Response

The primary goal is to aid family reunification in the event of a mass casualty event impacting hospitals in the Bethesda, Maryland area, within the Washington, DC region. Selected parts of Sahana, particularly the MPR, are exposed and customized for this purpose. Customization includes “Americanizing” the user interface and simplifying it so that direct access by the general public, and minimally-trained hospital volunteers and staff, is possible. Direct public access and reporting can make effective use of limited hospital personnel, and provide more timely updates to family members. Figure 1 shows the conceptual architecture.

Conceptual architecture of LPF

Figure 1. Concept Overview of the Lost Person Finder Project.

Central to the project is the LPF web site (Figure 2) and database, powered by Sahana.

 Home Page  After "Report a Person" is hit

 Start of "Report a Missing Person" Form

Figure 2. Lost Person Finder's Web Site, as of August 18, 2009. Top left. Home page. Top right. After “Report a Person” is hit. Bottom. Start of “Report a Missing Person” form. (Click any to enlarge.)

The web site and database is the hub, integrated with three additional sub-projects (Figure 3):

  • a mobile version of the LPF web site, which is initially search-only and limited to iPhones and certain Blackberries.
  • software that runs on a Windows laptop at the hospital perimeter triage station. As a victim arrives, the person must be photographed, given a mass casualty ID (and wristband), and quickly assigned a triage zone based on medical assessment. The software takes in each photo via Bluetooth and associates it with a mass casualty ID and doctor-chosen triage zone. It then immediately reports this information by email to designated recipients (e.g., hospital staff and reunification councilors), including the LPF/Sahana system to pre-identify “found” injured people.
  • a “Notification Wall”, to show missing and found people on large displays.

Search using LPFm prototype, shown on Apple iPhone emulator TriagePic's Main Info Page

Notification Wall

Figure 3. Additional Sub-projects, as of late August, 2009 Top left. LPFm, for cell phones. Top right. TriagePic, the Windows app. Bottom. Closeup of Notification Wall. (Click any to enlarge.) Names of people shown are imaginary.

II. Sahana Deployed By

Customization and hosting of Lost Person Finder is being done by U.S. National Library of Medicine, located on the National Institutes of Health (NIH) campus in Bethesda. NLM is in a partnership with 3 nearby hospitals (National Naval Medical Center, NIH Clinical Center, Suburban Hospital) to improve their emergency responses to a mass disaster. The partnership, called the Bethesda Hospitals Emergency Preparedness Partnership (BHEPP), received federal funding for IT projects, including LPF, beginning in July, 2008.

For a 9-minute Hollywood-style overview about BHEPP (including a somewhat-imaginary version of LPF), search for “BHEPP” on YouTube.

III. How Sahana was Used - October, 2009 Drill

The alpha components of the Lost Person Finder project were incorporated into a disaster preparedness drill for the first time, as part of BHEPP's Oct. 15 participation in CMAX 2009 (Combined Multi-Agency eXercise). CMAX is an annual joint civilian-military exercise in the DC area, involving simulated disasters with first responders and medical providers. The hospitals involved are evaluated during the drill by independent inspectors, as part of the accreditation renewal process.

The simulated disasters faced by BHEPP were a bomb exploding in a building on the National Naval Medical campus (Figure 4) and (on paper) a disaster in the Metro. Victims (volunteers in makeup) were brought by Montgomery County, Maryland ambulances to NNMC and Suburban Hospital. (Also, to clear beds at Suburban for disaster victims, “almost well patients” were transferred to the NIH Clinical Center. LPF was not involved with this.)

Escorting victim.  Photo - Karen Steely/NLM Ladder truck.  Photo - Sameer Antani/NLM

Figure 4. At the Simulated Bomb Blast. Local fire and rescue personnel respond and escort victims (some with wounds simulated by moulage) out from the building and into ambulances. (Click to enlarge.)

Pre-Drill Demonstration for Distinguished Visitors at NNMC

In advance, a few dozen simulated reports of persons either missing or at-triage were pre-loaded into the LPF database. During the demo, their names, pictures, and triage categories were displayed in the NNMC Hospital Command Center (HCC) by the Notification Wall web site (Figure 5). Immediately after the demo, the database contents were swapped, using Sahana's Snapshot module (developed by LPF's Greg Miernicki). It then had only 15 preloaded simulated missing person reports. During the drill, an additional 30+ “found” people would be reported by triage stations and counselors.

Michael Gill at Pre-Drill Demo of LPF.  Photo - Karen Steely/NLM

Figure 5. Pre-Drill Demonstration on Large Format Wall Displays in a HCC Conference Room. LPF's Michael Gill successfully presented the Notification Wall and the Sahana/LPF search capabilities to two groups of invited leadership guests, about 50 in all. Back in September, the larger main room of the HCC (not shown) was used to introduce the LPF components to about two dozen NNMC social workers in preparation for the drill.

Drill at Suburban Hospital

Triage Intake. A hospital perimeter triage station was set up on a cart, near the front and ER entrances, and operated by Suburban personnel (with our observation and assistance). The location was outside, but protected from the cold rain by the main entrance portico (upon which medivac helicopters land). As in the past, patients arriving from the ambulance were given a quick medical assessment (taking into account the first-responders tagging), given a blank triage form and wristband with pre-printed mass casualty number, and sent to a colored “zone”. Traditionally, a Polaroid camera is used to take each victim's picture, and a tally sheet kept at the cart. These latter steps were replaced with a Ricoh 500se camera that was Bluetooth-paired to a bright-screen, ruggedized Dell Windows laptop with our “TriagePic” software. Transmission of results by email was via Suburban's enterprise Wi-Fi.

Disaster reported! Triage station setup, with forms, laptop having TriagePic software, camera.  Photo - Lan Le/NLM Disaster gurneys unfolded & positioned.  Photo - Lan Le/NLM

Figure 6. Drill Starts, Disaster Reported. In Suburban's Emergency Operations Center (not shown), staff gather, roles are assigned, and preplanned mass casualty response steps taken. As part of this, a number of activities begin outside the hospital's Main and Emergency Room entrances. Left. A primary (and in some cases secondary) triage station is setup with preprinted forms. For CMAX 2009, this includes a digital camera and laptop having TriagePic software. Right. Nearby, gurneys and wheelchairs are readied, and a “green zone” area assembled to treat relatively-minor injuries.

Rockville, Maryland ambulance arrives with first victims.  Photo - Lan Le/NLM Victim leaving ambulance, already bandaged en-route.  Photo - Tehseen Sabir/NLM

Victim played by Merly Barahona escorted to triage station.  Photo - Tehseen Sabir/NLM Victim is triaged to green zone, for minor further treatment.  Photo - Tehseen Sabir/NLM

At green zone, temperature and vital signs checked.  Photo - Lan Le/NLM Green zone personnel gathering information.  Photo - Lan Le/NLM

Figure 7. First victims arrive. Top 2 rows. A Rockville, Maryland ambulance manned by Montgomery County fire & rescue personnel bring in a victim (played by Merly Barahon), who they bandaged on-route. Bottom row. From the triage station, she is escorted to the green zone for minor followup care and further information gathering.

Another victim from Rockville ambulance, at triage station.  Photo - Lan Le/NLM Mass casualty form and wristband assigned.  Photo - Lan Le/NLM

Crew and observers at the triage station.  Photo - Lan Le/NLM Victim, played by David Bates, leaving triage station to green zone.  Photo - Lan Le/NLM

At green zone, gathering info.  Photo - Lan Le/NLM After all Rockville ambulance patients triaged, discussing process with fire/rescue chief.  Photo - Lan Le/NLM

Figure 8. Another victim from Rockville ambulance. Top row. At the triage station, a mass casualty form and wristband are assigned, both with preprinted number, that TriagePic also uses. This victim, played by David Bates, is also sent to the green zone. Bottom right. After all victims on the ambulance are processed, rescue and hospital personnel take a moment to compare notes.

More victims arriving by ambulance bus.  Photo - Lan Le/NLM Victim placed on hospital gurney.  Photo - Tehseen Sabir/NLM

Severly injured victim, played by Renee.  Photo - Tehseen Sabir/NLM Rushing victim.  Photo - Lan Le/NLM

Passing quickly by triage station.  Photo - Lan Le/NLM In red zone for emergency treatment.  Photo - Lan Le/NLM

Figure 9. A Red Zone Victim. Top row. A severely injured victim, played by Renee, is brought in (with others) on a Montgomery County ambulance bus. Other rows. She is rushed through triage to the red zone for emergency treatment.

Notification Wall. In the Emergency Operations Center, a laptop and a desktop displayed all reported victims arriving at both hospitals. (Counselors in a private family reunification alcove could also bring this up.) A suitable-for-general-public version of this was also projected on the movie screen in Suburban’s auditorium (Figure 10), which as the main family-reunification area and waiting area for family members and treated “green zone” victims.

Notification Wall projected in Suburban's auditorium.  Photo - Tehseen Sabir/NLM

Figure 10. Notification Wall Projected in the Auditorium. This is the main family reunification and waiting area.

LPF and LPF Mobile. In an alcove (not shown), reunification counselors with “family members” could privately use the LPF web site via Wi-Fi from a medical computer on wheels. Counselors also briefly tested searching for people using an iPod Touch or iPhone over the in-house WiFi network, available anywhere in the hospital.

Drill at NNMC

Montgomery County, MD ambulance bus.  Photo - Cindy Love/NLM Male victim on gurney.  Photo - Cindy Love/NLM

Close view, male victim on gurney.  Photo - Deborah Bennett/NLM Another Montgomery County ambulance arriving.  Photo - Cindy Love/NLM

3 more victims leaving ambulance.  Photo - Cindy Love/NLM Close view, female victim on gurney, played by Heather Simons.  Photo - Deborah Bennett/NLM

Figure 11 - Ambulances with Victims Arriving at the Emergency Room Entrance of NNMC. (Click to enlarge.)

The situation for LPF at NNMC was more preliminary than at Suburban, and was used as an opportunity to demo, train, and get feedback on the system. Over two dozen social workers in shifts had an opportunity to work with the equipment.

Triage Intake. Social workers were running TriagePic and the Ricoh 500se camera, and (unlike at NNMC) getting the patient numbers and other data either orally from hospital triage staffers, or by reading wrist bands and triage tags. Inside the ER entrance, a table with a normal Dell laptop had TriagePic. Transmission was considerably more difficult from this site, since the interior military LAN was restricted. Instead, a 3G/Wi-Fi router (a Verizon Wireless MiFi 2200) placed near an exterior wall proved effective.

NNMC social worker taking photo to send to TriagePic.  Photo - Deborah Bennett/NLM NNMC social workers inspect triage tag for info to relay to TriagePic.  Photo - Deborah Bennett/NLM

Another social worker, Rob Thorner, photographing victim with Ricoh camera.  Photo - Cindy Love/NLM

Figure 12 - NNMC Social Workers Collecting Photo, Mass Casulty ID, and Other Info for TriagePic. (Click to enlarge.) It was raining the day of the drill, and (unlike at Suburban) the laptop available for TriagePic was not weatherproof. So the TriagePic station was setup indoors. Some arriving victims were processed at or near the station as they passed by, while for others, shown here, pictures and information was captured outside (with information written down) and reported inside. Range of picture transmission for the Bluetooth camera is a little more than a dozen feet. Pictures are stored on the SD card, so transmission can be delayed until back in range. (In the foreground of the top right image is shown another BHEPP/NLM project, a triage form with Digital Paper/Smart Pen.)

Poster in NNMC ER lobby announcing drill.  Photo - Karen Steely/NLM Victim in wheelchair at hospital emergency room entrance.  Photo - Deborah Bennett/NLM

Male victim badly burned.  Photo - Deborah Bennett/NLM Another victim being gurneyed to treatment in ER.  Photo - Sameer Antani/NLM

Figure 13. Victims with Simulated Severe Injuries inside Hospital, Enroute to Treatment in Emergency Room.

Photo - Sameer Antani/NLM  NNMC's Melika Dorroh entering data into TriagePic.  Photo - Karen Steely/NLM

 Photo - Deborah Bennett/NLM

Figure 14. TriagePic Station inside ER Entrance. Top right. NNMC social worker Melika Dorroh is entering data into TriagePic on the laptop, with NNMC's Terri Craig (in vest). In the background, ER staff and observers participate in the drill.

Notification Wall on second laptop by ER entrance.  Photo - Karen Steely/NLM NLM's Stacey Arnesen receiving email with photo from TriagePic.  Photo - Cindy Love/NLM

Figure 15. LPF Web Site, Notification Wall, and Email Distribution. Left. A second laptop (sharing the MiFi link) allowed social workers to view the Notification Wall, or try out the LPF web site. (A Notification Wall was also left running at the nearby NNMC Hospital Command Center, discussed above in the context of the pre-drill demo, to display updated images and data.) Right. Real-time information about each arriving victim, including photo, can be emailed to selected recipients, here NLM's Stacey Arnesen and (in background) Steven Phillips. (Dr. Phillips is Director of NLM’s Specialized Information Services (SIS). Stacey Arnesen is Head, Office of the Disaster Information Management Research Center (DIMRC) within SIS, and NLM's representative on the BHEPP Partnership Advisory Council.)

LPF Aspects Not Tested During CMAX 2009

Among opportunities passed up until a future drill were LPF mobile at NNMC (due to wireless restrictions), and simulation of real-time outside public access to the LPF mobile and regular web sites.

IV. How Sahana Community Supported the Deployment

On-site Project Personnel

LPF is being developed in the Communications Engineering Branch (CEB) of the Lister Hill National Center for Biomedical Communications (LHNCBC), the R&D arm of NLM. People most directly engaged with Sahana are in bold. Most participants have additional projects besides this one.

  • Dr. George Thoma, CEB Branch Chief
  • Michael Gill, co-lead and network engineer (federal) - Oversight, Design, Hardware Acquisition, Integration Testing, Deployment
  • Dr. Glenn Pearson, co-lead and software developer* - TriagePic, LPF Americanization, Design, Sahana Wiki
  • Greg Miernicki, software developer* - Sahana/LPF customizations and extensions (e.g., Snapshot module), Notification Wall
  • Anantha Bangalore, software developer - Bluetooth, Mobile LPF
  • Niyati Chhaya, student intern web developer, summer 2009 - Mobile LPF
  • Leif Neve, software developer* (from fall 2009) - active family notification; support for IE browser

*with Aquilent, Inc.; on-site at NLM.

With additional help from CEB network/web/database current support staff (Joseph Chow, Bill Neeriemer, Kameil Natour) and past staff (Mike Caisse). LPF's logo by CEB's graphics artist Michael Chung.

Please also see the “Acknowlegements” section at the end for other folks who helped make CMAX 2009 a successful and useful experience for us.

Sahana Community Input to This Project

LPF's Greg Miernicki is a Sahana code committer, a member of the Sahana Project Management Committee (PMC), and responsible for the Missing Person Registry, SnapShot, and Resources modules.

Sahana's Missing Person Registry, the basis for much of the LPF web site, was authored by Chamindra de Silva and Janaka Wickramasinghe. Early suggestions and assistance with our “Americanization” were offered by William Anderson, Dominic König, and Gavin Treadgold. More broadly, discussions on the main developers list have been invaluable for helping steer our project around shoals and towards the future. And much thanks to the Sahana army of bug finders and fixers.

V. Major Accomplishments/Outcomes

Sahana demonstrated once again its ability to serve as a reasonable foundation for a customized deployment. For CMAX 2009, management, IT, and operational persons from NLM and the other BHEPP partners were able to overcome substantial technical, operational, and policy obstacles and deliver a functional prototype version of the Lost Person Finder components at Suburban Hospital and National Naval Medical Center. With the luxury of extensive preparation, all computer and network systems performed as expected, to deliver a viable platform for our multi-component software system.

VI. Lessons Learned

Negative Aspects, and What We Learned

  1. At triage, maintaining synchronization of photos and patient IDs, as well as collecting patient names, was much harder than expected (due to weather, noise, confusion, and physical separations) and required more staffing than desired. One implication of this is that more serious consideration needs to be given to post-triage data entry and adjustment.
  2. Hospital personnel found using the LPF web site, particularly to report a missing person, confusing in spots due to navigation, field-ordering, and nomenclature issues. Also, user roles remain ill-defined.
  3. This was the first attempt at using LPF in a drill, and it suffered the usual problems of a prototype system: Sub-optimal equipment, fragile networking, still-early software implementations, browser dependencies, novice users, ill-defined and evolving incorporation into workflows, and a dash of random chaos.

Positive Aspects - Things that Worked & Should Be Replicated in Future Deployments

  1. The LPF system generally worked as planned.
  2. With only a little guidance, hospital staff and volunteers were able to successfully use its main aspects.
  3. In large measure, the system was received positively by users, in spite of its rough edges.

VII. Appendices

For More

Sahana near Washington, DC - Lost Person Finder

Other Sahana Deployments

User Guide, Standard (non-LPF) Missing Person Registry Module

Bethesda Hospitals' Emergency Preparedness Partnership

Henderson DK, Malanoski MP, Corapi G, Passamani E, Notobartolo C, Gillette C, Hawes P, & Lee LM, “Bethesda Hospitals' Emergency Preparedness Partnership: a Model for Transinstitutional Collaboration of Emergency Responses”, Disaster Med Public Health Prep, 3(3), Lippincott Williams & Wilkins, Oct. 2009, pp 168-73. Abstract in PubMed

Acknowledgments

We would like to thanks all those who worked with us by participating as observers, photographers, or LPF assistants in CMAX 2009. From NLM/CEB, that includes Branch Chief George Thoma, Frank Walker, Sameer Antani, Lan Le, Tehseen Sabir, and alumni Susan Hauser. Other NLM/LHC participants were Karen Steely, Deborah Bennett, and Sarah Ward. Stacey Arnesen at NLM/SIS arranged additional assistance from Disaster Information Specialists Elizabeth Norton and Cindy Love of NLM, and of Linda Spitzer of USHS. We appreciate their effort, insights, and photos.

We further would like to thank our BHEPP colleagues at NLM, Suburban Hospital, National Naval Medical Center, and the NIH Clinical Center, and those staffers at all locations whose long planning and effort made CMAX 2009 come together. Particular mention goes to Melissa Knapp, Chris Gillette, and Kathleen Baxley at NNMC, Donna Sasenick, Cindy Notobartolo, and Voula MacDonald at Suburban. Thanks also to Captain Mary Chaffee for co-ordination, and, with Stacey Arnesen, facilitating the posters and handouts. Further thanks to NLM/OCCS’s Wei Ma and colleagues for lending us additional data modems.

We also appreciate the interest of our photography, IT, and communication vendors, who lent equipment, sent representatives to CMAX, and provide continuing technical support.

Photo and Art Credits and Notices

See mouse-over tool tips for most photo credits.

Figure 1. Flowchart graphic by Captain Mary Chaffee (USN/BHEPP) and LPF team. Photo of “patient” shown is a participant from CMAX 2008 drill. People watching wall displays (suggesting Notification Wall concept) is from Sept 1 2007 archive of Eliane Alhadeff's “Future-Making Serious Games” blog (http elianealhadeff.blogspot.com). Specifically, Sept 17 post: “Serious Games Supporting Cooperative Exchange of Digital Media”, concerning Lynn Marentette's Dynamo project, a joint effort between the Mixed Reality Lab at Nottingham University and the Interact Lab at Sussex University.

Figures 2 & 3. Screen captures are by LPF team. People photos within Notification Wall figures are not of real patients, nor associated with CMAX drills, and names shown in almost all cases are imaginary.

Findings and opinions expressed here are those of the authors and do not necessarily reflect those of the Sahana Foundation, BHEPP and its constituent institutional partners (NLM, Suburban Hospital/John Hopkins, National Naval Medical Center, and NIH Clinical Center), or the US government.


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