CRASAR, with funding from the Center for Emergency Informatics, and the TEEX Product Development center held a two day series of workshops on robotics for medical disasters.  The major takeaway was that robots do exist that could be immediately repurposed now to protect Ebola health workers but how robots fit into the medical response enterprise is as important as what the robots can actually do. While most roboticists intuitively know that what will work in the US is not the same as what will work in West Africa, the differences go beyond physical constraints such as level floors, ample power, and reliable wireless communications infrastructure. Less intuitive is that the cultural appropriateness of the technology and the impact on the existing workflows and practices is equally important.

The workshops considered how robots could be used immediately and in future domestic medical responses. Hardened robots (and automation/CPS technologies) do exist that could be immediately repurposed to provide logistical services (e.g., packing and hauling contaminated waste) and reconnaissance (e.g. observing signs of mass graves near a village), less so for clinical applications (e.g., directly working with patients). The participants strongly concurred that a research roadmap is needed to prepare robots that the US can effectively use in future medical disasters.

The success of hardened robots in providing these services depends on ensuring that they are appropriate for the work domain in five ways:

1.  Fit the cultural context. For example, a telepresence robot allowing a certified medical interpreter to talk with the family and talk the patient’s history may overwhelm a non-Western family who has never seen a computer. A less obtrusive telepresence solution may be more practical in that cultural context.
2. Fit the existing workflow and practices. For the short term, solutions aren’t solutions if they require health workers or medical responders to adopt radically new procedures. They simply can’t handle more things to do or change how they perform their current tasks (which impacts how everyone performs all the other tasks- “simple” changes can have system ramifications). However, small changes that produce at least a tenfold benefit can make a difference.
3. Can function in the target environment. For example robots in West Africa would have work reliably in field hospitals with canvas floors and narrow doors, muddy dirt roads in the rainy season, with power and wireless communications limitations, etc., while robots in the US would have more pristine conditions. Different groups use different decontamination procedures and chemicals- such as dousing everything with chlorine beach solution (easy and inexpensive) or using more chemically sophisticated decontamination foams used by urban hazardous materials teams.
4. Are maintainable and sustainable. Health workers and medical responders won’t have the time and skills to repair robots (especially if wearing PPE) and may not have access to consumables such as batteries to enable operations for weeks and months. A problem with the Fukushima response was that many robots were actually prototypes functioning at a Technical Readiness Level of 7 rather than a well-tested Level 9 system.
5. Are easy to use and be trained on. This is related to fitting into the existing workflow and practices, but deserves special emphasis. The health workers and responders will not have significant amounts of time to learn new tools, as their days are already overloaded and they have little personal time.  Robots must be vetted for ease of use. Effective training for medical missions is important and the role of simulation or serious games should not under-estimated.

The sentiment shared by the TAMU participants was that the biggest barrier to near-term use was not the lack of capable robots but rather the lack of requirements that would allow industry to invest in repurposing robots and  enable agencies to test and evaluate the robots and develop training.  Currently there are no details on the operational envelopment for the robot or operator. There is no clearinghouse of social science data on cultural appropriateness or bioethics or specific missions.

OVERVIEW OF WORKSHOP ACTIVITIES

The first day of the workshop was hosted by CRASAR and held at the National Center for Therapeutic Manufacturing. The day was divided into two portions. One was a simulcast of shared presentations with the other three sites and brainstorming as part of the planning workshops on Safety Robotics for Ebola Workers for the White House OSTP/National Robotic Initiative. The other part, the Texas A&M Workshop on Robotic, Automation and Cyber Physical Systems for Medical Response to Disasters, provided additional talks and discussions on general domestic medical response. The Texas A&M talks covered the state of the practice in DoD robots (TARDEC) and casualty evacuation systems (TATRC) that can be repurposed, lessons learned so far in using robots at the Fukushima Daiichi decommissioning (University of Tokyo), and opportunities for community recovery (TAMU Hazards Reduction and Recovery Center). The day culminated with a reception and a thought provoking keynote talk by Andrew Natsios (TAMU Bush School of Government and Public Policy), who served as administrator of USAID from 2001-2006.

The second day, the Infectious Disease Response Workshop,  was hosted by Caleb Holt and the TEEX Product Development Center and held at the TEEX Emergency Operations Training Center/Disaster City® complex. The focus was on the practice of medical response (one of TEEX many courses that they teach). A major portion of the day was spent in demonstrations of the current practices in medical response, walking participants through 3 modules of a field hospital (also called an Emergency Treatment Unit or ETU), showing how contaminated waste is stored and overpacked, and how domestic responders, equipment, and ambulances are decontaminated. One demonstration was not a current practice but showed how existing robots might be of use.  That demonstration showed the General Dynamics Land Systems MUTT, a robot wagon that acts like a dog and can carry waste, supplies, or one or two litters. A responder guides the robot with a leash rather than a video game controller that is hard to carry and use while wearing personal protective equipment. If the responder stops, the robot stops. If the person backs up, the robot backs up. The second day also featured panels of practitioners, including from the Texas Ebola Task Force and the USMC Chemical Biological Incident Response Force, comparing military and domestic practices

TAMU FINDINGS ON WHAT ROBOTS CAN BE USED FOR

In terms of overall medical disasters, applications appear to fall into one of three broad categories below, regrouping the preliminary list of nine functions discussed in an earlier blog. Each category has a different set of stakeholders and a different operational envelope that the robots would operate in. Clinical applications are possibly what people think of first– how robots can replace what health workers do now—but logistical applications are perhaps the most feasible and practical.

Clinical:  Clinical applications are where robots are used in the ETU as a “force multiplier” (another way of saying “reducing manpower”) by taking over some of the activities that health workers do or as adding reliability by coaching or supervising activities. Ignoring for a moment the cultural appropriateness and other adoption issues, robots could enable

• Remote health workers to assist other health workers, such as telepresence robots (or just cameras/tablets) coaching or supervising taking off PPE– though the general consensus of our responder base was that having a second person physically helping with decon was more valuable than having someone saying “hey, you touched your face while trying to lift your hood.” Domestic hazmat responders and the USMC Chemical Biological Incident Response Forces use a two personal decontamination process.
• Health workers could use robots to interact with patients, reducing the number of times workers have to risk exposure.  Robots could provide non-invasive point-of-care such as changing IV bags, though the TAMU participants were more reserved about roboticizing invasive procedures such as starting IV lines.
• Remote health workers to interact with family members, such as remote qualified medical interpreters working through telepresence to help with patient intake forms.

Logistical: Logistical applications can take place within the ETU, but the construction, layout, and clutter of ETUs make it hard for mobile robots to move around. Some ETUs have canvas floors over dirt or mostly level manufactured floors, and almost all have raised areas to step over between modules that seem intended to foul wheels. The general thought is that flexible automation and materials handling are more likely to be of benefit within an ETU and that robots would be more useful for outside the ETU. Logistical robots are also interesting in terms of stakeholders. Since they are not performing clinical functions, in theory the robots could be operated by locals (assuming favorable cultural considerations).

Logistical robots could provide

• Materials handling. Robots could reduce the number of times humans handle contaminated waste or the number of people needed to carry a litter. The robots could pack and carry materials from the warm zone to the cold zone (e.g., taking out the trash) or carry supplies into the warm zone, saving another cycle of a person having to don and doff PPE.
• Decontamination. Robots could spray biocide foam on equipment, though there was several ideas for using gases to rapidly decontaminate ambulances so as to keep them in service.
• Delivery and resupply. Unmanned aerial vehicles or boats could drop off small amounts of supplies to villages cut off by the rainy season.

Reconnaissance: Reconnaissance activities take place outside of the ETU. Aerostats or UAVs can provide awareness of long lines or gathering refugees. A more somber recon activity is to fly over villages and look for signs of freshly turned earth indicating graves.

Other:  The workshops also touched on preparation for medical response, such as redesigning field hospitals to make it easy to use robots and to add cameras, internet repeaters, etc. The workshops raised the value of automated construction in reducing the non-medical members of the team needed to set up and maintain the ETU.