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DREAMS PROJECT
(Disaster Relief and Emergency Medical Services)
DREAMS is a US Army-sponsored program led by The University of Texas Health
Science Center at Houston, Texas A&M University, Texas Heart Institute and
Memorial Hermann Hospital. The program is aimed at improving the care of
emergencies, both on the battlefield and in civilian life. It takes advantage
of Houston's high incidence of medical emergencies and surgical trauma,
including natural disasters and industrial accidents, to test the latest
technologies for emergency care. The work is divided into three broad areas:
Digital EMS (Emergency Medical Services), Chemical Warfare Defense, and STAT
(Science Triage and Treatment), a program aimed at improving the diagnosis and
treatment of tissue injuries.
Desert Storm, Bosnia, the bombings in Oklahoma City and at the World Trade
Center all demonstrated opportunities for improvement. We proposed to the Army
that Houston could help, because of the high incidence of blunt and penetrating
trauma, and because The Texas Medical Center (the world’s largest), The
University of Texas and Texas A&M University combine leading medical
bioengineering and telecommunications research. The Army and Congress agreed,
and the $18m spent to date has accomplished all that was expected, and more.
The DREAMS program has resulted in numerous discoveries and inventions, as well
as a good deal of television coverage. Some examples are included in the
enclosed DREAMS video, which also documents the strong support from former
President Bush, Senator Hutchison, General John Parker, Representatives Delay,
Bentsen, Archer, Bonilla, Mayor Lee Brown, former Governor Bush and FEMA.
Also noteworthy are the spin-offs. For example, the DREAMS program initiated
four years ago to deploy automatic external defibrillators in Houston has led
hundreds of businesses, churches, civic groups, apartment houses, medical
offices and clubs to purchase these devices. Dozens of survivors of sudden
cardiac arrest are ample testimony to the success of this program. We are happy
to report that the City of Houston, led by the fire department’s EMS director,
David Persse, M.D., and Mayor Lee Brown, have made Houston the most advanced
city in the nation in the deployment of AEDs.
A second important spin-off has been the Houston Task Force for Counter
terrorism. Ambassador Ed Djerejian, Director of the James A. Baker, III
Institute for Public Policy at Rice University, has taken the lead in
organizing this task force, on which Dr. Duke and Dr. Casscells serve, together
with the Mayor, FBI leaders, public health officials and presidents of the
leading institutions in The Texas Medical Center.
Finally, DREAMS has already spun off at least two companies. One is Intelligent
Diagnostics, a Web site that helps people rapidly evaluate their symptoms and
decide whether (after consultation with their doctor) they can safely ignore or
watch these symptoms, or whether they need a doctor’s appointment or an
immediate visit to the emergency room. The goal is to decrease deaths (e.g.,
due to misunderstanding the warning signs of heart attack) and, conversely,
decrease unnecessary visits to the doctor or emergency room.
Another spin-off is Volcano Therapeutics, Inc. This company is developing
catheters to detect inflamed regions and local areas of inflammation, which are
signs of vulnerable atherosclerotic plaques (precursors to heart attack and
stroke) or cancer.
DREAMS has been a successful public-private partnership. It has funded a
program too broad for the mandate of the NSF, too high-risk for the mandate of
the National Institutes of Health, and not “risky enough” for the mission of
DARPA. The Congressional support has been critical in catalyzing this unique
program. Listed below are the projects for which $10M is requested from
Congress for the FY 2002 Army budget.
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I. DIGITAL EMS. The digital emergency medical services (Digital EMS) program is
led by famed trauma surgeon and educator, Dr. James H. "Red" Duke, Jr., the
pioneer of helicopter rescue. Dr. Duke is the Holmes Professor of Surgery at UT
Houston and Medical Director of LifeFlight. The software, hardware and
telecommunications aspects of this program are led by Texas A&M Professors,
Jim Wall, Ph.D., and Larry Flournoy, under the leadership of A&M’s Vice
President for Research, Professor Richard Ewing, Ph.D. The digital EMS program
is developing wireless video communications and combining GPS (Global
Positioning System) technology and advanced software to enable ambulances and
helicopters to reach the victim sooner, begin diagnosis and treatment on the
scene, and coordinate helicopters and ambulances to minimize transport time to
the nearest appropriate facility, using continuous communication with these
facilities and Houston's Intelligent Highway System. Other technical support
for this program is generously provided by Johnson Space Center and the U.S.
Navy. Details of the current work follow: (per Joan Tatge and Doug Tindall).
II. CHEMICAL WARFARE DEFENSE.
Per A&M
III. SCIENCE, TRIAGE AND TREATMENT (STAT). The Science, Triage and Treatment
(STAT) program complements the Digital EMS and Chemical Warfare Defense Program
by focusing on the basic and applied sciences that will enable us to better
diagnose and treat injuries. The program is led by James T. Willerson, M.D.,
Randall Professor and President, UT Health Science Center at Houston, Medical
Director of the Texas Heart Institute, Editor-in-Chief of Circulation, member
of the Institute of Medicine, and the American College of Cardiology’s
Distinguished Scientist for 2000.
Body Defenses Against Chemical and Biological Threats.
1. Detection and Quantitation of Bacillus anthracis in Macrophages.
Under the direction of Theresa M. Koehler, Ph.D., scientists are investigating
the germination and growth of the anthrax bacterium in macrophages, a critical
early step in anthrax pathogenesis. B. anthracis is considered to be among the
microorganisms with potential use as a biological weapon in a terrorist or
military act.
2. Up-Regulation of P450--a Natural, Broad-Based Defense Against Chemical and
Biological Threats.
Henry Strobel, Ph.D., and colleagues are studying the cytochrome P450 system.
The lungs are the major point of entry for microbes and airborne toxins. This
project will characterize the response of cytochromes P450 to infection. The
eventual goal is to maximize the protection afforded by P450 cytochromes in the
lung by gene therapy or pharmacologic up-regulation of P450s.
B. New Diagnostic Techniques.
1. Is Hypothermia Helpful in Triage?
Ward Casscells, M.D., Tyson Distinguished Professor and Chief of Cardiology,
and colleagues have discovered a simple but previously unsuspected finding,
namely that a fall in body temperature is an accurate predictor of death within
hours or days in patients with congestive heart failure. If this finding is
also applicable to patients with surgical shock and other conditions (and Dr.
Duke believes it is), this would provide a simple, fast and inexpensive way to
improve triage, the imperfect process in which medical personnel try to divide
the injured into those who need immediate help in order to survive, those who
cannot be helped, and those whose injuries can wait.
2. Infrared Spectroscopic Diagnosis of Vulnerable Atherosclerotic Plaques.
Morteza Naghavi, M.D., and colleagues are developing the use of infrared
spectroscopy, an instantaneous, noninvasive and relatively inexpensive
technology--to detect areas of inflammation, areas of cell death, and foreign
bodies. The model they have been using is atherosclerotic plaque, the leading
cause of heart attack and stroke. The progress made to date suggests that it
will soon be possible to identify vulnerable plaque earlier and intervene to
prevent heart attack and stroke. Detection of abscesses, necrosis, and
malignancy may follow from this work.
3. Thermal Detection and Treatment of Inflammation and Necrosis.
A second and even simpler means of approaching the above problems is being
developed by S. Ward Casscells, M.D., and colleagues. They have discovered that
thermal imaging is a feasible means of detecting vulnerable atherosclerotic
plaque. Alone, or in combination with the infrared spectroscopy being developed
by Dr. Naghavi, thermal imaging holds great promise in preventing heart attack
and stroke. A second discovery by Dr. Casscells is that heat has an
anti-inflammatory effect. Casscells and colleagues are developing this into a
treatment to reduce inflammation, for example, to prevent heart attack and
stroke.
4. Physiological Magnetic Resonance Imaging.
James T. Willerson, M.D., and Morteza Naghavi, M.D., have developed ways that
magnetic resonance imaging can be adapted to provide noninvasive thermal
mapping. They have further developed a technique for imaging inflammation by
adapting a paramagnetic particle for high specificity uptake by macrophages.
They are also exploring the therapeutic potential of magnetic resonance-induced
heating.
5. A Surgical Instrument for Real-Time Tissue Analysis.
S. Ward Casscells, M.D., is developing a device that uses multiple biophysical
techniques to determine, on line, the type of tissue and the state of its
health. This should prove useful to surgeons, gastroenterologists and others
who need to make tissue diagnoses on line, for example, during cystoscopy,
bronchoscopy, laparoscopy, arthroscopy, etc.
C. Extending the Golden Hour.
1. Evaluation of a New Axial Flow Pump, Inserted by Minimally Invasive
Thoracotomy, to Maintain Cardiac Output in a Porcine Model.
O.H. Frazier, M.D., is determining whether the Jarvik 2000 pump, pioneered by
him at the Texas Heart Institute, can be used urgently to support victims of
hemorrhagic shock. He has developed a porcine model to determine whether
clinical trials are warranted.
2. Mechanisms of Cardiomyocyte Injury in Shock.
L. Maximilian Buja, M.D., Dean of the Medical School, and Jeannie McMillin,
Ph.D., are dissecting the roles of cytokines and reactive oxygen species in the
injury caused to the heart after reperfusion, such as during resuscitation of
shock victims. In our studies with the endotoxin, lipopolysaccharide (LPS), a
know initiator of programmed cell death (apoptosis) in other systems, we found
that our cultured neonatal cardiomyocytes are resistant to the LPS cell
death-signaling cascade even though the same cells are capable of undergoing
apoptosis in response to chronic exposure to the saturated fatty acid,
palmitate. In our most recent studies, we demonstrated that the
anti-inflammatory prostanoid, CydPGJ2, prevents nuclear translocation of NFkB
and phosphorylation of IkB alpha, inhibits secretion of TNF-alpha when added
prior to LPS and results in a 10-fold activation of caspase 3-like activity (a
key enzyme in apoptosis). We find these results to be extremely exciting as
they suggest (in agreement with other investigators) that gene transcription by
NFkB is cardioprotective and that synthesis of the anti-inflammatory PGJ2 may
be suppressed in the neonatal cardiomyocytes compared to adult cardiomyocytes,
thereby conferring differential susceptibility to apoptosis in adults versus
neonates. We are actively pursuing the implications of these findings in our
current work.
3. Molecular Regulation of Apoptosis in Wound Healing.
Yong-Jian Geng, M.D., Ph.D., is trying to determine: 1) the effects of heat or
gene expression, 2) the role of heat-shock proteins in inflammation and
apoptosis using the model of experimental atherosclerosis, 3) the mechanism of
preferential sensitivity of macrophages to thermal apoptosis, 4) whether
oxidized LDL cholesterol interferes with the apoptosis clearance mechanism.
4. Nitric Oxide in Organ Failure.
Bruce Kone, M.D., is exploring the beneficial and detrimental effects of nitric
oxide—which impacts thrombosis, vascular tone and apoptosis—in models of sepsis
and multiple organ failure.
5. Nitro Tyrosine Formation, Metabolism and Function.
Ferid Murad, M.D., Ph.D., Using endotoxin and/or various proinflammatory
cytokines to induce inflammation in animals and/or cell culture systems, we are
identifying proteins that are nitrated on their tyrosine residues. Protein
nitration can occur due to increased formation of nitric oxide, superoxide
anion and peroxynitrite that results from inflammation and tissue injury. The
identification of these nitrated proteins and their function could provide new
approaches for therapy of inflammation and tissue injury.
D. Prevention of Complications, Promoting Wound Healing and Regeneration.
1. Gene Transfer of Tissue-Factor Pathway Inhibitor to Prevent Thrombosis and
Restenosis after Arterial Injury.
Pierre Zoldhelyi, M.D., is developing improved gene therapy techniques to
prevent the blood clotting and subsequent restenosis that often complicates
angioplasty and other interventions.
2. Induction of Chemokine Expression in Endothelial Cells by C-reactive
Protein.
Ed Yeh, M.D., Chairman of Cardiology at M.D. Anderson Cancer Center, is
characterizing the adhesion molecules that mediate the adhesion of monocytes to
atherosclerotic plaques.
3. Pathophysiology, Prevention and Treatment of Atrial Arrhythmias.
Hasan Garan, M.D., the President George H.W. Bush Professor of Medicine, is
exploring the feasibility, in an animal model, of a less damaging means of
eliminating clusters of cells that cause cardiac arrhythmias.
4. Genes Regulating Wound Healing and Susceptibility to Oxidative Injury.
Using an inbred canine model of atherosclerosis as a model of chronic wounding
and oxidative stress, James T. Willerson, M.D., is identifying novel genes
involved in the response to these stresses.
Disaster Relief and Emergency Medical Services Project (DREAMST):
UT-Digital EMS Project
That life threatening injuries and acute illnesses occur on the battlefield, on
highways and in urban settings is a harsh reality. It is also a fact that early
accurate diagnoses and institution of appropriate therapy improves survival in
many instances. During recent decades, significant progress has been made in
reducing the interval between the onset of the problem and the institution of
treatment as a result of the development of skilled medics and paramedics and
improved equipment modes of rapid transportation. With recent advances in
telecommunication technology, it is now possible to decrease even further the
time lapse between the incident and the institution of appropriate therapy
utilizing digital technology to transmit real time physiologic data and two-way
audio- visual communications. It will be possible to have physician present on
the battlefield or the highway mentoring the first responding medical personnel
which will improve outcome in many instances through improved diagnoses,
implementation of life saving procedures and institution of definitive
treatments. Wherever possible new military technologies for combat casualty
care will be integrated into the program. DREAMST builds upon an earlier
USAMRMC DAMD 17-98-2-8002 and the Advanced Research Projects Agency (ARPA)
sponsored project titled, "Advanced Fire Protection Technologies", June 23,
1995, where UTHSCH tested a prototype "Emergency Information Resource and
Response Management System."
Current Statement of Work:
The dates given for completion of milestones and deliverables follow the
Federal Government Fiscal Year calendar, with the first quarter of Fiscal Year
(FY) 2000 beginning December 1, 1999.
University of Texas Health Science Center at Houston Digital EMS Project
1. Work with Texas A&M University to Enhance Current Technologies within
the Digital EMS Vehicle and Associated Hospital Systems -- The University of
Texas Health Science Center at Houston (UTHSCH) personnel will work closely
with Texas A&M University System (TAMUS) to continue the design,
development, integration, and operation of a system (Digital EMS) which allows
telecommunication (video, voice, and data) between rural and remote emergency
services and the physicians in the trauma center. UTHSCH is responsible for the
identification of candidate medical technologies for inclusion by the TAMUS
Digital EMS design team. Additionally, UTHSCH will develop online medical
protocols of currently approved Life Flight emergency protocols to be
integrated into the Digital EMS project by TAMUS project team.
Deliverables:
· Convert existing approved emergency care protocols 2nd Quarter 2000
2. Enhance the Existing Digital EMS System to Accommodate Additional
Functionality --UTHSCH personnel will work in close collaboration with the
Naval Research Laboratory (NRL) to develop a next generation
satellite-networked system capable of two-way audio, video, and data
communication between an ambulance and the UTHSCH.
Deliverables:
· Modify one existing ambulance test vehicle for satellite testing 1st Quarter
2000
· Initial satellite prototype testing 2nd Quarter 2000
· Mobile satellite prototype testing 4th Quarter 2000
3. Integrate Online Treatment Protocols and Medical Records Information into
the Existing System for Enhancing System Functionality -- Using approved
medical treatment protocols and Digital EMS technology, UTHSCH physicians will
perform expeditious patient evaluations and guide appropriate interventions.
Where available, UTHSCH will create access to emergency records databases
queried for patient specific medical information allowing the TAMUS design team
to integrate previous medical history into the emergency medical record as
directed by the UTHSCH medical director.
Deliverables:
· Addition of emergency medical records information into system 2nd Quarter
2001
4. Enhance the Existing Infrastructure for Supporting a Network of Multiple
Digital EMS Vehicles and Hospital Systems in an Integrated Environment - UTHSCH
will link the UT-Houston Medical School and the TAMUS' Institute of Biosciences
and Technology (IBT) facility via a private fiber network path. The fiber path
will allow the Digital EMS facilities at UTHSCH and the affiliated teaching
hospital, Hermann Hospital, to communicate at a high data rate to multiple
statewide, national, and international high bandwidth networks at the IBT
gigapop.
Deliverables:
· Hardware ordered connection points, and network installed 2nd Quarter
2000
5. Develop and Test a Prototype Digital EMS Vehicle in Diverse Urban and Rural
Settings for Evaluation and Performance Analysis of Integrated Digital
Technologies -- As integrated by the Texas A&M System Engineering team,
deploy new Digital EMS vehicles and technology in several rural and remote
locations within Texas. Digital EMS prototypes tested in these field locations
provide user feedback during real life emergency calls.
Deliverables:
· 2nd Digital EMS Vehicle Prototype 3rd Quarter 2000
· 3rd Digital EMS Vehicle Prototype 1st Quarter 2001
6. Study of Developed Technologies for Application in the Digital EMS Life
Flight Vehicles to Support Additional Medical Functionality for Trauma Care at
Remote and Hospital Sites - The Digital EMS system includes plans for
outfitting rotary and fixed wing aircraft used by the Hermann Hospital Life
Flight service. Re-certification of the avionics and airframe for the
installation of new communications hardware and computer systems developed by
the Digital EMS team is expected. The extent of the process is unclear at this
time, but UTHSCH and TAMUS researchers are committed to serious consideration
to outfit Life Flight vehicle(s) with Digital EMS technology.
Deliverables:
· Initial meetings with Life Flight and FAA Personnel 1st Quarter 2000
· Develop a clear plan to include or exclude Life Flight vehicles 4th Quarter
2000
7. Evaluation of New Technologies for Inclusion in the Digital EMS Vehicle to
Support Additional Medical Functionality for Trauma Care at Remote and Hospital
Sites - Noise within the ambulance patient compartment is a problem if the
Digital EMS computer system is to use advancing technologies like voice
recognition software for command and control. UTHSCH has identified several
methods for noise cancellation developed by others in industry and will
evaluate the candidate technologies for the Digital EMS vehicles.
8. Develop Methodologies for Using New Local, State, and National Network
Infrastructures for Providing the Digital EMS Vehicles with High Speed
Terrestrial Connectivity to the Hospital Nodes - UTHSCH will work closely with
TAMUS and with organizations funded under the Texas Infrastructure Fund,
Internet2, and the National Science Foundation networking initiatives to
provide high speed terrestrial connectivity.
9. Publish Findings and Results in Appropriate Conference Proceedings and
Journals and Demonstrate Capabilities of the Digital EMS Ambulance.
10. Provide Project Progress Reports Quarterly
Executive Summary / Project Overview
The Disaster Relief and Emergency Medical Services (DREAMS tm) project is a
consortium of scientists, medical professionals, and engineers from The
University of Texas Health Science Center at Houston (UTHSCH) and the Texas
A&M University System. The goal of DREAMS is to improve the diagnosis and
treatment of critically ill or injured soldiers in the field by expediting
their access to medical experts at trauma centers or field hospitals. DREAMS
will test the new systems developed in this program in varied rural, remote and
urban settings in Texas. We hope to qualify and overcome not only the
technology issues while communicating with a mobile distant emergency vehicle,
but also to develop procedures for tele-mentoring of remote medics and other
medical personnel through the transportation and transfer of critically injured
people.
The UT-Digital EMS Project builds upon an earlier USAMRMC DAMD 17-98-2-8002,
February 3, 1998, and the Advanced Research Projects Agency (ARPA) sponsored
project titled, "Advanced Fire Protection Technologies", June 23, 1995, where
UTHSCH tested a prototype "Emergency Information Resource and Response
Management System". UTHSCH researchers and engineers are working on two
components of the DREAMS program:
1. The University of Texas Digital EMS Project, and
2. Mechanisms, Diagnosis, and Treatment of Tissue Injuries.
*************** [NOTE: Now renamed STAT]****************************
1.1 The University of Texas Digital EMS Project
Digital EMS is the DREAMS component that allows trauma and other medical
specialists to treat patients more quickly by providing a "virtual" presence of
a physician on the battlefield or at the emergency scene. Physicians and
engineers of the UT-Digital EMS team provide medical direction, practical
knowledge, and experience to apply advancing technologies to the treatment of
patients before they reach the trauma center. Additionally, the UT-Digital EMS
team identifies candidate medical technologies for inclusion in the Digital EMS
project, develops online medical protocols, and supervises field-testing of the
Digital EMS emergency vehicles. UT-Digital EMS researchers and Texas A&M
System Digital EMS engineers completed the Digital EMS phase one ambulance
prototype, InteractTM, shown at the ATA 1999 conference in Salt Lake City.
InteractTM connects emergency medical personnel on the scene with trauma
specialists in distant hospitals, allowing physicians to monitor patients using
real-time video and vital signs data from a suite of advanced digital medical
monitoring equipment. The proposed duration of this subproject is 18 months
from December 1, 1999 through May 31, 2001.
1.2 Mechanisms, Diagnosis, and Treatment of Tissue Injuries
Researchers at UTHSCH will submit a separate proposal for the DREAMS:
Mechanisms, Diagnosis, and Treatment of Tissue Injuries (MDTTI). While the
Digital EMS projects at UTHSCH and Texas A&M University are ready to field
test new therapies developed by the MDTTI Project, the MDTTI proposal is
completely separate in scope of work and deliverables. Hence, details of the
MDTTI Projects are not addressed in the present proposal. Please refer to the
Mechanisms, Diagnosis, and Treatment of Tissue Injuries proposal (Log No.
99200002) for more information their role in DREAMS Project.
1.3 Role of Texas A&M University Collaborators
Researchers at Texas A&M University will submit separate proposal for their
role in the DREAMS: Digital EMS project. Texas A&M University will continue
to work closely with the UT-Digital EMS Project team to develop the medical
needs of remote and rural emergence medicine into an integrated system of
varied communications and medical technologies to fulfill the identified goals
of the Digital EMS project. Hence, detailed engineering and design of the TAMUS
project are not addressed in the present proposal except where necessary for
clarification of UT-Digital EMS work. Please refer to Texas A&M
University's proposal (Log No. 99200004) for more information their roles in
DREAMS Project.
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