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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.

 


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.
 

Defense of Houston was made possible by the Disaster Relief and Emergency Services (DREAMS) program of the US Army based at the University of Texas Health Science Center at Houston and Texas A & M University (DoD grant no.DAMD17-98-1-8002). DREAMS physicians and scientists acknowledge with gratitude the vision, leadership, and advice of Senator Kay Bailey Hutchison, and Congressmen Tom DeLay, Ken Bentsen, Henry Bonilla, and Kevin Brady.