How Advanced Military Medical Technology Could Help in the Fight Against COVID-19
The deadly and gruesome realities of war have long both aided and accelerated medical innovation. World War I, the first mass killing of the 20th century, led to the development of modern ambulances, antiseptics, and anesthesia. The next world war brought about the development of penicillin and blood banks. More recently, the proliferation of improvised explosive devices in Operations Enduring Freedom and Iraqi Freedom have led to innovations in treating hemorrhagic shock and traumatic brain injuries.
Looking ahead, the Department of Defense has focused investments in recent years on addressing near peer competition under the rubric of multi-domain operations. Wars against great powers are expected to result in mass casualties across a dispersed battlespace, leading to delayed evacuation times, further strain on resources, and additional pressure on the ability to scale training and deployment of trained combat medics. As such, the department is seeking out technologies to help mitigate these challenges. Since it is not new for military investments in technology to ultimately accrue benefits for civilians, we should not be surprised that recent military research and development into medical technologies for the next generation of warfare could be accelerated and applied in tackling COVID-19 and future pandemics.
The Problem
The recent report on COVID-19 published by the Society of Critical Care Medicine outlines perceived resource constraints of the U.S. medical system that will have severe ramifications as the number of cases continue to climb. Unlike bed space and equipment, which can be improvised and manufactured with shorter notice, staffing — especially relatively scarce specialties — is a far more difficult resource to scale. Not only are we unable to scale the training and staffing of medical professionals, but the current workforce is also dwindling as hospital staff have been and will be disproportionately affected by the virus. Hospitals in both the United States and globally find themselves lacking sufficient personal protective equipment: gloves, aprons, and fluid resistant surgical masks. The latter are in particularly short supply. All of these obstacles, in addition to the high patient-to-provider ratios during a pandemic, make it difficult for the few available expert physicians to interact with every patient showing symptoms of the virus. In their report, the Society of Critical Care Medicine encourages civilian hospitals to adopt a tiered staffing strategy to prepare for an influx of patients who will require intensive care and respiratory therapy, and to leverage telemedicine to reach the more experienced physicians as needed.
Leveraging Military Advances in Telemedicine
This concept of pushing expertise far forward into the front lines and, in particular, leveraging telemedicine as a force multiplier has been a focus in military medicine for decades. Why is this exactly? The first hour following any traumatic event is the most critical and clinically complex; in theatre, that burden falls on young combat medics with limited medical training and resources. They not only lack the expertise to deal with complex poly-trauma cases but are also often providing care in dangerous environments. In order to provide medics with remote expertise, the Defense Department has invested in the research and acquisition of telemedicine and data systems that can not only assist medics with care, but can also prepare the receiving medical facility in the upper echelons of care for incoming casualties.
Telemedicine programs such as the Army’s Advanced Virtual Support for OpeRational Forces (known as ‘ADVISOR’) provides both synchronous (real time) and asynchronous on demand tele-consultative services to special operations forces in Africa and the Middle East. The program connects operational forces to critical care physicians at Brook Army Medical Center’s Virtual Medical Center at Ft. Sam Houston, Texas over either voice or video teleconference lines. Through ADVISOR, special operations medics were able to text, email, talk, and even send images to these remote experts who advised on combat traumas, as well as disease and non-battle injuries.
However, the U.S. armed forces expect to face constrained communication capabilities and high patient-to-provider ratios in a war against a peer adversary. This would limit the utility of the telemedicine systems that have been or will be deployed. In response, research organizations are now focusing on leveraging advancements in artificial intelligence and computer capabilities to develop clinical decision support systems that would provide the expertise needed on a small device that can operate offline. These systems will act as virtual assistants that can make clinical inferences and decisions without connectivity or a remote physician.
Critical Care Goes Autonomous
Severe hypoxic respiratory failure, which demands mechanical ventilation to allow patients to breathe, is the most common reason intensive care units admit COVID-19 patients. The problem is, the United States does not have nearly enough ventilators to cope with the coming wave of patients who will need them. Furthermore, mechanical ventilation requires specialized training, and each patient will ideally be managed by a physician, respiratory therapist, or critical care nurse. So, even if more ventilators are manufactured, shortages of qualified critical care personnel will limit the ability to care for patients on ventilators.
Technologies being developed by the Defense Department aim to provide AI-based or remotely controlled mechanical ventilation. The military is interested in providing these solutions so wounded service members could be kept stable from the point of injury to arrival at a medical treatment facility, even in the absence of a bedside expert clinician. This could help fill this staffing gap and allow a single clinician to manage a larger number of patients.
As the COVID-19 virus spreads and federal and local governments continue to extend restrictions and take more extreme precautions to limit its spread, there is clearly a need to invest in military medical technologies developed for future near peer battles and multi-domain operations to address the issue of scale. Some of the technologies such as telemedicine solutions and rule-based ventilators that follow narrow guidelines and protocols have already been developed and fielded. However, rule-based ventilators cannot be used in clinically complex cases. Nor can they employ data driven models to predict events, resulting in earlier interventions and better outcomes.
Bringing together the data, data scientists, regulators, and other stakeholders to accelerate the development and availability of these advanced AI and machine learning solutions will require deliberately shifting priorities as well as dedicating funding and loosening regulatory barriers, real or perceived. This has already begun in response to COVID-19, but there is more to do before fielding such data-driven ventilator systems that lack the transparency and explainability needed in critical decision-making systems. There are technological, regulatory, ethical, and political hurdles to overcome and unless things start moving faster, it will take several years before they are ready for patient use. To get things moving, the Department of Defense and other stakeholders will need to recognize and continue to support investments in AI-enabling infrastructure and data collection, and a desire to accelerate and deliver AI capabilities.
The last few weeks show the urgency of these solutions, not just for a future war, but for pandemics. In order to help everyone from the combat medic or infantryman performing “buddy aid” in a megacity to the respiratory therapist at a rural clinic managing dozens of patients with a dwindling number of beds, masks, and ventilators, it is time to leverage the expertise and current work going on at organizations such as the U.S. Army Medical Research and Development Command’s Telemedicine and Advanced Technology Research Center and the Joint AI Center’s Warfighter Health National Mission Initiative.
This could save lives everywhere from hospitals in your hometown to the future battlefield.
Rebecca Lee is a project manager and researcher at the Medical Intelligent Systems Lab at the U.S. Army Medical Research and Development Command’s Telemedicine and Advanced Technology Research Center. She focuses on clinical decision support systems in support of combat casualty care. She holds degrees from the Johns Hopkins University and the George Washington University.
Col. Jeremy Pamplin is the director for the Telemedicine and Advanced Technology Research Center. Prior to this assignment, he was the director of Virtual Critical Care at Madigan Army Medical Center where he began the first Army Tele Critical Care service and integrated it into the Joint Tele Critical Care Network. He has deployed in support of Operation Iraqi Freedom and Operation Enduring Freedom, once to Iraq as the chief of critical care for the 86th Combat Support Hospital and once to Afghanistan as the deputy deployed medical director for the 33rd Field Hospital and the American contingent’s physician leader.
The views, opinions and/or findings contained in this presentation are those of the author and do not necessarily reflect the views of the Department of Defense and should not be construed as an official position, policy, or decision of the Department of Defense or the U.S. Army unless so designated by other documentation.
Reference herein to any specific commercial products, process, or service by trade name, trademark, manufacturer, or otherwise, does not necessarily constitute or imply its endorsement, recommendation, or favoring by the U.S. government.
Image: Madigan Army Medical Center (Photo by John Wayne Liston)
