WMD Terrorism and the Role of First Responders

by Douglas Sanderford

0830 hours, May 24, Washington D.C. A group of unknown individuals pose as subway workers and place two ordinary looking aerosol delivery devices in the Rosslyn Metro Station. The devices activate as two trains enter the station. As many as 3200 people are exposed to the nerve agent aerosol from the devices. [1] The subway employee in the kiosk (information booth) dials 911 and reports "sick people everywhere".

This fictitious event will set off an enormous local, state, and federal response. Which one response will have the most significant impact on saving lives?

A look at the many agencies who have response responsibilities readily becomes a look at the difference between crisis management (dealing with an incident before and at an NBC release) and consequence management (all the various tasks to restore people, services, and environment to their proper functioning). Due to the fast acting nature of many potential WMD (weapons of mass destruction) agents, the rapidity of the response often becomes the critical factor in determining the nature of the job, not the amount of money given to the agency. Many first responders feel they have been by-passed as the government spreads out the funds to become prepared to handle chemical and biological terrorism.

First Responders

First responders are fire, rescue, and emergency medical services (EMS) personnel and are part of the local community. (In this article, we exclude law enforcement because we are focusing on the groups saving lives. Hazardous materials response and medical intervention is not a common law enforcement mission.) WMD include nuclear (radioactive particles), chemical, toxin and biological agents. Although approximately 70% of all terrorist attacks involve bombs, we leave explosives out of this discussion.

First responders recognize the importance of time and intervention when dealing with terrorism, while they acknowledge confusion about their roles.

The first hour is the real crucial time when lives will be saved. If the first responders can use their respiratory gear properly and protect themselves, then they will be able to help others. We can not afford to wait for the federal authorities to arrive. [2]

Fire chiefs have to face the fact that in the first few hours of a terrorist incident, all they can count on is their own department and local mutual aid - and those companies better be ready to do their job. [3]

"In this scenario, the first responder- whether police, fire, or medical- should have but two responsibilities: to recognize the possibility of a chemical attack, and to take action to gain control and contain the situation. Responders at this level do not need to know how to establish a decontamination station or conduct personnel decontamination, but they should understand the necessity of contamination control, and have an in-depth understanding of how to establish and maintain a contamination control zone. This is all that most police and fire personnel need to know about chemical response: They must be able to recognize that trouble exists and establish the "line in the sand". They must then hold that line until specialized help arrives." [4]

In a letter sent to fire chiefs around the country, Chief Neil Svetanics warns:

"If lives are going to be saved from an act of terrorism, it will be the actions of organizations that can respond within minutes, not hours or days...There is only one agency that can do that and it's the fire service." [5]

After a chemical attack, there is a "golden hour" within which to make a difference. After that hour, those who are going to survive do and those who are not, do not. [6]

Are first responders to limit their roles to seal off the area and wait for specialized help? After six to ten hours, when the Department of Defense units begin to arrive, what sort of help will a nerve agent victim need, decontamination, atropine/2-PAM chloride, or just a body bag? Is WMD terrorism a mysterious super killer that only the military can handle or is it another mission to be absorbed by first responders?

Local Community Resources

Fire departments have a long history of dealing with industrial hazardous materials. Out of necessity, they have had to mitigate emergency situations. Several years ago the Occupational Safety and Health Administration (OSHA) created the Hazardous waste operations and emergency response standard. Since that standard was introduced, first responders have been donning respiratory and chemical protective clothing, resolving chemical incidents and performing chemical decontamination.

Today, most first responders are well-trained and equipped for “conventional” disaster response. They know their jobs, generally have the equipment they need, have developed and tested procedures, and are dedicated professionals. First responder vehicles are equipped with the North American Emergency Response Guidebook, which provides basic information on chemical identification, evacuation distances, and how to control the material. CB warfare agents properties have been plugged in these manuals.

Although trained in Class A poisons (CW agents are in this class), first responders have not had training in CB warfare agent behavior, effects, or defense. Despite this, their training and experience gives them 80-90% of what they need to respond to WMD terrorism. [7] The agents used by a terrorist may not be the “classical” CBW agents. Although vesicant and nerve agents have a high potential for use, terrorists can easily obtain and use toxic industrial chemicals for similar purposes. A railcar containing phosgene, detonated remotely as it passes through a city, can be just as effective a terrorist device as a man-packed container of GB. [7]

Not every firefighter in rural America has the training for these chemical incidents, but in larger metropolitan areas they are trained to recognize when a chemical release has occurred and when local hazardous materials personnel are needed. Firefighters are equipped with self contained breathing apparatus (SCBA), which offers the highest protection factor for respiratory protection. Their structural firefighting clothing may offer some chemical protection. Tests are being conducted using nerve agent simulants to determine the level of protection offered. Tokyo first responders who were wearing SCBA and structural firefighting clothing did not become serious casualties. Many first responders are trained to initiate the incident command system, isolate the site, initiate evacuation, notify additional resources, implement mass decontamination, and to take defensive actions that would not place them into IDLH/LD50 atmospheres. The average response time to an incident in a metropolitan area is approximately five minutes.

Fire department hazardous materials response teams (HMRT) are trained for offensive operations: entering toxic atmospheres, mitigating hazards (vapor suppression, containment, positive pressure ventilation), and decontaminating personnel, equipment and areas. They have encapsulating and non-encapsulating chemical protective clothing, which provide protection from industrial chemicals, as well as chemical warfare agents. In addition they may have equipment to detect all known chemical warfare agents and equipment to control the size of the release. The average response time for hazardous materials response teams in large metropolitan areas is under 30 minutes.

First responders have been educated and trained in both hazardous materials and mass casualty incidents, but the two have not often been combined in field training exercises. Many departments do not have standard operating guidelines for terrorist incidents or mass casualty decontamination.

State and Federal Resources

Initially first responders must realize an incident is a WMD incident, establish command and notify the mayor or county executive who would then contact the governor. Once an incident takes place, the primary responsibility for emergency response is with the state and local governments. The Federal government provides assistance after the governor of the affected state requests assistance. [8]

Some states have regional hazardous materials vehicles, chemical warfare agent detectors, and personnel trained and equipped for offensive operations. The response times for these teams are likely to be 30 minutes or more. The emergency management agencies of many states have contingency plans in place for WMD response.

The state governor may call up the National Guard medical, decontamination, transportation, and other support services. However, most National Guard units require a 12 and 24 hours notice to mobilize to an armory and prepare to deploy to an incident site. [9] The Army Reserve does not train or prepare to respond to civil emergencies; and although the Army Reserve has some equipment, it does not have the substantial stores of decontaminants, antibiotics, or atropine sure to be needed in such a crisis. [10] Such units will arrive too late for immediate medical assistance, although they can provide security, communications, decontamination, and other services helpful in safe and effective cleanup after the attack. [11]

Various U.S. military and federal agencies have been tasked to respond to a chemical and biological attack (See Table 1), but these efforts to date have been largely uncoordinated. Each agency can act independently, with the possibility of "turf battles" that could cost lives in an emergency situation. [12]

From the viewpoint of the first responder, the entire response process may not be fast enough to help victims of a WMD incident in need of decon and antidotes. Can the federal government really correct this problem by disseminating millions of dollars to agencies that cannot respond quickly enough to help the victims? What support has it given to the first responders. How fast does the response have to be to make a difference?

Part 2

In the second part of this article, the importance of response time, WMD agent, and type of response will be examined. In this critical look of response gaps and relative ability to save people, perhaps we can find a guide to effectively spending the millions of federal dollars available to maximize the country’s preparedness.

DOD has been training on the art of battlefield NBC defense for decades. Despite numerous reports that the development and procurement of CB defense equipment and training in procedures are not proceeding as quickly as planned, the USA has one of the best prepared NBC fighting force in the world.[48,49] However, that does not make it the best for domestic response in the civil sector, where DOD has little experience.

Military medical personnel of the United States have not treated a chemical casualty on the battlefield for nearly eight decades, and they have never treated a biological casualty. [50] Even military units prepared to fight in a NBC environment are not trained or equipped to support response to victims of attacks in the USA.[53]

According to various missions and responsibilities of the federal (DOD and DOE) and state agencies, in the response to the fictitious subway attack in Part I, local responders will be overwhelmed almost immediately. In addition, state resources will be quickly depleted, and federal rapid response teams will arrive quickly, with decontamination gear and medical triage personnel to save the wounded. But in reality, only first responders will be on scene quickly enough to save dying casualties. Not all national assets, such as the CBIRF, unless already deployed to potential terrorist targets, such as the Super Bowl or an Inauguration, are going to be able to respond to an incident within 6 to 12 hours. In all those cases, local responders will carry the burden of immediate response.[54]

THE THREAT OF NUCLEAR, BIOLOGICAL AND CHEMICAL TERRORISM.

First Responders, local communities, and state and federal resources all have roles in a WMD response. The importance of the role in saving lives varies depending upon the weapon used. The First Responder is the primary lifesaving group in a chemical attack, but also has important roles in nuclear and biological attacks. The three scenarios are discussed below.

Nuclear

In nuclear or radiological terrorism, the weapon expected is a radiological dispersal device (RDD), not a weapon capable of producing a nuclear yield. Suppose the truck bomb used in Oklahoma City was an RDD, the contamination would have blanketed a large area of the city. Casualties would have suffered non-lethal doses of external irradiation, complicating their conventional injuries, and internal contamination with radionuclides. First responders with structural firefighting clothing and self contained breathing apparatus (SCBA) would have had the proper protection available. Some units, such as the hazardous materials team would have immediate access to survey meters and personal dosimetry. It is a requirement of OSHA CFR 1910.120 to monitor for ionizing radiation during site entry.[56] State radiation safety officers also have survey meters and dosimeters. First responders would not have waited for federal assets to arrive to begin saving lives. Using the common principles of time, distance, shielding, and quantity, first responders could safely initiate the rescue effort.

Mass decontamination is a basic first responder skill and can be implemented in less than 10 minutes. Decontamination is a priority to avoid incorporation of radioactive particles, if there is radioactive contamination. Since prodromal symptoms will not occur for 24-48 hours after radiation exposure, patients will likely be triaged based on their conventional injuries. Care for the patient with radiation exposure does not include rapid lifesaving techniques or antidotes. Long term care including chelation therapy, cytokines, aggressive antimicrobial measures, and bone marrow transplantation may be required. Total patient recovery time could take several months.

First responders will manage the triage, and treatment, just as they did in Oklahoma City. Federal resources such as Disaster Medical Assistance Team's and military medical personnel will be needed to help manage the long-term patient care. Site remediation, a responsibility managed by the DOE and EPA will be necessary. DOD assets will be required, possibly for site remediation and field hospitals. A four hour deployment time, plus transportation and set-up time by federal assets is not an immediate life saving activity, but will be needed for longer term contamination management and clean-up.

Biological

A biological attack is likely to go undetected until symptoms begin appearing in the victims. It is likely to appear as a public health emergency, as a sudden demand upon the public health infrastructure with no apparent explanation for the occurrence.[57] Since the incubation periods vary for each agent, from minutes to 20 days, the possibility of each agent would need to be examined separately.

As an example, let us look at a possible covert anthrax attack. Anthrax is a simple case because no cases of person to person anthrax transmission have been reported [60] However, almost all cases of inhalational anthrax, in which treatment was begun after patients were symptomatic, have been fatal, regardless of treatment.[61] Using the 1970 World Health Organization study, which estimated that 50 kg of anthrax spores dispensed by a line source 2 kilometers upwind of a population center of 500,000 unprotected people in ideal meteorological conditions, up to 220,00 people could be killed.[59]

The ramifications of even a modest sized release of anthrax spores in a city are profound. Perhaps 3 to 4 days after exposure, emergency rooms would begin seeing a few patients with high fever and difficulty breathing. By the time the patients were seen, it is almost certain that it would be too late for antibiotic therapy. All patients would die within 24 to 48 hours. No emergency room physicians or infectious disease specialists have ever seen a case of inhalation anthrax; medical laboratories have had virtually no experience in its diagnosis. Thus, at least 3 to 5 days would elapse before a definitive diagnosis would be made.[62]

If the attack is undetected until symptoms develop, there will not be a massive emergency response to the incident but possibly a deluge of patients appearing in doctors offices, calling for ambulances, or taking themselves to the hospital. Specialists in infectious diseases thus constitute the first line of defense. The rapidity with which they and emergency room personnel reach a proper diagnosis and the speed with which they apply preventative and therapeutic measures may spell the difference for thousands of casualties.[63]

What roles do first responders play in a biological attack? A trained 911 operator may realize he or she is receiving multiple calls with patients displaying similar symptoms. EMS personnel are often the first members of the health care community to have contact with patients and are the first "eyes and ears" of care providers at higher levels of the system. Hospital care providers might miss epidemiological clues if several patients with similar symptoms are distributed among numerous hospitals. Trained responders will recognize a characteristic pattern of patient problems and complaints and report these findings to appropriate medical and public health officials.[64] Although secondary aerosols are not efficiently generated, first responders could also provide decontamination capability at local hospital emergency department entrances.

Unknowingly, ambulances will transport biological casualties to local emergency rooms, exposing their personnel. OSHA bloodborne pathogen standards require that EMS and hospital personnel be equipped with gloves, gowns, eye protection, and filter masks capable of stopping biological aerosols. However, because of the non-specific symptoms, it is likely that both EMS and hospital personnel will be exposed prior to suspecting a biological attack.

An incident on a larger scale could create a panic and cause hundreds or thousands of people to seek medical care. The potential impact on health care facilities in the area of an attack or even a threatened attack is tremendous. Emergency departments may be "overrun" with patients, open hospital beds may become scarce, intensive care units may be filled, and antibiotic stocks may be depleted.[65]

State health officials would be involved early in the attempt to determine the cause of the illnesses. If minor flu-like symptoms were present in the victims, the health department would spend valuable time attempting to identify the cause. A BW attack alarm would not be sounded until patients started dying or they realized it was something serious. Federal resources such as the Center for Disease Control (CDC), US Army Medical Research Institute of Infectious Diseases (USAMRIID), the Naval Medical Research Institute (NMRI), and the National Institute of Health (NIH) will be needed to make an actual identification of a BW agent. These federal laboratories will be the key to preventing further disease and setting treatment priorities, but will only be called in when the local health care community realizes it needs their assistance.

Some of the labs such as NMRI's Mobile analytical laboratory are portable. Unfortunately, there are few laboratories available with the capability for analyzing environmental specimens for the presence of a wide range of different BW agents.[66] Once the agent has been identified, proper medication stockpiles may be accessed. While the Pentagon has accumulated some medicines to shield American troops from a handful of BW agents, no similar reserve exists for civilians. Establishing stockpiles for U.S. cities could easily cost billions of dollars and require years before adequate levels are reached.[67] The $94 million plan to stockpile antidotes is deeply flawed. Federal and private experts said the plan was hastily developed amid fears of threats from Iraq and BW terrorists and was ill conceived.[68]

Are the rapid federal and DOD response teams useful in a biological scenario? Certainly, medical and laboratory personnel will be desperately needed. Field hospitals will be needed for isolation and proper disposal of the dead will be necessary. Reserve hospital units would have to come from outside the affected city or region. To do otherwise could remove from the affected area medical personnel whose presence would be required at the local hospitals and clinics where they work in peacetime.[69] Coordination of vaccines, antibiotics, other medical supplies and additional logistics will be the largest mission. Timely management of the CDC, WHO and DOD medication stockpiles will be crucial.

Chemical

Chemical attacks would yield almost immediate casualties (injuries, deaths, and mass hysteria) and probably would not involve persistent agents. The appearance of casualties would be an immediate "spike," causing medical personnel a tremendous overload but without additional casualties. There would be no structural damage hindering casualty location and recovery.[71] It is unlikely that terrorists would use persistent chemical agents such as VX, since non-persistent agents such as sarin can cause casualties that are more widespread.[72] The chemical scenarios vary with the chemical used, but important in all cases is quick treatment and removal from the area of toxic exposure.

CHEMICAL

The use of chemical warfare agents against civilians has the potential to cause injuries, deaths, and mass hysteria. Chemical attacks would yield almost immediate casualties and probably would not involve persistent agents. Here the appearance of casualties would be something of an immediate "spike," leaving medical personnel with a tremendous overload but without the specter of additional casualties. There would be no structural damage hindering casualty location and recovery.[71] It is unlikely that terrorists would use persistent chemical agents such as VX, since non-persistent agents such as Sarin can cause more widespread casualties.[72]

Think back to our scenario at the beginning of this article. Recall that an aerosol was dispersed in an enclosed environment with unprotected citizens. What can we expect to find when we arrive? Many suggestions have been made: a tomb full of bodies, seizing casualties everywhere, a mass of people fleeing so forcefully that first responders will not be able to get near the scene. What's the truth?

In order to fully understand the chemical scenario, it is necessary to review the different agents. The effects of each chemical will not be listed. Only that which truthfully supports decontamination and treatment.

Nerve Agents

Nerve Agents are divided according to volatility as either persistent or non-persistent. We cannot examine each agent separately. The focus will be on the effects of vapor as opposed to liquid, toxicity, need for decontamination, medical care, and the impact of time on survivability.

Per LCt50/LD50 data nerve agents are most toxic if inhaled. This could be debated because, victims may self evacuate as they did in Tokyo, thus removing themselves from the toxic atmosphere. Inhalation of nerve agent vapor inhibits blood ChE activity and produces sign and symptoms of exposure more rapidly than does dermal contact.[73] In liquid exposure, victims would continue to absorb the agent after self evacuation because they may not realize they were contaminated.

The signs and symptoms a casualty has when he presents to a medical care provider minutes after exposure depend on the route of exposure, the amount of agent to which he has been exposed, and the time that has elapsed since exposure.[74]

NERVE AGENT VAPOR

Suppose we have an unprotected person exposed to nerve agent vapor. We can expect to see miosis, rhinorrhea, shortness of breath for a low exposure. A high exposure would present with immediate loss of consciousness, seizures, apnea, and flaccid paralysis. These effects typically occur within seconds of exposure and peak within a few minutes. If the exposure has been small and a victim is removed from the area of exposure, shortness of breath may improve. In this situation, removal of clothing is often adequate decontamination. After exposure to a large amount of vapor, the casualty will almost immediately lose consciousness, and seizures will begin within 1 to 2 minutes. After several minutes of convulsing, apnea and flaccid paralysis will occur.[75]

After vapor exposure, the biological response begins within seconds, and unless the concentration is quite small, reaches maximal intensity within minutes. After vapor exposure ceases the response does not significantly increase.[76] Because effects from vapor occur within seconds to minutes, if these are not present by the time medical assistance arrives, they most likely will not occur, and the individual needs no further medical attention.[77]

If the casualty is seen within 15 to 30 minutes after the vapor exposure has terminated, an antidote is not needed if miosis is the only sign. Effects caused by nerve agent vapor will not progress after this time.[78]

Although some have stated that decontamination is not necessary after vapor exposure, it will still be performed. All chemical casualties require decontamination. One can seldom be certain that in a situation in which both vapor and liquid exist, some liquid is not also present on the casualty.{79]

A logical conclusion from the data presented would be that mild vapor casualties will improve if removed from the toxic atmosphere and severely exposed casualties will die before first responders arrive. Those in between could be saved by rapid decontamination, antidote administration and artificial ventilation. First responders can isolate the agent by using vapor suppression techniques or containment shelters. Any contamination resulting from "pooling" of non-persistent agents should be quite localized and consequently fairly easy to decontaminate, both physically and logistically.[80] There is nothing a response team several hours away can do to impact patient survivability. Only first responders can respond within the time frame that will impact patient survivability.

NERVE AGENT LIQUID

Liquid contamination, is a much less probable occurrence than vapor, but still possible.[81] If a casualty has nerve agent on their skin and receives a small dermal exposure, localized sweating and fasiculations should be expected. A moderate exposure (LD50) would include gastrointestinal effects and a severe exposure (LD50) would present with sudden loss of consciousness, seizures, and apnea.[82]

After very large amounts of nerve agent (multiple LD50's) are placed on the skin, signs and symptoms occur within minutes and inhibition of blood ChE activities occur equally quickly. However, with smaller amounts of agent, the onset is not so rapid.[83] The onset of effects is rarely immediate; they may begin within minutes of exposure or as long as 18 hours later. As a general rule, the greater the exposure, the sooner the onset; and the longer the interval between exposure and onset of effects, the less severe the eventual effects will be.[84] On the plus side, however, effects that occur many hours after exposure are usually non-lethal.[85] Delayed onset has been reported 3 hours after decontamination.[86] In general, an asymptomatic person who has had skin contact with a nerve agent should be kept under medical observation, because effects may begin precipitately hours later.[87] The longer the interval until the onset of signs and symptoms, the less severe they will be, but medical assistance will still be necessary.[88]

Because of the small amount of nerve agent needed to cause death and because of the short time (10-15 min) in which a lethal amount will cause severe effects in an untreated casualty, it is unlikely that a living nerve agent-poisoned casualty with nerve agent on his skin will be brought to a medical care facility.[]To successfully reduce damage to the casualty, decontamination must be performed within minutes after exposure. The only decontamination that prevents or significantly reduces damage from a chemical agent, whether a nerve agent or another agent, is that done within the first several minutes: self decontamination.[89]

Experience has shown that 80 percent of the decontamination process is achieved by merely removing the victims clothing. This is true for liquid chemical or radiation external contamination and should be followed with soap and water decontamination.[90]

Here is an interesting comment about decontamination from the pioneer Dr. Fred Sidell:"Decontamination: decontamination, I think is over emphasized. By the time the casualty hits a medical response station, you are not going to do the casualty one bit of good by decontaminating the casualty's skin. You are decontaminating the casualty at that point in time to protect yourself and to protect your medical facility I think we all understand that. But you are not going to do the casualty any good. After 30 minutes, that agent is in the skin; mustard is in the skin. The nerve agent has either killed the casualty or else there has not been enough on the skin to do any harm."[91]

The final assumption is that decontamination is important. Showering with high flow water will greatly reduce the amount of contaminant remaining on the skin, minimizing the risk of secondary contamination.[92] Timely copious flushing with water physically removes the chemical agent and produces good results.[93] Based on immediate availability, the recommended decontaminant is water. The better decontaminant is soap and water. The best decontaminant is a 0.5% hypochlorite solution.[94] An expedient emergency decontamination capability such as a wide, low pressure fog pattern from master streams or hand lines, using a 2.5 inch hose may be used to hydrolyze.[95] A rapid response is required because of the speed with which many of the chemical agents affect the body. Decontamination must be swift to save lives and minimize casualties.[96]

Nerve agents are rapidly acting chemical compounds that can cause respiratory arrest within minutes of absorption. Their speed of action imposes a need for rapid and appropriate reaction by exposed soldiers, their buddies, or medics, who must administer antidotes quickly enough to save lives.[97] Atropine is the drug of choice for intoxication by a ChE-inhibiting substance. Atropine should be started as soon as possible after onset of agent effects, and the initial dose should be at least 2 mg and as much as 6 mg or more.[98]The initial 2 or 4 mg has proven adequate in conscious casualties. Although 6 to 15 mg has been required for apneic or nearly apneic casualties, the need for continuing atropine has not extended beyond 2 to 3 hours (although distressing but not life threatening effects, such as nausea and vomiting, have necessitated administering additional atropine in the following 6-36 h).[99] As long as agent remains on the skin or on clothing that may touch the skin, the casualty will not improve no matter how much antidote is administered.[100]

In addition to all the other reasons why true rapid intervention is paramount, there is the irreversible reaction of aging. The clinical importance is that oximes are relatively ineffective after aging occurs.[101] The aging half time for GD (Soman) is 2 minutes and 3 to 4 hours for GB (Sarin).[102]

After reviewing these facts on dermal nerve agent exposure, it should be clear that these casualties must have immediate decontamination, antidote and oxime administration, and ventilatory support. Casualties with a lethal skin exposure will likely die before first responders can reach them. Victims with a moderate or mild exposure can be rescued and treated by first responders. First responders will remove the people from the environment containing the agent and remove the agent from the people by gross decontamination. The decontamination and medical components of a response team that is more than four hours away is useless to these casualties. The aging half times will occur well ahead of the arrival time for federal response teams. First responders will be unable to administer oxime therapy, such as 2-PAM Cl, in time to help Soman victims, but can impact the survival of victims exposed to the other nerve agents. Using the opening scenario of nerve agent vapor, which usually dissipates in minutes to a few hours,[103] it is possible that the vapor will have done so prior to the arrival of the federal response teams.

VESICANTS

Mustard, Lewisite, and Phosgene Oxime are classified as vesicants. Each one is different in many ways.

Lewisite causes immediate pain on contact and tissue damage in seconds to minutes. Phosgene Oxime causes immediate pain on contact and tissue damage within seconds. The onset of pain from a Mustard exposure will occur hours later, but tissue damage is immediate.[104] Lewisite vapor is extremely irritating to the nose and lower airways, causing individuals exposed to it to seek immediate protection, thus limiting further exposure.[105]

Mustard fixes to tissue within minutes, and no matter what is done later, tissue damage will occur if decontamination was not carried out before that time.[106] With vesicant agents it is unlikely that immediate decontamination at the first medical facility will change the fate of the patient or the outcome of the injury. The casualty will not seek care until the injury becomes apparent which is usually long after he was contaminated and by that time most of the agent will have been absorbed. The small amount remaining to be absorbed or absorbed during a wait for decontamination is very unlikely to be significant.[107]

In laboratory animals, decontamination done one minute after agent contact prevented about 80% of the damage that would have occurred without decontamination. Decontamination done 5 minutes after contact prevented 50% of the damage, and decontamination done after 30 minutes after exposure prevented only 7% of the potential damage.[]Almost immediate (1 minute) decontamination did not prevent the lesion, and decontamination done later (30 minutes) helped very little.[108]

A casualty with a vesicant burn exceeding 5% and less than 50% of body surface area or with eye involvement will require hospitalization, but needs no immediate, lifesaving care.[109]

A positive side of early decontamination is that Trichothecene mycotoxins, a toxin vesicant, are slowly absorbed through the skin. Washing the contaminated area of the skin with soap and water within 1 to 3 hours after exposure to a T-2 toxin will eliminate or greatly reduce the risk of illness or injury.[110] Soap and water, or just water, can be very effective in removing most toxins from skin, clothing, and equipment.[111]

The onset time for clinical Mustard effects ranges from 2 to 48 hours, and most commonly is between 4 and 8 hours. EMT's will not be treating and assessing at the scene, but may be transporting severely ill casualties to the hospital hours later.[112] Because the effects of mustard are delayed, the early responder who sees casualties within minutes to an hour after contact with an agent will rarely see casualties with clinical effects. Any person possibly exposed to Mustard should be kept under medical observation for at least 8 hours.[113]

Early care for the vesicant casualty will include decontamination to protect medical personnel, wound care to prevent infection, and airway management. A casualty with severe pulmonary signs should be intubated early, before laryngeal spasm makes it difficult or impossible. Recovery may be within days for milder injuries, while those with severe damage will take approximately a month or longer to recover.[114]

These facts indicate that even first responders cannot arrive in time to provide decontamination that will change the outcome of injury to the victims. They can provide decontamination at the scene of attack or at hospital entrances to decrease the possibility of medical provider contamination. The decontamination capabilities of a federal response teams are again useless. The military medical personnel will be needed to supplement hospital personnel and to establish field hospital for the overflow that will come from community hospitals.

CYANIDE

The use of Cyanide as a WMD weapon would require that it be used in an enclosed environment. After exposure to Cyanide, loss of consciousness and convulsions occur in about 30 seconds, breathing stops in three to five minutes, and the heart stops in five to eight minutes.[115] If a patient is exposed to a low concentration of vapor and removed from the source of the Cyanide, the symptoms should not progress.[116 ]Cyanide casualties present the triage officer with few problems. In general, one exposed to a lethal amount of Cyanide will die within 4-5 minutes and will not present at the medical treatment area. Conversely, one who is able to return to the medical area will not require therapy and will probably be in the minimal, soon to returned to duty category.[117]

Antidotes are effective if they can be administered before the patient suffers irreversible brain damage. Treatment is with a Cyanide antidote kit which uses nitrites followed by thiosulfates.[118]

It should be apparent that the only resource that has even a slim chance of administering lifesaving care to casualties is the first responder. Response teams arriving hours later will only need cadaver bags.

PHOSGENE

The last chemical agent to discuss is Phosgene. Phosgene is a lung damaging agent. Sometime between 2 and 24 hours after exposure the casualty will notice shortness of breath. A casualty with a very mild exposure will develop dyspnea from 6 to 24 hours after exposure. With proper care he will do well and recover completely. A casualty with a severe exposure will note shortness of breath within several hours after exposure. By 4 to 6 hours after exposure he will find it increasingly hard to breathe even at rest. He may not do well even with intensive pulmonary care. The average casualty from a lung-damaging agent will be between these two extreme cases. He will have the onset of dyspnea about 6 to 8 hours after exposure, and may progress to have dyspnea at rest. However, with good pulmonary care beginning early after the onset of effects he will recover completely.[119]

A casualty who is in marked distress, severely dyspneic, and coughing up frothy sputum might be saved if he entered a fully equipped and staffed hospital; at least, he would receive the full capabilities of that facility. s If this casualty does not receive some ventilatory assistance within minutes to an hour, he will not survive.[120]

For casualties with significant Phosgene injury, evacuation should not be delayed. If the casualty is to be saved, medical intervention must occur as quickly as possible.[121]

These chemicals are vapor hazards but victims need decontamination because clothing may have liquid exposure which will continue off-gassing.

If the attack with phosgene goes unnoticed, the first sign will be patients presenting with dyspnea at various locations. The window of opportunity between exposure and sickness will have been lost. Patients will overwhelm hospitals. Ventilators may be too few for the many casualties. There is no antidote for Phosgene exposure.

Many have pointed to the 1984 Bhopal, India incident as a warning of chemical terrorism. At the Union Carbide plant a release of methylisocyanate killed 3,300 and injured 10,000.[122] An incident involving industrial chemicals is possible in thousands of U.S. cities. The deliberate targeting of industrial facilities in populated areas could cause casualties reminiscent of Bhopal.

TOKYO

This event sounded the alarm for the impending need for WMD response capability. Had the terrorists properly executed the attack on the citizens of Tokyo, the results would have been catastrophic. A careful examination of the facts will show that the emergency care that impacted patient survival on this incident was performed primarily by first responders and community hospital personnel. Federal and DoD response team planners have thrown the 5510 casualties statistic in the face of first responders like some sort of trophy to say that first responders can't do the job without them. Let's look at the facts.

Just after 8:00 a.m. on Monday March 20, 1995 several persons put vinyl bags, containing substances which produced poison gas (later identified as Sarin), on trains of three subway lines, effecting 16 subway stations. The first request for an ambulance was made at 8:09 a.m. The Tokyo Fire Department sent 340 units and a total of 1,364 personnel to the 16 stations and other places. The Tokyo Fire Department was responsible for transporting only 688 victims. The remainder of the victims were dealt with by police vehicle, taxicabs, or able to visit hospitals by themselves.[123]

The Tokyo Fire Department took immediate action by conducting rescue work, first aid treatment, gas analysis, and clean up of the scene after neutralization of the toxic substance.[124] Japanese Defense Forces' Chemical Troops did not arrive until mid-day.[125]

Although the medical facilities were deluged with patients after the attack, only 21 patients remained in hospitals the following morning.[126]

A large number of psychological casualties should be expected at any WMD incident. The vast majority of people within the area affected by an NBC event are not going to be seriously injured. Many will not show symptoms at all. [131] Many experts have concluded the crush of psychosomatic casualties, piled on top of the physical ones, will overwhelm the local health care system.[132] However, if the START (Simple Triage and Rapid Treatment) triage technique is properly used, all walking wounded will be directed to a designated area upwind of the hazard area and labeled as minimal.[133]

Think back to our scenario at the beginning of this article. Recall that an aerosol was dispersed in an enclosed environment with unprotected citizens. What can we expect to find when we arrive? Many suggestions have been made: a tomb full of bodies, seizing casualties everywhere, a mass of people fleeing so forcefully that first responders will not be able to get near the scene. The response by the Tokyo Police gives a good picture of what really can be expected.

The fact that Tokyo first responders became casualties has been fuel for the fire that first responders are victims in the waiting and not capable without federal response teams. About 10% of the total responders (1,364) were injured after the direct/indirect exposure to the poisonous gas; they were 135 in all. Responders who wore SCBA were not among the casualties. Eventually 52 members were transported to hospitals directly from disaster scenes. Meanwhile, 83 others consulted doctors after returning to fire stations. In all 43 persons were hospitalized, while 92 people were found to be mild cases. Some severe cases had mental sequelae for a long period, suffering from hallucinations and nightmares. Each of these people is presently healthy and back at work. Of the injured fire service personnel, 101 members, including the EMS groups first dispatched underground, were engaged in their activities down at subway stations. These responders were equipped with little protective gear because the initial reports were for ordinary ambulance service.[136]

The information on chemical agent attacks is overwhelming that immediate response, not hours later, will be the only chance for saving victims with a lethal exposure. The emergency response community has been lead to believe that decontamination and antidote treatment several hours after exposure will have an impact in patient survival. This is untrue. Unfortunately, many in the emergency response community believe the military has told only parts of the truth, those that support the creation of special response teams. They ask: “Is this actually an attempt to cease the drastic and very turbulent years of downsizing active duty and reserve forces?”

Recommendations

Several things must be done to prepare the US for a WMD response:

1. Tell the truth. The first responders, hospitals, state resources, federal response teams, and DOD assets are not prepared to respond to a mass casualty WMD incident. After a disaster drill Tuesday (9/22/98) at RFK Stadium, local and federal officials admitted they would be ill-prepared to deal with an attack on the nation's capital in which terrorists released a toxic chemical into the air.[143] Only first responders can be on scene quick enough to affect victim survival. First responders must be prepared to expand their scope of services to treat victims of a NBC weapons attack. This will require EMS to stockpile certain antidotes, provide various levels of PPE (protective clothing), and commit to training their staff.[144] The problem is not one of too little money, rather too much money being spent ill-advisedly.[145] More money is being spent without any assurance of whether it is focused in the right programs or in the right amounts.[146] Who should get the training and equipment? If the President and Congress want to fund federal/DOD multimillion dollar response teams, that is fine. Nevertheless, they should have the truth before doing so.
2. Train and equip first responders. The Domestic Preparedness Program was poorly conceived and it has suffered from inefficiencies and inadequacies.[147] Twelve states and the US territories have no cities in the program and 25 percent of the cities are in California and Texas.[148] The Government Accounting Office (GAO) recently criticized the Domestic Preparedness Program for being slow to train and equip cities. It was also criticized for not performing threat and risk assessments on the 120 cities. The GAO's solution: delay the purchase of equipment that first responders desperately need, until these assessments are made.[149] Delaying equipment for first responders is akin to playing Russian roulette. How many times have we heard "It is not a matter of if, but when?"
3. Establish a coordinator for federal programs. There is no single agency in charge of the WMD effort.(150] Agencies and military branches are scrambling to get their piece of the funding pie. Bureaucratic turf protection and budget priorities rather than a growing threat have also contributed to the muddle in US counter terrorism programs, especially those designed to combat NBC terrorism. Government agencies and departments have discovered that having a mission that deals with WMD guarantees bureaucratic survival and budget growth.[151] The Department of Justice is planning a new program to provide $12 million in funds to equip first responders.[152] That is great, but is that really their responsibility? The Army is still mad at the Marines for stealing the glory with CBIRF. A senior Army expert recently endorsed CBIRF as "oversold and overrated".[153] Now retired CBDCOM Commander, Major General George Friel even took time to criticize CBIRF in a recent article.[154] The military should be placed in its proper role of training and advising first responders. If we are going to get serious about protecting America, other people are going to have to be allowed to play in the Army's sandbox.
4. Wake up the health care community. The "broken piece" in the program is the hospitals.[155] If both hospital and pre-hospital providers are not fully committed to this level of preparedness, the goal of quickly and effectively decontaminating patients will be unsuccessful.[156]

Editors’ Notes:

1. The complete article, with references, is posted on ASA’s website. The article has been shortened and presented in two parts in the ASA Newsletter (ASA 99-2 and 99-3).
2. The issues Mr. Sanderford highlights are constantly in the news. On May 29 Honolulu was the 12th among 120 cities to conduct a drill in the Domestic Preparedness Training Program. On June 1, J.R. Gilchrist, director of the Hygienic Laboratory at the University of Iowa, spoke at the American Society for Microbiology advocating a National Laboratory Network for Bioterrorism Detection.

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ASA 99-3, issue no. 73