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Nuclear, Biological and Chemical (NBC) Medical Information and Resources A post to the EMED Listserv, 10/3/01 Snip< I think the military is ready against an attack, I think our doectors at every ER in the county are ready to recognize an agent. We have many strick teams and DMAT teams trained to help.> I guess I'm not quite as convinced of our (or any other) government's ability to deal with a pandemic. I was taught that if you don't study history, you are doomed to repeat it. I've studied this problem for a lot longer than it has been politically popular. I wrote the chapters in Sullivan's Toxicology on Chem, Biowarfare, and decontamination. in both the first and second editions. I wrote the chapter on bioterrorism in Paul Maniscalco's book on terrorism,i and I was the author of a piece published by Emergency Medicine Reports on Bioterrorism, last year.ii I speak Russian, and spent 2 months in Svedlovsk (Ekatrinburg) working as a visiting professor in 1996. I have talked at length to several of the physicians who took care of patients in the 1979 "incident." A better model of what might happen is found in the influenza pandemic of 1918-1919.iii This pandemic was not curable by the medical technology of 1918 (nor is it curable by today's technology.) Influenza is rapidly spread, made almost half of the world's population ill, and killed between 21 and 40 million people. All medical care was overwhelmed. Society was unable to contain the infection as it was aided by ship, railroad, and the migrations of both civilians and military during the war. Acute illness caused critical personnel shortages in sanitation, law enforcement, postal delivery, food delivery, transportation, and health care. Enough physicians were killed that medical students were graduated early and dentists relicensed as physicians for the duration. Inundated with patients, hospitals turned away people for lack of space and personnel. This was despite makeshift patient accommodations in halls, offices, porches, school gymnasiums, armories, and even tents (during late fall!). Indeed, cities were so short of coffins that Washington, DC seized a train load of coffins en route to Pittsburgh. Many patients were buried in mass graves. Public gatherings were suspended, retail hours were curtailed, and churches were closed. Imagine the chaos if a similar agent were deliberately spread throughout the United States. We still don't have the ability to produce a vaccine rapidly enough to protect the entire population of the United States in any reasonable time frame. It takes 6 months from the identification of a strain to production of live attenuated virus vaccine. This prohibits production of vaccine to protect the first wave of illness of any viral agent. Our hospitals already have acute shortages of staff, beds, and equipment due to a harsh fiscal climate. In many parts of the country, emergency departments routinely have 4-8 hour waits for current patient loads. The health care system was barely able to cope with the nominal upswing in patient load during the 1999-2000 flu season.iv There is simply no reason to think that it will be able to cope with a deliberately engendered pandemic or pandemics. One must also look at the panic that accompanies such a pandemic. Panic that would make people fight for supposed protective agents, flee for supposedly safe locales, or even just try to protect family and loved ones. Think about how to enforce a quarantine for smallpox in Los Angles for example. with multiple ways to get out of the city, including both land and sea. Panic that would suborn our already-decimated law enforcement services and make martial law inevitable. With current news reporting, this panic will be spread by CNN and MSNBC on a real time basis. Think how many times you saw the second plane going into the tower? Snip< Anthrax does not have to be treated with a floroquinolone. Doxycycline (preferred for post-exposure prophylaxis) penicillin and amoxicillin (alternative) can be used. IV doxy can be used to treat, as can IV erythro.> It looks good to stockpile Cipro, various other antibiotics, and vaccines. but it really takes a while to detect these diseases. Most physicians won't think about bioterrorism until they have several cases of xx disease in their emergency department on their shift. If the disease has common initial symptoms such as fever, sniffles, and a sore throat and occurs in the winter, they wouldn't think about it until many folks started to arrive in their ED.or the urgent care center or their PMD's office. This may be 5-10 days after the initial exposure. and these now-exposed medical providers will be part of the second wave. Some of the new casualties will be lethally sick and some will be simply damn scared. The patients with the usual illnesses will continue to need emergency care but may be far sicker due to a mild infection on top of their already fragile health. You need to remember that it isn't until somebody reaches up and pulls the cord that stops the train that the CDC, FBI, DMAT, special rescue groups etc are going to be mobilized and those stockpiles of supplies parceled out. and the odds are that the terrorist reads just as well as you and I, and knows the current threat list. Choose one from column A, one from Column B, and add in a little from Column C. mix all in a few different parts of the United States and you will have all the Cipro needed in Buffalo, all the smallpox vaccine needed in Los Angles, and flu shots in Atlanta. Remember that a good terrorist team is going to go after at least three targets simultaneously. as they did in NY, and DC and Pennsylvania. We only have about 6 million doses of smallpox vaccine, so there is a real problem in logistics if smallpox is used in a major metro area. And just how many doses of Cipro/Doxy/PCN are stockpiled.assume the exposure is over a city of 1 million, and a possible 250,000 people are exposed (not a real unusual scenario, by the way).. and you have to give 60 days supply or 28 days supply and an immunization series..60x2x250,000 = 30 million pills of Cipro needed. Pretty big stockpile! (Add in the distribution/transportation difficulties caused by fleeing refugees, panic, quarantine and possible martial law.) . oh and by the way, Ken Alibek says that there is a very, very good chance that the stockpiled antibiotics will not be effective if a mil-grade anthrax is used. For real entertainment, do two agents in the same town, preferably with similar initial symptoms. Seed the second agent about 5 days after the first agent is used and make sure that the second agent is completely unaffected by whatever treatment is appropriate for the first agent. Remember that to totally engender panic you don't need the second agent to actually kill people, just make them fairly sick. Call me a little paranoid. but. I don't think these people are either stupid or cowards and they want to make us suffer . This is war and war is not pretty and not glorious. Sherman's quote is not trite. I think the threat needs to be taken quite seriously.not just lip service and a promise that "the Government is here to help you." If you normally see 100 patients per day in your emergency department, think about how you would see 1000 patients or more in a day. Don't just think about the problem of you personally examining these patients. think about the logistics involved in simply caring for them, feeding them, and keeping life support going for a significant percentage of them. Remember that you won't get significant help for a minimum of 24 hours after the cord is pulled. It really does take a while to load crates, transport them, and unload them at the site. I think that responsible biowarfare planning should make a hospital administrator consider staffing for 10 times (or more) his/her rated bed capacity and thinking about where the extra cots, blankets, and most of all gloves and gowns are going to come from. and how he/she is going to get them to the hospital. and how he/she is going to staff when 25% of the staff are casualties and 50% of the staff is so panicked that they want to stay home. and I'm not talking about the physicians and nurses. We always seem to ignore the efforts of the registration clerks, cooks, lab techs, bottle washers, security, and even janitorial services needed for a ramp-up of 1000% or more of current capacity. By the way.a little history. Anthrax was used as a bioweapon in Washington D.C. by Dr. Anton Dilger to infect over 3000 horses and mules destined for Allied forces in Europe. He brewed it up in his basement in 1915. It just ain't real tough to do. Instructions are available in any good microbiology course supplemented with just a little light reading. Viral agents are an order of magnitude more difficult, but well within the capabilities of all PhD's in micro and most MS's. Charles Stewart MD They
taught me in the military that...
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