The challenges of deliberate chemical/biological attack

David Lockey a,*, Gareth Davies b

a Anaesthesia and Intensive Care Medicine, Frenchay Hospital, Bristol BS16 1LE, UKb Emergency Medicine and Pre-Hospital Care, Royal London Hospital, London E1 1BB, UK

Received 17 July 2003; accepted 17 July 2003

Resuscitation 58 (2003) 293�/296

www.elsevier.com/locate/resuscitation

Abstract

Major incident plans in many countries have recently been updated to address the issues surrounding the deliberate release of

chemical and biological agents. Despite this, many ‘front line’ doctors who would be responsible for treating victims of such

incidents are poorly integrated into the plans. This article examines some of the challenges that face clinicians in the pre-hospital and

hospital phases of a deliberate release incident.

# 2003 Elsevier Ireland Ltd. All rights reserved.

Keywords: Challenges; Attacks; Agents

Resumo

Em muitos paıses os planos de resposta as situacoes de catastrofe ja incluem actualizacoes sobre agentes quımicos e biologicos.

Apesar disso muitos medicos da ‘‘linha da frente’’ com responsabilidade no tratamento de potenciais vıtimas nao estao integrados

nesses planos. Este artigo fala de alguns dos desafios que se colocam aos clınicos em caso de libertacao propositada destes agentes,

na fase pre-hospitalar e hospitalar.

# 2003 Elsevier Ireland Ltd. All rights reserved.

Palavras chave: Libertacao propositada; Agentes quımicos; Agentes biologicos

Resumen

En muchos paıses los planes para manejo de incidentes mayores han sido puestos al dıa para considerar temas relacionados con

liberacion deliberada de agentes quımicos y biologicos. Pese a ello, muchos medicos de ‘primera lınea’ que serıan responsables de

tratar vıctimas de tales incidentes estan pobremente integrados a esos planes. Este artıculo examina algunos de los desafıos que

enfrentan los clınicos en las fases pre e intra hospitalaria de un incidente de liberacion espontanea de agentes nocivos.

# 2003 Elsevier Ireland Ltd. All rights reserved.

Palabras clave: Liberacion deliberada; Agentes quımicos; Agentes biologicos

1. Introduction

In 1999 a series of articles were published in this

journal that discussed the management of patients

exposed to toxic substances [1]. The articles covered

both accidental release of toxic substances and, stimu-

lated by the release of Sarin on the Tokyo subway in

1996 [2], deliberate release. The events of September

2001 brought the issues surrounding the deliberate

release of chemical and biological agents into sharp

focus and since then there has been a significant increase

in interest and information on the subject. It is difficult

to separate the intense media approach with predictions

of ‘inevitable’ deliberate release by terrorist groups and

the actual threat, but it is clear that thorough prepara-

tion of the emergency services for this type of incident is* Corresponding author.

E-mail address: djlockey@hotmail.com (D. Lockey).

0300-9572/03/$ - see front matter # 2003 Elsevier Ireland Ltd. All rights reserved.

doi:10.1016/S0300-9572(03)00260-0

a high priority. This year the US government has called

for ‘$518 million to enhance preparedness at the nations

hospitals to respond to incidents of biological or

chemical terrorism’ and ‘another $100 million forbioterrorism training for healthcare professionals, poi-

son control centres and emergency medical services for

children’ [3]. The medical literature on this subject is

dominated by public health specialists, toxicologists and

the military. These specialists have a vital role to play,

but doctors in the acute specialities who would be

responsible for treatment of victims in the first hours

after exposure (emergency medicine, anaesthesia, inten-sive care and acute medicine), are equally important but

currently underrepresented. This gap needs attention.

There is a great deal of information available on this

subject, much of it readily available on the internet. The

UK Public Health Laboratory Health Service (PHLS)

[4] and the US Center For Disease Control (CDC) [5]

websites are up to date and valuable. In the UK, the

National Poisons Information Service and Departmentof Health also provide comprehensive information.

Many of the major anaesthesia journals have recently

published review articles that cover much of the back-

ground information [6�/8]. To date, the emergency

medicine literature lacks similar publications, though

some specific issues have been addressed very recently

[9,10]. Other specialist journals have concentrated on the

areas that impact directly on the speciality of theirreaders [11,12]. Has information that is available got to

front line emergency doctors? A survey of UK emer-

gency physicians, anaesthetists and intensivists pub-

lished in this journal [13] suggests that there are major

gaps in knowledge and training in this group of doctors.

Despite recent publications in the anaesthetic literature,

emergency physicians and intensive care doctors scored

more highly than anaesthetists. This situation could beaddressed with the use of practical exercises. Some 79%

of respondents in this survey had not been involved in

any training exercises for this type of incident. Exercises

too often involve only planners, administrators and a

token clinical presence in table top scenarios.

The remainder of this article will consider some of the

practical challenges that face acute speciality doctors in

the current UK climate. The straightforward questionsposed may be of use to doctors testing or questioning

the capacity of their local system or planning an

exercise.

2. Pre-hospital care

In the UK, pre-hospital care is delivered primarily by

paramedics supported at major incidents by MedicalIncident Officers (also known as medical commanders),

mobile medical teams and pre-hospital physicians. UK

paramedics have advanced life support skills, but are

able to use only a very limited range of drugs.

Emergency physicians are rarely used in UK pre-

hospital care. This is in sharp contrast to most European

countries. In France, for example, there is a co-ordinated EMS response with emergency physicians

directing at every stage [14]. In London, all three

emergency services have teams trained to work in

personal protective equipment (PPE) at the site of an

incident. When looking at the efficiency of a local

system, response times are important*/how long will

it take for trained first responders to arrive at an

incident in PPE? If they are not immediately availablea significant delay will occur. Response time, travel

time, equipment collection/dressing time and travel to

scene time are all required. It is safe to assume that

during the first 30�/60 min after deliberate release, many

first responders will not be equipped with PPE. This will

result in either the rescuers being ineffective or putting

themselves at considerable risk. Department of Health

guidelines encourage the former and advise rescuers ‘notto enter an area without appropriate PPE’ [15]. Some

delay in a ‘PPE response’ is inevitable, but it should

ideally be as short as possible. The question to be posed

when exercising the local system is ‘what will happen on

scene during this period?’ The fire and police services

will be responsible for the setting up of cordons around

the incident, but what proportion of mobile victims will

wait for this to happen? A key principle in the successfulmanagement of such an incident is decontamination at

the scene. This is made much more difficult if some

casualties move before cordons are erected. Effective

mobile decontamination units exist, but they take time

to set up and can be slow to decontaminate large

numbers of casualties. In this scenario, ‘mass casualty

decontamination procedures will be commenced with

high volume low pressure water’ [15]. This appears veryreasonable, but casualties treated in this way will still

require full decontamination on arrival at hospital. In

the UK, patients who require immediate on scene

treatment for life threatening compromise can be treated

only after decontamination. This is in contrast to the

French system where physicians and paramedics are

available to deliver advanced resuscitation, including the

delivery of antidotes (e.g. high dose atropine andoximes) and drugs to achieve tracheal intubation and

respiratory support, at any point in the evacuation

process [14,16]. UK paramedic protocols do not cur-

rently allow administration of the required drugs in the

pre-hospital phase even after decontamination. In

response to this problem, the military established the

concept of self and ‘buddy’ administration of anti-nerve

agents by non-medical personnel many years ago.If there were personnel who could administer treat-

ment on scene, where would ‘antidotes’ come from? For

nerve agent release very large doses of atropine may be

required [9,10,17] and early administration of oximes is

D. Lockey, G. Davies / Resuscitation 58 (2003) 293�/296294

also recommended [4]. Currently NHS hospitals do not

stock oximes and have only modest quantities of

atropine. This problem has received attention in the

US where one solution is to make up large quantities ofatropine in hospital pharmacies from powder during an

incident. This can be achieved relatively quickly [9,10]

but still represents another potential delay. In the UK,

antidote supplies are held centrally and supplied by the

National Blood Transfusion Service who have an

established distribution network. This is another poten-

tial source of delay. Much information from govern-

ment agencies is freely available on the Internet.Information should also be available at local level. If

it is not, physicians need to consider why. Although

there are obvious security issues concerning terrorist

activity, most aspects of emergency health planning have

to be accessible to those health care providers who are

an integral part of it. Specific training of paramedical

and medical providers in chemical incident management

is essential and is established in some countries [18].Although the deliberate release situation may be extra-

ordinary, many treatment principles and procedures are

familiar to rescuers [19] and guidelines are available

[20,21]. Practitioners who work in industrial areas who

have prepared for non-deliberate release incidents are

well placed to deal with the issues [22].

3. Emergency department

Patients may arrive at the emergency department well

or unwell, contaminated or decontaminated. The im-

portance of a deliberate release ‘plan for every emer-

gency department’ has been emphasised recently in the

US [23]. Although all major incidents are unique, the

‘standard’ major incident procedures will cover many of

the important issues in deliberate release incidents. Staffneed to be fully aware of the hazards of incompletely

decontaminated casualties [2] and be directed by knowl-

edgeable physicians with access to up to date clinical

information. The survey published in this journal [13]

suggests that these points need urgent attention. The

geography of the emergency department may also be

relevant. Hospitals close to an incident are more likely

to be closed because of contaminated casualties selfreferring to the emergency department. Security cordons

need to be rapidly erected to prevent this. Hospital

security personnel are unlikely to be trained to man a

proper cordon around an emergency department and

local police may be overstretched. Effective security may

be vital to a hospitals continued ability to treat

casualties in major incidents [24].

Hospitals with decontamination facilities need topractice their procedures regularly. Provision of capa-

city for this type of incident is not just the domain of a

few regional units. The UK department of health

‘expects all major Accident and Emergency Depart-

ments and NHS Ambulance Services to have the

necessary equipment to deal with chemical contamina-

tion incidents that may result from industrial ortransportation accidents, or deliberate terrorist releases’

[25]. Provision also needs to be made for the difficulties

of working in high level PPE. Using emergency depart-

ment staff to decontaminate patients requires a great

deal of the available resource. These individuals are

removed from their normal duties in the emergency

department, which may make proper staffing of the

department difficult. Also, staff using this equipmentneed to be changed regularly or given regular breaks

because of the fatigue associated with working in PPE

and the limited battery life of the power units used on

high level PPE suits. Class ‘A’ and class ‘B’ PPE provide

the highest level of protection against contaminants and

have a power source to provide a positive pressure

environment within the protective suit. The military has

recognised the impracticality of class ‘A’ and ‘B’ suits onthe battlefield and have opted for the lower level of

protection provided by class ‘C’ PPE which is easier to

work in (these suits have no power or positive pressure

facility). The fact that NATO forces faced with the most

toxic chemical agents known use level ‘C’ protection

indicates that there is no place for higher level protection

for medical staff in the civilian deliberate release

situation.There is also considerable anxiety created by this type

of incident and there is the possibility that off duty staff

may respond less enthusiastically to this than to a

conventional incident where volunteers often converge

on the scene and hospitals [24]. Onward movement of

patients from the emergency department is important in

any major incident. Deliberate release incidents have the

potential to generate multiple patients who requirerespiratory support. The ever present shortage of

intensive care beds in the UK makes this scenario a

cause for considerable concern. There is also the

possibility of an ‘intermediate’ syndrome occurring after

nerve agent exposure, which could make respiratory

support necessary relatively late after exposure. The

theoretical problem of patients with contamination of

their exhaled respiratory gases may mean that ventilatedpatients require gas scavenging which, though common

in anaesthetic circuits, is rare in emergency departments

and intensive care units.

4. Conclusion

The threat of deliberate release of chemical or

biological agents is unlikely to recede in the foreseeablefuture. Progress has been made to prepare the emer-

gency services for such an incident in many countries

including the UK and a great deal of information is now

D. Lockey, G. Davies / Resuscitation 58 (2003) 293�/296 295

available. Unfortunately, despite this progress, it ap-

pears that doctors in relevant emergency specialities

have not been properly trained, educated or fully

integrated into the pre-hospital and hospital emergencyresponse. Since they will be the first medical contacts for

victims of deliberate release it is vital that this expertise

develops. Emergency plans are well developed in most

regions but there are a number of practical problems

that need careful consideration, preferably in regular

practical exercises rather than during an actual incident.

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