MOSCOW TOLL REVIVES CONCERNS OVER CHEMICAL ATTACK
11 Nov 2002
Source: New York Times, November 11, 2002.
THE DOCTOR'S WORLD
Moscow Toll Revives Concerns Over Chemical Attacks
By LAWRENCE K. ALTMAN, M.D.
Russia's decision to blow an aerosolized form of a powerful narcotic through the ventilation system of a theater to end a hostage crisis in Moscow late last month raised anew an inevitable and terrifying question: what if a terrorist unleashed a potentially lethal chemical in this country?
Particularly since Sept. 11, many public health officials have worried about possible bioterrorist attacks with chemicals, smallpox or other microbes. Now, the use of the narcotic fentanyl has refocused attention on those concerns, particularly in light of Russian doctors' criticism that their government did not organize enough rescue workers to give victims an antidote, naloxone.
Time is critical in seeking the identity of any chemical used as a weapon because the body can wash it out or break it down into other compounds in minutes, leaving health officials unsure what the substance is or how to treat its effects.
Timing of treatment is also crucial because many chemicals start producing damage immediately and delayed treatment can permanently damage the brain and other organs. Antidotes exist for many chemical agents, but not for many others. In such cases, all doctors might be able to offer is fresh air and supportive care.
Dr. Lewis R. Goldfrank, who directs emergency medicine at Bellevue Medical Center and at New York City's Poison Control Center, voiced confidence in the ability of American health care to respond successfully to a chemical attack.
"We'd have no difficulty recognizing" the chemical and providing the appropriate care, Dr. Goldfrank said. But the Moscow disaster and a theoretical attack on this country differ in crucial ways.
Russian officials knew what agent they used, although they did not publicly identify fentanyl until four days after the attack. Fentanyl is a short-acting painkiller that is 100 times as powerful as morphine and accounts for about half of the use of anesthestics in the United States, said Dr. James E. Cottrell, who is chairman of anesthesiology at the State University of New York Downstate in Brooklyn and president of the American Society of Anesthesiologists.
But in the first hours of a chemical attack, authorities may not know the agent's identity. Because chemicals often bring on classic symptoms, doctors may guess the type of agent by observing the victims and their physical reactions and use that information to begin therapy.
If the agent is a narcotic like fentanyl or heroin, victims will probably be calm, their pupils pinpoint size, their breathing and heart rates slow and their blood pressures low. Other types of drugs could produce opposite symptoms. If it is scopolamine, an anti-motion sickness drug that robbers have used to incapacitate victims, people may be delirious.
A toxin that causes botulism will lead to double vision, difficulty speaking, weakness and other neurological problems.
Emergency responses to chemical attacks are based in part on what doctors learned in World War I and more recently from heroin overdoses, which can be treated with naloxone.
After Sept. 11, public health officials were given increased government money to buy equipment and train workers for a possible chemical attack.
Standard procedure at the scene of an attack calls for evacuating victims, getting people to fresh air, putting masks around victims' faces to help provide respiratory support for those needing it, placing breathing tubes in windpipes and determining victims' conditions to decide who is sent to a hospital first.
All emergency medical service ambulances in New York City and most large American cities carry naloxone, Dr. Goldfrank said. In many cities standard protocol calls for immediately injecting sugar water (in case of an insulin coma) and naloxone into someone who is unconscious and a suspected poisoning victim.
Ideally, workers would decontaminate victims at the scene by removing their clothes and giving them showers. At a hospital, patients could receive showers outside. Bellevue soon expects to complete a new $500,000 decontamination unit, where large numbers of victims can be washed down by huge amounts of water. Many other hospitals are equipped with tents and portable units for such emergencies.
While treatment progresses, toxicologists will use laboratory tests to try to quickly identify the chemical used in the attack. All major cities have equipment to identify or rule out certain classes of chemicals. Many hazardous materials teams carry mass spectrometers and other analytical tools that can screen a large number of chemicals and provide specific identification of an agent, said Jerome M. Hauer, who directs the Office of Public Health Preparedness in the Department of Health and Human Services.
But toxicologists must guard against misreading the information and falsely identifying a particular chemical unrelated to the attack. Another worry is that if terrorists develop and use a novel agent, American scientists may not have a good standard to detect it, Mr. Hauer said.