The Role ofEmergency Physicianin Response toCBRNE AttackDr. Chew Keng ShengEmergency MedicineUniversiti Sains Malaysia
Objectives Definitions Key criteria for determining a terrorist attack Overview on selected terrorists’ attacks and WMDs Major Lessons Learnt from Previous Disasters Syndromic Surveillance Defining roles of EPs in response to CRBNE Terrorist Attacks – ―7Ds in Disasters‖ Q&A
Definitions of Disaster, Mass Casualty Incidents and Terrorism
Definitions Disaster – defined as a sudden ecologic phenomenon of sufficient magnitude to require external assistance In the Emergency Department, disaster exists when the number of patients presenting in any given space of time are such that even minimal care cannot be offered without external assistance.
Definitions Disasters occur when normal, basic services of a society become disrupted to such extent that widespread human and environmental losses exceed the community‟s management capacity (SAEM Disaster Medicine White Paper Subcommittee) Disasters characterized by large numbers of deaths and injuries are also referred to “Mass Casualty Incidents”
Definitions However, disasters are not defined only by a given number of victims Example: The arrival of one VIP guest with severe medical or trauma emergency conditions can completely disrupt normal operations of even the most efficient emergency departments. In short, the essence of the concept of disaster is it has a “massive disruptive impact”
Definitions Mass Casualty Incidents (MCI) – events resulting in a numbers of victims large enough to disrupt normal course of emergency and health care services of the affected community Disasters result in MCIs, but encompass a broad range of calamities beyond just the high numbers of casualties ―All MCIs are disastrous, but not all disasters are due to MCIs‖
Definitions Disasters can be divided into two: Natural Disasters OR Man-made Disasters External Disasters (events occurring outside the hospital) OR Internal Disasters (events involving the physical structures of hospital itself - e.g. fire, lab accident involving radioactive materials) Terrorism – man made, external disasters
Directive 20, National Security Council A Disaster is1. an event that occurs suddenly.2. complex in nature.3. loss of lives.4. destruction of property and/or environment.5. disruption of the community daily activities
Three Levels According to Directive 20, NSC Level 1 Localized, well-controlled, manageable by local authorities Level 2 Well-controlled, management at state or national level Level 3 Complete destruction, disruption of routine activities,
Directive 20, NSC Disaster can be divided into 3 levelLEVEL 11. Localized major incident2. Under controlled3. Not complex4. Small no. of casualties and property loss5. Minor disruption of daily community activities6. Manageable by the local authorities requiring7. Multisectoral involvement. Example: bus accident, train derailment, landslide.
Directive 20, NSC LEVEL 2 Disaster1. Widespread over a large area but under controlled2. Complicated and complex3. Large no. of casualties and property loss.4. Affecting daily community activities5. Not manageable by the local authorities requiring6. Assistance from other states or National Authorities7. Support required, Regional or National Support Examples: Highland Towers Collapse, Greg Storm Sabah, Bright Sparklers.
Directive 20, NSC LEVEL 3 Disaster1. Involves a very large area.2. Loss of many lives.3. Total Destruction of infrastructure and public facility.4. Complicated and complex.5. High risk to rescue workers.6. Complete disruption of daily community activities.7. Major destruction of resources.8. All local resources destroyed and assistance from external resources required. e.g. Earthquake, typhoons, volcanoes, war.
Disasters Vs Emergencies Routine Emergencies DisastersInteraction with familiar Interaction with unfamiliarparties partiesFamiliar tasks/procedures Unfamiliar tasks/proceduresIntra-organization Intra- and inter-coordination organization coordinationIntact communications, Disruptedroads, etc. communications, blocked roads, etc
Disasters Vs Emergencies Routine Emergencies DisastersFamiliar terminology Unfamiliar, organization- specific terminologyLocal press attention National/international media attentionResources adequate for Resources overwhelmed formanagement management capacity
Know Your Role! Hospital Director INCIDENT SITE MEDICAL MANAGER NGO COMMAND POST ADVANCED MEDICAL POST Temporary Medical/Health Officer Morgue Acute Treatment Manager•JPA 3 Medical Red Team Yellow Team Green Team Evacuation Transport•SJAM Triage Officer Leader Leader Leader Officer Officer•MRCS. Admin. Admin. Ambulance Clerk Doctors & Paramedics Clerk Drivers PRE-HOSPITAL MANAGEMENT ORGANIZATION
Key Criteria Defining a Terrorist Attack Violence "the only general characteristic [of terrorism] generally agreed upon is that terrorism involves violence and the threat of violence" -Walter Laqueur of the Center for Strategic and International Studies Psychological Impact and Fear attack was carried out in such a way as to maximize the severity and length of the psychological impact. Perpetrated for a Political Goal This is often the key difference between an act of terrorism and a hate crime or lone-wolf "madman" attack The political change is desired so badly that failure is seen as a worse outcome than the deaths of civilians.
Key Criteria Defining a Terrorist Attack Targeting of non-combatants It is commonly held that the distinctive nature of terrorism lies in its deliberate and specific selection of civilians as direct targets. Much of the time, the victims of terrorism are targeted not because they are threats, but because they are specific "symbols, tools, or corrupt beings" that tie into a specific view of the world that the terrorist possess. Their suffering accomplishes the terrorists goals of instilling fear, getting a message out to an audience, or otherwise accomplishing their political end. (en.wikipedia.org)
Overview of Selected Terrorist Incidents Bombing of WTC New York City 1993 Sarin Gas Attack by Aum Shinrikyo in Matsumoto, Japan, 1994 Truck Bomb explosion of Alfred P. Murrah Building in Oklahoma, 1995 Sarin Gas Attack by Aum Shinrikyo in five subway train stations simultaneously in Tokyo, 1995 WTC Bombing, New York, September 11, 2001 US Anthrax Incident, 2001 Bombing in Bali, Indonesia 2002
Major Lessons Learnt Incident Confirmation At time of incident (whether biological, chemical or even high explosive incidents), most people at the scene and even the initial responders did not recognize the event as a terrorist attack E.g. during the Sarin Gas Attack in Matsumoto, Japan, emergency responders initially thought that the first victims were ill from food poisoning, contaminated water, or natural gas To improve early detection, a process called Syndromic Surveillance is employed
Syndromic Surveillance A method to aid the early detection of bioterrorism events This is to respond to bioterrorism attack – time is essential This type of surveillance involves collecting and analyzing statistical data on health trends – such as symptoms reported by people seeking care in emergency rooms or other health care setting – or even sales of flu medicines.
Syndromic Surveillance Because bioterrorist agents such as anthrax, plague, and smallpox initially present ―flu-like‖ symptoms, a sudden increase of individuals with fever, headache, or muscle pain could be evidence of a bioterrorist attack. By focusing on symptoms rather than confirmed diagnoses, syndromic surveillance aims to detect bioterror events earlier than would be possible with traditional disease surveillance systems.
Syndromic Surveillance In other words, the term syndromic surveillance refers to methods relying on detection of clinical case features that are discernable before confirmed diagnoses are made
Recommended WebsiteCenters for Disease Control and Prevention – (http://www.bt.cdc.gov/)Emergency Preparedness & Response
Major Lessons Learnt Command and Control Unlike smaller emergencies where one single Incident Commander in charge, in a terrorist attack, numerous agencies and organizations involved The need to speedily establish a secure perimter around the incident. Failure to do so during the Oklahoma bombing Communications Communications failure Overloaded land lines and cell phones with calls from public trying to obtain info about their loved ones
Major Lessons Learnt Initial Responders Traditionally initial responders are defined as the local police, firefighters, EMDs, paramedics. Well trained, part of daily routine In overwhelming terrorist attacks, other professionals were needed at the scene – NGOs, volunteers, mental health workers These individuals thrust into new roles – without proper training. Safety of these responders – 1993 WTC bombing, 124 emergency responders injured; in Oklahoma bombing, one nurse killed from falling debris.
Major Lessons Learnt The Volunteers Volunteers, though well intentioned, often created problems Most not familiar with the emergency command and control system The Victims At most disasters, victims left the scene and sought medical help on their own Need for rapid establishment of a centralized database containing identification victims from all responding medical sites. E.g. in Bali Bombing – internet database used extensively
Major Lessons Learnt Psychological Effects PTSD – Example 11 months after 9/11 incident, 1277 stress related illnesses reported Need for debriefing and de-stressing; short briefings prior to change of shift for responders Tokyo Sarin Attack and Anthrax threat – created unique psychological fear – the healthy but anxious lots taxed the health services at a time when others needed care. Need for proper public education
Major Lessons Learnt Mortuary Affairs Temporary morgues, body bags Body decay Rapid identification of victims – for family members, law, insurance companies, etc; the need for DNA analysis Example – Oklahoma bombing – unavoidable delays in official death notifications added emotional trauma to the already bereaved families The need for religious sensitivity in handling bodies
Major Lessons Learnt Duration of event Prolonged duration – strained the human and material resources; depletion of stocks Need for regular work shifts Criminal Investigations One of the main difference between natural disaster and man-made disaster The concern to preserve the evidence Medical emergency responders help protect the evidence by only touching and removing items when necessary
Major Lessons Learnt Media Mixed blessings Disseminate information Yet, in an effort to provide information ASAP, sometimes media give false and confusing information VIP Visits Politicians, celebrities, etc Timing of these visits sometimes interfered with ongoing recovery efforts
Overview Chemical Weapons Radiation Nerve Agents – G series (GA, α radiation GB, GD), V series β radiation Blood Agents - cyanides γ radiation Blistering Agents Nuclear Biological Weapons A bomb (Atomic) Biological Agents – viruses (e.g H bomb (Hydrogen) Ebola), bacteria (Yersenia pestis, anthrax) Explosives Biological Toxins – botulism, Large scale - Incendiary ricin, Staphylococcal bombs, Napalm-B, Mark 77 Enterotoxin B Smaller scale - Molotov Cocktail (Poor man’s hand grenades)
Explosives The use of Napalm-B in Vietnam in 1966Molotov Cocktail (Reference: en.wikipedia.org)
How Prepared are the ED? In 1997, Burgess et al. reported that only 44.2% of hospital EDs had the ability to handle any chemically contaminated patients from HAZMAT 41.1% - no designated decontamination facilities Greenberg et al. in June 2000, conducted a survey to assess the level of preparedness of hospital EDs in a large metropolitan area to evaluate and treat victims of a terrorist biological or chemical agent release 44 out of 62 ED directors responded to the questionnaire
How Prepared Are the EDs?(Figures given in percentage) Yes No DKDecon facilities 90.7 9.3 0Ability to decon:a. < 10/Hr 83.3 - -b. 10-19/Hr 7.4 - -c. 20-50/Hr 5.6 - -d. >50/Hr 3.7 - -Written plan for handling post-decon waste water 63 18.5 18.5Written plan for handling contaminated clothings 42.6 29.6 27.8Presence of detection equipment in ED 14.9 68.5 16.7Personal Protective Clothing 87 13 0 (Greenberg et al., 2000)
Suggested Criteria for Minimum Preparedness ofEDs to Evaluate and Treat Victims of Biological orChemical Agent Release1. At least one EP who has completed formal training regarding biological and chemical WMD2. Ability to decon ≥10 patients/Hr3. Written policies addressing the evaluation and treatment of biological and chemical casualties4. Written cooperative agreements with local agencies addressing issues of biological and chemical terrorism5. Participation in a disaster exercise involving biological or chemical agents within the past 12 months6. Self characterized adequate supplies of appropriate antidotes
Roles of Emergency Physician in DISASTERS –EIGHT „D‟s Detection and Diagnosis Rapid Recognition Declaration and Activation Activate contingency plans Establish intra-hospital, inter-hospital, inter-agencies, inter-states, international communications Defense Self-protection Decontamination Delegations Drugs Disposition Delivering right patients to right place and right time Debriefing and De-stressing
The Main Problem with Biological Weapon Biological weapons can be divided into two categories Overt (Announced) First responders (fire fighters or law enforcement) are most likely to respond to the announced release, or more likely the hoax Covert (Unannounced) First responders would probably be the GPs, family doctors, EPs, etc. Furthermore, patients exposed to biologic agents usually present with vague symptoms associated with flulike illnesses (latency period).
Overt Attack First responders (trained fire fighters or law enforcement) are most likely to respond to the announced release, or more likely the hoax In recent anthrax attack, an example would be the letter received and opened in a Senator’s office in the Hart Senate Office Building. The envelope contain a letter stating that it contained anthrax spores and the opener was going to die. First responders called, the presence of spores of Bacillus anthracis confirmed. Exposed individuals given prophylaxis. To date, none in the Senate Building has developed anthrax
Covert Attack Current NO REAL TIME environmental monitoring for a covert release of biological weapon A covert attack would probably go unnoticed, with those exposed leaving the area long before the act of terrorism became evident Furthermore, because of the incubation period, the first signs of the biological agent released not be recognized until days or weeks later. Thus those first responders would probably be the family doctors, GPs, EPs, etc
Factors indicative of a Potential Bioterrorism Event Multiple simultaneous patients with similar clinical syndrome Severe illnesses, especially among the young and otherwise healthy Predominantly respiratory symptoms Unusual (non-endemic) organisms Unusual antibiotics resistance Atypical clinical presentation of disease Unusual patterns of disease such as geographic co-location of victims Intelligent information – tips from law enforcement, discovery of delivery devices, etc Reports of sick or dead animals or plants (Richards et al., 1999)
ON SITE MANAGEMENT WORK MATRIX YELLOW ZONE OSC (POLICE ) M.E.L.O.FORENSIC P.K.T.K. QUARTER O.M.C. MASTER BOMBA MEDICAL BASE SAR M.E.S.A.R.O. SAR CRTICAL S.CRITICAL SPECIALISTS N.CRITICAL SJAM COMMAND POST MRCS DEAD JPA 3 F.F.C. - BOMBA RESCUERS BOMBA S.B. SAR TEAM RED ZONE
ON SITE MANAGEMENT – TRIAGE SYSTEM TO NEAREST APPROPRIATE HOSPITAL GREEN
Victims Collecting Point Impact ZoneWorking Area COLLECTING POINT Advance Medical Post
Simple Triage and Rapid Treatment START Triage System * Victims who can walk are first identified and be diverted to one designated area
VICTIM FLOW ―Conveyor Belt‖ Management Triage Evacuation Triage Treatment TreatmentImpact Collecting ADVANCE TRANSFER HOSPITAL Zone Point MEDICAL POST Victim Flow Transport Resource Flow
Initiating Isolation Ideally be decontaminated outside the hospital Approach from upwind direction Isolate at least 100 m radius (initial isolation) for hot zone If large spill, 500 m; and if on fire (flammable substances), 800 m Establish three zones Hot zone where the spill/contamination occurred Only trained personnel with proper attire to enter Only the most immediate life threats addressed here – like opening up airway, cervical spine immobilization, bleeding control Warm zone area for thorough decontamination Theoretically no risk of primary contamination but secondary contamination still possible
Initiating Isolation Initial IsolationProtectiveAction Zone
Principles of Decontamination Removal of clothings most important step (accomplishes 80-90% of decon) From top to bottom The more the better Privacy is an issue Water flushing the best Typically shower 3 – 5min Decon ASAP Expect a 5:1 of unaffected: affected casualties ratio First responders must self- decon too
Summary Terrorist Attacks are disastrous – but that does not mean that there is nothing we can do. Though we are probably helpless in preventing them from coming, yet our preparedness would hopefully be able to lessen the magnitude of severity of the attack
Sarin Gas Attack on Tokyo Subway Attack on 20th March 1995 was the second attack – 12 people died. Shoko Asahara – Founder of AUM First attack 1994 – 7 Shinrikyo died. How many perpetrators were involved and how many train stations were contaminated? Ikuo Hayashi – one of the How did they do it? perpetrators
The Attack Attack at approximately 7:55 AM on March 20, 1995. 8:16 AM - the St Lukes ED was alerted 520-bed tertiary care located near the affected subway stations (within 3 km) received the largest number of victims from the subway attack. services comparable to those of any medical center within the United States. Within hours of the terrorist incident, St Lukes emergency department received 640 patients.
The Attack 8:28 AM - the first subway victim arrived at the St Lukes ED. This patient was ambulatory and arrived without assistance from ambulance personnel. The patients only complaints were of eye pain and dim vision. 8:43 AM – arrival of first ambulance arrived During the next hour, approximately 500 additional subway victims, including 3 patients who were in cardiopulmonary arrest on arrival, presented to the ED Five of the female patients were pregnant.
The Attack 9:20 AM - hospital directors activated the hospitals disaster plan. This resulted in the cancellation of all routine surgeries and outpatient activity. More than 100 doctors and 300 nurses and volunteers were immediately called to care for victims Victims into three clinical groups - mild, moderate and severe
The Attack Mild cases (528, or 82.5%) - only eye signs or symptoms (eg, miosis, eye pain, dim vision, decreased visual acuity) on presentation released after a maximum of 12 hours of ED observation Moderate cases (107, or 16.7%) - systemic signs and symptoms (eg, weakness, difficult breathing, fasciculations, convulsions) BUT not require mechanical ventilation Severe cases (5, 0.78%) - emergency respiratory support (eg, intubation and ventilation support)
Outcomes of Patients Admitted to St. Luke‟s Hospital ED, Tokyo
Lessons Learnt Delay in confirming the nature of the toxin Delay in organizing an effective mass casualty strategy Poor ventilation in patient reception area Secondary exposure by medical staffs treating the patients Inadequate provision of privacy to remove contaminted clothings Inadequate shower facilities
Treatment Three drugs are the mainstay treatment Atropine Counteract primarily the muscarinic effect Administer doses of 2 mg every 5 – 10 min to minimize dyspnea, airway resistance or respiratory secretions Pralidoxime To reactivate acetylcholinesterase and counteract the nicotinic effect Over time, OP-acetylcholinesterase bond becomes irreversibly covalent and resistant to reactivation by pralidoxime (―aging‖ process) But still, Pralidoxime should never be withheld. Diazepam The only effective anticonvulsant drugs for nerve gas poisoning patients with seizure
Nerve Gas Agents Are organophosphates Inhibits acetylcholinesterase, block degradation of Ach at postsynaptic membrane. Two main classes G series ―G‖ because accidentally first discovered by German scientist, Dr. Gerhard Schrader GA (Tabun), GB (Sarin), GD (Soman) and GF (cyclosarin). Why no GC? SARIN (most toxic of the four in G series) named in honor of its discoverers: Gerhard Schrader, Ambros, Rüdiger and Van der LINde. V series V stands for ―venomous‖. Examples: VX, VR All G series – watery, high volatility, serious vapor hazard; VX – oily, less vapor hazard, but poses a greater environmental hazard over time.
Nerve Gas Different from organophosphate insecticides Much more toxic VX – most toxic substance synthesized de novo (botulinism toxin – biological) Unlike typical OP, no association with urination Bradycardia is rare Its miosis effect does not respond to systemic therapy
Clinical Features There is no delay effects Symptoms of sarin gas occur within seconds of inhalation and peak at 5 minutes. If patients remaining asymptomatic 1 hour after possible exposure, have not been contaminated. In vapor exposed – miosis first appeared but in liquid exposed – miosis usually last sign Unlike botulinism toxin, flaccid paralysis never on initial presentation.
Differences between Nerve Agents and CyanideCharacteristics Nerve Agent CyanideOdor None Bitter AlmondEyes Miosis (unresponsive Pupils normal or to nalaxone), dim dilated vision, pain and lacrimationOral, nasal and Copious secretions Relatively fewrespiratory system secretionsSkin Profuse sweating, Profuse sweating, cyanosis likely sometimes also cyanosis
Differences between Nerve Agents and CyanideCharacteristics Nerve Agent CyanideInitial CVS response HPT, tachycardia Often hypotensionMuscle Weakness, Twitching of body generalized parts (but not fasciculations, fasciculation) eventually paralysisArterial Blood Gas Resp alkalosis or High AG, aboveand Acid Base hypoxemia with normal venousBalance respiratory acidosis oxygenation
Vesicants Cause blistering and irritations to eyes, skin and airway (example – Mustard) Ophthalmic effect – conjunctivitis, corneal damage, temporal or permanent visual loss Skin effect – blistering like 2nd degree burn Systemic toxicity – BM suppression, leukopenia Indicators of fatal exposure Airway burn within 6 hours Burn >25% Absolute WBC <200/mm3
Blood Agents Blood agents such as cyanide Bind to cytochromes within mitochondria and inhibit cellular oxygen use Low-dose exposures result in tachypnea, headache, dizziness, vomiting, and anxiety. Symptoms subside when the patient is removed from the source In higher doses the symptoms progress to seizures, respiratory arrest, and asystole within minutes of exposure. Victims should be removed from the area, should have their clothing discarded, and should receive oxygen (100%). If no improvement occurs, the cyanide antidote is given (amyl nitrate, sodium nitrite, sodium thiosulfate)
Anthrax Current assessment suggests that three biologic agents—anthrax, plague, and smallpox—represent the greatest threat Bacillus anthracis a gram-positive spore-forming bacterium, is the causative agent of anthrax the spores are extremely hardy survive for years in the environment the disease is caused by exposure to the spores normally a disease of sheep, cattle, and horses and is rarely seen in developed countries because of animal and human vaccination programs disease in humans can occur when spores are inhaled, ingested, or inoculated into the skin spores germinate into bacilli inside macrophages bacteria then produce disease by releasing toxins that cause edema and cell death.
Nuclear and Radiation Attack Terrorists selecting radiation as a means to inflict casualties are unlikely to employ nuclear weapons are heavily guarded difficult to move due to their size and weight easy to detect Sabotage at nuclear power stations is possible, but given tight security, multiple safety systems, and thick concrete housings surrounding the reactors, the threat is probably low
Nuclear and Radiation Attack Instead, simple radiologic devices, such as those used by hospitals for radiation therapy, are thought to be the source of choice. These sources are plentiful and usually unguarded The only wartime use of atomic and nuclear energy was the detonation of atomic bombs over Hiroshima and Nagasaki in 1945. However, with the dissemination of technical information and raw materials, many nations now have nuclear weapons in their arsenals. The real possibility of terrorist groups obtaining and using such weapons also exists.
Bombings of Hiroshima and Nagasaki The first event occurred on the morning of August 6, 1945, when the US dropped a uranium gun-type device code-named "Little Boy" on the Japanese city of Hiroshima. The second event occurred three days later when a plutonium implosion-type device code-named "Fat Man" was dropped on the city of Nagasaki. (en.wikipedia.org)
Being Exposed or Being Contaminated? Being exposed to heat; or being The first step of recognizing burned (external and internal contamination is to burn)? understand the difference between exposure to and contamination by radiologic agents. Exposure is defined by an individuals proximity to material emitting ionizing radiation. Actual touching, inhaling, or swallowing that material is contamination.
Personal Protection Equipment (PPE) PPEs are respiratory equipment, garments, and barrier materials used to protect rescuers and medical personnel from exposure to biological, chemical, and radioactive hazards. The goal of PPE is to prevent the transfer of hazardous material from patients or the environment to health care workers. Different types of PPE may be used depending on the hazard present PPE can be divided into Civilian PPE – especially those working in hot zone (IDLH) Military PPE (www.emedicine.com)
SCBA SCBA: Self Containing Breathing Apparatus Vs SCUBA: Self Containing Underwater Breathing consists of a full face piece connected by a hose to a portable source of compressed air. the open-circuit, positive-pressure SCBA is the most common type this SCBA provides clean air under positive pressure from a cylinder; the air then is exhaled into the environment. (www.emedicine.com)
Civilian PPE Self-contained breathing apparatus Supplied-air respirator Air-purifying respirator High-efficiency particulate air filter HEPA filters 0.3-15 micron efficiency of 98-100% exclude aerosolized BWA particles in the highly infectious 1- to 5-mm range Surgical mask Protective Clothing (www.emedicine.com)
Levels of Civilian PPE Level A SCBA and a totally encapsulating chemical-protective (TECP) suit highest level of respiratory, eye, mucous membrane, skin protection Level B positive-pressure respirator (SCBA or SAR) nonencapsulated chemical-resistant garments, gloves, and boots, which guard against chemical splash exposures. highest level of respiratory protection with a lower level of dermal protection. (www.emedicine.com)
Levels of Civilian PPE Level C APR and nonencapsulated chemical-resistant clothing, gloves, and boots. same level of skin protection as Level B, with a lower level of respiratory protection. used when the type of airborne exposure is known to be guarded against adequately by an APR. Level D standard work clothes without a respirator. In hospitals, it consists of surgical gown, mask, & latex gloves (universal precautions). no respiratory protection and only minimal skin protection (www.emedicine.com)
Decontamination Extenal Decontamination Gross Decontamination Removal of clothings; done before reaching hospital Secondary Decontamination Designated site at ED; with advice from Radiation Safety Officer; head to toe survey Internal Decontamination Blockade of enteral absorption Gastric lavage Use emetic agents – Barium sulphate Blockade of end organ uptake Potassium Iodide
References Kales, S. N. & Christisni, D. C. (2004) Acute Chemical Emergencies. NEJM, 350, 800-8. Greenberg, M. I., Sherri, M. J. & Gracely, E. J. (2002) Emergency Department Preparedness For The Evaluation And Treatment of Victims of Biological or Chemical Terrorist Attack. Journal of Emergency Medicine, 22, 273-78. Roy, M. J. (Ed.) (2004) Physicians Guide to Terrorist Attack, Totowa, New Jersey, Humana Press.
References Schultz, C. H., Koenig, K. L. & Noji, E. K. (1996) Current Concepts - A Medical Disaster Response To Reduce Immediate Mortality After An Earthquake. NEJM, 334, 438-44. Richards, C. F., Burnstein, J. L., Waeckerie, J. F. & Hutson., H. R. (1999) Emergency Physician and Biological Terrorism. Annals of Emergency Medicine, 34, 183-190. Mandl, K. D., Overhage, J. M., Wagner, M. M., Lober, W. B., Sebastiani, P., Mostashari, F., Pavlin, J. A., Gesteland, P., Treadwell, T., Koski, E., Hutwagner, L., Buckeridge, D. L., Raymond, D. A. & Grannis, S. (2004) Implementing Syndromic Surveillance: A Practical Guide Informed by the Early Experience. Journal of the American Medical Informatics Association, 11, 141-150
A particular slide catching your eye?
Clipping is a handy way to collect important slides you want to go back to later.