Physician’s Guide to Terrorist Attack

397 Pages·2004·9.893 MB·English

by  Bonnie L. Smoak MD, PhD, MPH, James A. Geiling MD, FACP, FCCP (auth.), Michael J. Roy MD, MPH, FACP (eds.)

PHYSICIAN'S GUIDE TO TERRORIST ATTACK
PHYSICIAN'S GUIDE TO
TERRORIST ATTACK
Edited by
J.
MICHAEL ROY, MD, MPH, FACP
Department ofM edicine
Uniformed Services University oft he Health Sciences
Bethesda, MD
~ HUMANA PRESS
~
TOTOWA, NEW JERSEY
© 2004 Humana Press Inc.
Softcover reprint of the hardcover 1st edition 2004
999 Riverview Drive, Suite 208
Totowa, NJ 07512
www.humanapress.com
All rights reserved. No part of this book may be reproduced, stored in a retrieval system, or transmitted in any form or
by any means, electronic, mechanical, photocopying, microfilming, recording, or otherwise without written permission
from the Publisher.
The content and opinions expressed in this book are the sole work of the authors and editors, who have warranted due
diligence in the creation and issuance of their work. The publisher, editors, and authors are not responsible for errors
or omissions or for any consequences arising from the information or opinions presented in this book and make no
warranty, express or implied, with respect to its contents.
Due diligence has been taken by the publishers, editors, and authors of this book to assure the accuracy of the infor
mation published and to describe generally accepted practices. The contributors herein have carefully checked to ensure
that the drug selections and dosages set forth in this text are accurate and in accord with the standards accepted at the
time of publication. Notwithstanding, as new research, changes in government regulations, and knowledge from
clinical experience relating to drug therapy and drug reactions constantly occurs, the reader is advised to check the
product information provided by the manufacturer of each drug for any change in dosages or for additional warnings
and contraindications. This is of utmost importance when the recommended drug herein is a new or infrequently used
drug. It is the responsibility of the treating physician to determine dosages and treatment strategies for individual
patients. Further it is the responsibility of the health care provider to ascertain the Food and Drug Administration status
of each drug or device used in their clinical practice. The publisher, editors, and authors are not responsible for errors
or omissions or for any consequences from the application of the information presented in this book and make no
warranty, express or implied, with respect to the contents in this publication.
Cover design by Patricia F. Cleary.
Cover photo: BrandX Pictures.
For additional copies, pricing for bulk purchases, and/or information about other Humana titles, contact Humana at
the above address or at any of the following numbers: Tel.: [phone]; Fax: [phone], E-mail:
[email protected]; or visit our Website: www.humanapress.com
This publication is printed on acid-free paper. GV
ANSI Z39.48-1984 (American National Standards Institute) Permanence of Paper for Printed Library Materials.
Photocopy Authorization Policy:
Authorization to photocopy items for internal or personal use, or the internal or personal use of specific clients is granted
by Humana Press, provided that the base fee of US $25.00 per copy is paid directly to the Copyright Clearance Center
(CCC), 222 Rosewood Dr., Danvers MA 01923. For those organizations that have been granted a photocopy license
from the CCC, a separate system of payment has been arranged and is acceptable to the Humana Press. The fee code
for users of the Transactional Reporting Service is 1-58829-207-X/04 $25.00.
Library of Congress Cataloging-in-Publication Data
Physician's guide to terrorist attack 1 edited by Michael J. Roy.
p.; cm.
Includes bibliographical references and index.
Additional material to this book can be downloaded from http://extras.springer.com
ISBN 978-1-4684-9814-1 ISBN 978-1-59259-663-8 (eBook)
DOI 10.1007/978-1- 59259-663-8
I. Terrorism--Health aspects. 2. Disaster medicine. [DNLM: I. Disaster Planning--organization & administration.
2. Emergency Medical Services--organization & administration. 3. Terrorism--prevention & control. 4. Biological
Warfare--prevention & control. 5. Chemical Warfare Agents--toxicity. 6. Decontamination--methods. 7. Nuclear
Warfare. WX 185 P5785 2004] 1. Roy, Michael J., 1962-
RC88.9.T47P482004
362.18--dc21
2003008190
This book is dedicated to the survivors oft he terrorist
attacks that occurred on September 11, 2001, and oft he
anthrax attacks that followed that fall as well as to the
families andf riends who lost loved ones as a result of
these horrors. Let us hope and pray that we will be able
to prevent such senseless loss ofl ife in the future.
PREFACE
Terrorists seek to maximize economic, political, and psychological disruption through
their actions. To capture media attention for their cause, terrorists often engage in one
upmanship, acting in a more horrific and spectacular manner than has been previously
seen, from the Olympic Village attack in Munich in 1972, to the airliner crashes into the
World Trade Center and the Pentagon in 2001. The use of biological, chemical, or nuclear
weapons has been contemplated by many terrorists, and even carried out with some
success on occasion, but the medical community justifiably fears that we are likely to see
more calamitous use of such agents for terrorist means in the future.
Terrorist events in the fall of 200 I-the attacks upon the World Trade Center and the
Pentagon on September 11, followed by dissemination of anthrax through the US mail
painfully emphasized the need for physicians to be able to diagnose and manage individu
als suffering injuries as a result of exposures to biological, chemical, and nuclear, as well
as explosives. Physician's Guide to Terrorist Attack is intended to prepare physicians and
other health care workers to respond knowledgeably and confidently to a terrorist event.
Whether you are a first responder working with emergency personnel amid the chaos of
a disaster scene or at a hospital receiving mass casualties, a provider in the community
responding to an anxious patient fearful of exposure to a biological agent, or a primary
care provider or mental health specialist helping patients and their family members to
cope with the psychological aftermath, this book will provide the information you need,
in an easy-to-follow, clinically relevant, case-based format.
Dr. Smoak, a veteran of the US Embassy bombing in Nairobi, Kenya, reviews lessons
learned from previous events with regard to the initial response. Dr. Geiling, who was
chief of medical services at the Pentagon on September 11, 2001, details the impact that
a terrorist event is likely to have on the medical system, providing valuable guidance on
what to expect and how to prepare for a future event. Drs. Yeskey and Morse of the
Centers for Disease Control and Prevention outline the approach that a community
provider should take, from the initial suspicion of a terrorist event, to the involvement of
public health authorities.
Dr. Murray reviews the historical use of biological, chemical, and nuclear agents, from
ancient times through the present, putting into perspective recent concerns, and providing
an introduction to the ensuing chapters, which provide an agent-by-agent review for the
clinician. A number of the world's leading infectious diseases experts on potential bio
logical agents focus on the key aspects of diagnosis and therapy for the 13 most feared
bacteria, viruses, and toxins. A comparable field of experts then reviews the diagnostic
and therapeutic approach to various chemical agents. Many of the authors have been
involved in various aspects of evaluation and management of biological and chemical
threats, in homeland defense efforts to combat terrorism, and in a variety of educational
endeavors to help fellow clinicians prepare to diagnose and treat victims promptly should
an event come to pass.
The subsequent three chapters provide critically important information as well. A
chapter on blast injuries, written by leading authorities on this subject, is significant
because conventional explosives are still far more likely to be used by terrorists than
vii
viii Preface
anything else. A chapter on nuclear and radiological weapons, written by experts at the
Armed Forces Radiobiologic Research Institute, covers the gamut from a "dirty bomb"
to the use of a high-powered nuclear device. Last but not least, members of the Depart
ment of Psychiatry at Uniformed Services University, internationally recognized for
their disaster response experience, review the immediate and late psychological effects
of terrorist events. This is particularly salient, since no matter how severe and numerous
the physical casualties, it is safe to assume that they will be exceeded by those suffering
from psychological traumatization.
Although it would be nice to think that physicians need not know the information that
is covered here, the reality is that it is critically important for physicians to prepare
themselves by acquiring the knowledge and skills necessary to cope effectively with a
major terrorist event now, rather than learning through painful experience.
Michael J. Roy, MD, MPH, FACP
CONTENTS
Preface ......................................................................................................................... vii
Contributors ................................................................................................................... xi
PART I: RESPONDING TO AN INCIDENT
1 Mass Casualty Events: Lessons Learned ......................................... 3
Bonnie L. Smoak and James A. Geiling
2 Hospital Preparation and Response to an Incident ........................ 21
James A. Geiling
3 Physician Recognition of Bioterrorism-Related Diseases ............. 39
Kevin Yeskey and Stephen A. Morse
4 Introduction to Biological, Chemical, Nuclear, and Radiological
Weapons: With a Review of Their Historical Use ............................ 47
Clinton K. Murray
II:
PART BIOLOGICAL AGENTS
5 Anthrax ............................................................................................ 65
Steven J. Durning and Michael J. Roy
6 Plague .............................................................................................. 87
Jennifer C. Thompson
7 Tularemia ...................................................................................... 103
Christian F. Ockenhouse
8 Brucellosis ..................................................................................... 111
David L. Hoover
9 Q Fever .......................................................................................... 123
R. Scott Miller
10 Melioidosis and Glanders ............................................................. 143
Aileen M. Marty
11 Botulinum Toxins ......................................................................... 161
Naomi E. Aronson
12 Ricin Toxin ................................................................................... 175
Glenn Wortmann
13 Staphylococcal Enterotoxin B ...................................................... 181
David L. Blazes
ix
x Contents
14 Mycotoxins .................................................................................... 189
Duane R. Hospenthal
15 Smallpox ....................................................................................... 197
James V. Lawler and Timothy H. Burgess
16 Viral Hemorrhagic Fevers ............................................................ 221
Thomas W. Geisbert, Aileen M. Marty, and Peter B. Jahrling
17 Viral Encephalitides ...................................................................... 243
Niranjan Kanesa-thasan
III:
PART CHEMICAL AGENTS
18 Pulmonary Toxic Agents .............................................................. 253
Rafael E. Padilla
19 Cyanide .......................................................................................... 263
Steven I. Baskin, Jonathan S. Kurche, and Beverly I. Maliner
20 Vesicants ....................................................................................... 279
Edward Lucci
21 Nerve Agents ................................................................................. 297
Jonathan Newmark
22 Incapacitating Agents ................................................................... 311
Sage W. Wiener and Lewis S. Nelson
23 Riot Control Agents ...................................................................... 325
Richard J. Thomas and Philip A. Smith
PART IV: ADDITIONAL CONSIDERATIONS
24 Radiation Effects ........................................................................... 339
Vijay K. Singh and Thomas M. Seed
25 Explosives ..................................................................................... 363
John M. Wightman and Barry A. Wayne
26 Psychological Impact of Terrorist Incidents ................................ 379
Timothy J. Lacy and David M. Benedek
27 Conclusions ................................................................................... 391
Michael J. Roy
Index ........................................................................................................................... 397
CONTRIBUTORS
NAOMI E. ARONSON, MD, FACP • Colonel, Medical Corps, US Army; Director, Division
of Infectious Diseases, Associate Professor of Medicine, Uniformed Services
University of the Health Sciences, Bethesda, MD
STEVEN I. BASKIN, PharmD, PhD, FCP, FACC, DABT, FATS • Division of Pharmacology,
US Army Medical Research Institute of Chemical Defense, Aberdeen Proving
Ground, MD
DAVID M. BENEDEK, MD· Major, Medical Corps, US Army; Associate Professor
of Psychiatry, Uniformed Services University of the Health Sciences,
Bethesda, MD
DAVID L. BLAZES, MD, MPH· Lieutenant Commander, Medical Corps, US Navy;
Assistant Professor of Medicine, Uniformed Services University of the Health
Sciences; Infectious Diseases Service, National Naval Medical Center,
Bethesda, MD
TIMOTHY H. BURGESS, MD, MPH· Lieutenant Commander, Medical Corps, US Navy;
Naval Medical Research Center, Silver Spring, MD
STEVEN J. DURNING, MD, FACP • Major, Medical Corps, US Air Force; Director,
Clinical Concepts Course, Assistant Professor of Medicine, Uniformed Services
University of the Health Sciences, Bethesda, MD
JAMES A. GElLING, MD, FACP, FCCp· Colonel, Medical Corps, US Army (Retired);
Department of Medicine, VA Medical Center, White River Junction, VT; Assistant
Professor of Medicine, Dartmouth Medical School, Hanover, NH
THOMAS W. GEISBERT, PhD· US Army Medical Research Institute of Infectious
Diseases, Fort Detrick, MD
DAVID L. HOOVER, MD· Colonel, Medical Corps, US Army; Department of Bacterial
Diseases, Walter Reed Army Institute of Research, Silver Spring; Professor
of Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD
DUANE R. HOSPENTHAL, MD, PhD, FACP • Lieutenant Colonel, Medical Corps, US Army;
Chief, Infectious Disease Service, Brooke Army Medical Center, San Antonio, TX
PETER B. JAHRLING, PhD· US Army Medical Research Institute of Infectious Diseases,
Fort Detrick, MD
NlRANJAN KANESA-THASAN, MD, MTMH • Lieutenant Colonel, Medical Corps, US Army;
Medical Division, US Army Medical Research Institute of Infectious Diseases,
Fort Detrick, MD
JONATHAN S. KURCHE, BS· Research Fellow, Division of Pharmacology, Oak Ridge
Institute for Science and Education (ORISE); US Army Medical Research Institute
of Chemical Defense, Aberdeen Proving Ground, MD
TIMOTHY J. LACY, MD· Lieutenant Colonel, Medical Corps, US Air Force; Assistant
Professor of Psychiatry and Family Medicine, Uniformed Services University
of the Health Sciences; Program Director, National Capital Consortium Combined
Residency in Psychiatry and Family Practice, Uniformed Services University
of the Health Sciences, Bethesda, MD
xi